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Quality and safety go hand-in-hand; by improving one, the other rises as well. Creating a quality and safety program is vital to the function of any IR practice or division, but to have a truly effective program, human emotion and good data must combine into productive and safe outcomes, according to panelists at the 2023 session “Building a Quality and Safety Program.”
Evaluating mistakes
The goal of a quality and safety program is to create a learning environment where patient safety is consistently optimized through a commitment to preventing, understanding and reliably responding to medical errors, said Mikhail Higgins, MD, MPH.
“When we talk about errors, complications and adverse events, we have to understand that not all poor outcomes are the result of an error,” he said. “There are so many contributors to something going wrong, which may be both individual or more commonly systemic.”
When something goes wrong, people want an answer, Dr. Higgins said, and in many situations the investigation doesn’t get past the individual level. Thus, the backlash focuses not on the flawed situation or processes that likely gave rise to the incident in question, but on the person deemed responsible.
“A huge barrier to an effective safety and quality program is fear,” Dr. Higgins said, which perpetuates silence and future errors. “Medical culture has not been traditionally supportive of disclosing errors, and there is an associated fear of liability, retribution and professional discord.”
To succeed in your commitment to quality and safety, Dr. Higgins said, facilities and physicians must transition from a culture of shame to a learning culture that values the local rationality principle. Dr. Higgins said that this principle asks us to presume that no one comes to work wanting to do a bad job, but also calls us to seek to understand not where people went wrong first and foremost but why what they did made sense to them. A robust safety culture built on shared learning from errors is associated with fewer events and fewer barriers to adverse event reporting—and when things go wrong, it constructively shifts the question from who to why.
Understanding the factors
“Everyone makes mistakes,” said Noor Ahmad, MD. It’s the first thing to understand when engaging in a safety culture. No one comes to work intending to do a bad job, and it’s more important to understand the factors that led to error.
The person who has just made a mistake does not need punitive action focused on what went wrong, Dr. Ahmad said. “That physician will remember the mistake forever. They need support, not condemnation.”
He shared an example of a physician who had an adverse event after using the wrong catheter. A reactive solution would be to tell the physician to pay more attention. But instead, the case was reviewed and investigators found that the intended catheter and the one actually used had similar brand names. As a result, the staff made a system change and took out brand names to avoid future error. In addition, they saw an opportunity for creating another step in the process for catheter verification.
“You have to look at how humans interact with systems and take into account human characteristics,” Dr. Ahmad said.
Medical workers tend to lack the ability to be self-critical, Dr. Ahmad says, either due to ego or fear—which leads to poor communication and inaccurate reporting.
“In one study, 70% of surgeons said that fatigue doesn’t impact their performance,” Dr. Ahmad said. “But we know that’s not true.” External factors like noise, light and distractions, and internal factors like stress, fatigue, hunger or illness all play a part in creating errors and can happen to anyone.
Using the example of a delayed diagnosis of an aortic dissection, Dr. Higgins explained how many different internal and external factors can lead to an error.
“Through a root cause analysis, we found that the emergency department was unusually busy that day, and the ultrasound wasn’t working. The provider was on their third night shift in a row and was fatigued. The intern was on her first day and felt hesitant making decisions. The patient was also aggressive and difficult to deal with. And at this particular institution, there is an unspoken rule that you don’t call others for help, as everyone is busy trying to keep their heads above water and care for their own patients,” said Dr. Higgins. “The outcome of any of these situations was that the patient had a delayed diagnosis of a thoracic aortic dissection that could have been treated, and as a result, the patient sadly expired while awaiting care.”
So how does this facility learn from this patient’s death and move forward?
A culture of safety
Building a culture of safety requires utilizing data and respectful discussions to identify the root cause of an adverse event, and then adjust accordingly, Dr. Ahmad said.
He suggests using a safety event review tool to walk through each aspect of the complication or event. Did it meet the standard of care? If you substituted another provider, would they make the same mistake? Did the provider intend to make the mistake? According to Dr. Ahmad, if the answer to substitution is “yes,” then the provider needs coaching—not punitive action.
Supporting a culture of respectful interviews and data collection, where that data leads to demonstrated improvement, makes it easier to avoid complications, he said. Tracking tools such as standardized templates, review panels like morbidity and mortality conferences, and project management approaches like the LEAN or a3 methods can identify problems, review the root causes, and put systems in place to create better results.
Establishing a peer-review process is another way to track complications, regardless of practice size.
“In academics, the peer review process is often focused on training,” said Hector Ferral, MD, FSIR. “But in private practice, any complication may become a legal problem. A documented peer review process can help prove lack of negligence.”
Dr. Ferral’s practice has instituted a peer review process and conducts review sessions monthly. These cases are selected by attendings and residents, and they discuss adverse events, communication issues and “near misses.”
The group reviews imaging, discusses and classifies the adverse event, and reviews literature to determine if they need to change practice patterns. Sometimes these changes are broad, such as when they reviewed the case of a PE patient who had a negative outcome. After discussion, staff agreed to create a PE response team, revised their anesthesia protocols and improved practice patterns.
Better experience
While a quality and safety culture improves patient outcomes, it should also improve the overall patient experience.
Bradley B. Pua, MD, FSIR, shared his experiences with using call metrics at his facility to improve productivity, streamline call scheduling and facilitate downstream imaging appointments so patients had less turnaround time between appointments and a more tailored experience all around.
Dr. Pua started this work by organizing customer service courses for scheduling staff and gathered them for a conversation. “I asked them what they were hearing from patients, and how we could make their jobs easier,” he said. This made the group more comfortable voicing concerns and identifying problem areas that they may have previously been unwilling to document or discuss.
“We created a culture of comfort talking about problems and we broke down that silo of finger-pointing, and then worked together to enhance the system for a better patient experience,” Dr. Pua said.
Joshua Weintraub, MD, FSIR, had a similar experience when trying to improve start times at his facility.
“Our day used to start at least two hours behind,” he said. “IRs were lucky to go home at 7 or 8 p.m.” Late starts also lead to fewer patients treated, increased length of stays and decreased patient and workforce satisfaction he said.
They brought in quality and patient safety experts to help improve this workflow.
“We wanted to create a process so that our first case of the day was on track 30% of the time within 100 days,” he said. To do this, they collected data for a week on every checkpoint, then held an in-depth team conference where everyone looked at every step of the patient experience—from arriving in the parking lot to leaving recovery—to find the root cause of inefficiency.
From there, they created a priority matrix to determine which fixes could be done quickly, which would be major projects, and which would take a long time to implement. Then they put the plan into action.
According to Dr. Weintraub, they had patients receive confirmation calls the night before and arrive earlier. One of the doctors was assigned a day of the week to serve as central command. Then they put in a system so that drugs could be localized, rather than retrieved from a central pharmacy. They added more computers to the practice, put up better signage, and then standardized the supply room and how techs made up trays.
Within 30 days, Dr. Weintraub said, they went from having 1.7% of cases start on time to 6%. Within 100 days, 76% of the first cases started on time.
“This makes an impact on the entire day,” Dr. Weintraub said, “and it improves our patient experience.”
Conclusion
Quality and safety programs are complicated, but they are crucial for improving patient and workforce experience and creating better patient outcomes. Through an open culture of communication and data-informed improvement, any facility can become engaged in actively learning and improving, rather than assigning blame and perpetuating shame.
“You can’t change the human condition,” Dr. Ahmad said, “but you can change the condition they work in.”
