Peer learning in abdominal radiology: iterative process improvements over a 20-year experience

PURPOSE

After a slow and challenging transition period, peer learning and improvement (PLI) is now being more widely adopted by practices as an option for continuous personal and practice performance improvement. In addition to gaps that exist in the understanding of what PLI is and how it should be practiced, wide variation exists in how the process is implemented, administered, how outcomes are measured, and what strategies are employed to engage radiologists. This report aims to describe lessons learned from our 20-year experience with the design, implementation, and continuous improvements of a PLI program in a large academic program.

METHODS

Since initial implementation in 2004, an oversight team prospectively documented iterative process improvements and data submission trends in our PLI process. Process data included strategies for engaging radiologists in the PLI process (fostering case submission, PLI meeting participation), steps for achieving regulatory compliance, and template content for facilitating the value and impact of PLI meetings (case analysis, review of contributing factors, identification of improvement opportunities).

RESULTS

Submission trends, submitted case content, and improvement opportunities varied by clinical section. Process improvements that fostered engagement included closing the loop with participants, expanding criteria for case submission beyond interpretive disagreements (e.g., great pickups, near misses), minimizing impacts to workflow, and using evidence-based templates for case and contributor categorization, bias analysis, and identification of improvement opportunities.

CONCLUSION

Implementing an effective PLI program requires sustained communication, education, and continuous process improvement. While PLI can certainly lead to process and individual performance improvement, the program requires trained champions, designated time, effort, resources, education, and patience to be effectively implemented.

Radiologist and Radiology Practice Wellbeing: A Report of the 2023 ARRS Wellness Summit

In April 2023, the first American Roentgen Ray Society (ARRS) Wellness Summit was held in Honolulu, Hawaii. The Summit was a communal call to action bringing together professionals from the field of radiology to critically review our current state of wellness and reimagine the role of radiology and radiologists to further wellbeing. The in-person and virtual Summit was available free-of-cost to all meeting registrants and included 12 sessions with 44 invited moderators and panelists. The Summit aimed to move beyond simply rehashing the repeated issues and offering theoretical solutions, and instead focus on intentional practice evolution, identifying implementable strategies so that we as a field can start to walk our wellness talk. Here, we first summarize the thematic discussions from the 2023 ARRS Wellness Summit, and second, share several strategic action items that emerged.

Emotional Harm in the Radiology Department: Analysis of an Underrecognized Preventable Error

Background Emotional harm incidents in health care may result in lost trust and adverse outcomes. However, investigations of emotional harm in radiology departments remain lacking. Purpose To better understand contributors and clinical scenarios in which emotional harm can occur in radiology, to document incidences, and to develop preventative countermeasures. Materials and Methods A large tertiary hospital adverse event reporting system was retrospectively searched for submissions under the category of dignity and respect in radiology between December 2014 and December 2020. Submissions were assigned to one of 14 categories per a previously developed classification system. Root-cause analysis of events was performed with a focus on countermeasures for future prevention. The person experiencing emotional harm (patient or staff) was noted. Results Of all radiology-related submissions, 37 of 3032 (1.2%) identified 43 dignity and respect incidents: failure to be patient centered (n = 23; 54%), disrespectful communication (n = 16; 37%), privacy violation (n = 2; 5%), minimization of patient concerns (n = 1; 2%), and loss of property (n = 1; 2%). Failure to be patient centered (n = 23) was subcategorized into disregard for patient preference (12 of 23; 52%), delay in care (eight of 23; 35%), and ineffective communication (three of 23; 13%). Of the 43 incidents, 32 involved patients (74%) and 11 involved staff (26%). Emotional harm in staff was because of disrespectful communication from other staff (eight of 11; 73%). Seventy-three countermeasures were identified: staff communication training (n = 32; 44%), individual feedback (n = 18; 25%), system innovation (n = 16; 22%), improvement of existing communication processes (n = 3; 4%), process reminders (n = 3; 4%), and unclear (n = 1; 1%). Individual feedback and staff communication training that focused on active listening, asking for the patient's preferences, and closed-loop communication addressed 34 of the 43 incidents (79%). Conclusion Most emotional harm incidents were from disrespectful communication and failure to be patient centered. Providing training focused on active listening, asking for patient's preferences, and closed-loop communication would potentially prevent most of these incidents. © RSNA, 2021 See also the editorial by Bruno in this issue.

Procedure-specific Training for Robot-assisted Distal Pancreatectomy

OBJECTIVE

To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality.

BACKGROUND

RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce.

METHODS

A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy.

RESULTS

After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP.

CONCLUSION

Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.

Radiologist Well-Being and Professional Fulfillment in the COVID-19 Era: Fostering Posttraumatic Growth

The acute consequences of the COVID-19 pandemic have impacted wellness strategies aimed at mitigating the pre-existing epidemic of burnout in radiology. Specifically, safety measures including social distancing requirements, effective communications, supporting remote and distributed work teams, and newly exposed employment and treatment inequities have challenged many major efforts at fostering professional fulfillment. To get our wellness efforts back on track and to achieve a new and perhaps even a better "normal" will require refocusing and reconsidering ways to foster and build a culture of wellness, implementing practices that improve work efficiencies, and supporting personal health, wellness behaviors, and resilience. Optimizing meaning in work is also critical for well-being and professional fulfillment. In addition to these earlier approaches, organizations and leaders will need to reprioritize efforts to build high-functioning cohesive and connected teams; to train, implement, and manage peer-support practices; and to support posttraumatic growth. This growth represents the positive psychological changes that can occur after highly challenging life circumstances and, when successful, allows individuals to achieve a higher level of functioning by addressing and learning from the precipitating event. Our practices can support this growth through education, emotional regulation, and disclosure, by developing a narrative that reimagines a hoped-for better future and by finding meaning through services that benefit others.

Enabling Your Radiology Business to Thrive Strategic Lessons Learned During the Initial and Subsequent Surges of the Covid-19 Pandemic

The Covid-19 pandemic surges of 2020 resulted in major operational, personal, and financial impacts on US radiology practices. In response, a series of strategic and intentional operational changes were implemented, varying by practice size, structure and model. In reviewing the many business lessons that we learned during the pandemic, it became clear that for a business to be successful, a host of additional supportive factors are necessary. In addition to timely expense reductions, optimizing revenue capture and close monitoring and management of cash and reserves available for use, we also consider effective leadership and communication strategies, maintenance of a healthy and adequately staffed team, support for a remote work environment and flexible staffing models. Other ingredients include effectively embracing digital media for communications, careful attention to current and new stakeholders and the service delivered to them, understanding federal and state regulatory changes issued in response to the pandemic, close collaboration with the Human Resources office, and an early focus on redesigning your future practice structure and function, including disaster and downtime planning. This review aims to share lessons to enable leaders of an imaging enterprise to be better prepared for similar and future surges.

The Road to Wellness: Engagement Strategies to Help Radiologists Achieve Joy at Work

Physician wellness is recognized as a critical component of enhancing the quality of health care. An epidemic of symptoms related to stress and burnout among medical professionals, including radiologists, in the workplace is threatening not only health care providers at a personal level but also the entire health care system. In this review, the authors highlight recognized stressors in the contemporary radiology workplace and offer practical suggestions for mitigating burnout, improving professional engagement, and promoting wellness. Thematic goals to focus on include fostering an integrated and harmonious community at work, diminishing workplace detractors, creating opportunities to cultivate positive attitudes and intellect, and implementing effective leadership practices. ^©RSNA, 2018.

A Road Map to Foster Wellness and Engagement in Our Workplace-A Report of the 2018 Summer Intersociety Meeting

The 2018 radiology Intersociety Committee reviewed the current state of stress and burnout in our workplaces and identified approaches for fostering engagement, wellness, and job satisfaction. In addition to emphasizing the importance of personal wellness (the fourth aim of health care), the major focus of the meeting was to identify strategies and themes to mitigate the frequency, manifestations, and impact of stress. Strategies include reducing the stigma of burnout, minimizing isolation through community building and fostering connectivity, utilizing data and benchmarking to guide effectiveness of improvement efforts, resourcing and training "wellness" committees, acknowledging value contributions of team members, and improving efficiency in the workplace. Four themes were identified to prioritize organizational efforts: (1) collecting, analyzing, and benchmarking data; (2) developing effective leadership; (3) building high-functioning teams; and (4) amplifying our voice to increase our influence.

Big Data and Machine Learning-Strategies for Driving This Bus: A Summary of the 2016 Intersociety Summer Conference

The 38th radiology Intersociety Committee reviewed the current state and future direction of clinical data science and its application to radiology practice. The assembled participants discussed the need to use current technology to better generate and demonstrate radiologists' value for our patients and referring providers. The attendants grappled with the potentially disruptive applications of machine learning to image analysis. Although the prospect of algorithms' interpreting images automatically initially shakes the core of the radiology profession, the group emerged with tremendous optimism about the future of radiology. Emerging technologies will provide enormous opportunities for radiologists to augment and improve the quality of care they provide to their patients. Radiologists must maintain an active role in guiding the development of these technologies. The conference ended with a call to action to develop educational strategies for future leaders, communicate optimism for our profession's future, and engage with industry to ensure the ethics and clinical relevance of developing technologies.

Root Cause Analysis: Learning from Adverse Safety Events

Serious adverse events continue to occur in clinical practice, despite our best preventive efforts. It is essential that radiologists, both as individuals and as a part of organizations, learn from such events and make appropriate changes to decrease the likelihood that such events will recur. Root cause analysis (RCA) is a process to (a) identify factors that underlie variation in performance or that predispose an event toward undesired outcomes and (b) allow for development of effective strategies to decrease the likelihood of similar adverse events occurring in the future. An RCA process should be performed within the environment of a culture of safety, focusing on underlying system contributors and, in a confidential manner, taking into account the emotional effects on the staff involved. The Joint Commission now requires that a credible RCA be performed within 45 days for all sentinel or major adverse events, emphasizing the need for all radiologists to understand the processes with which an effective RCA can be performed. Several RCA-related tools that have been found to be useful in the radiology setting include the "five whys" approach to determine causation; cause-and-effect, or Ishikawa, diagrams; causal tree mapping; affinity diagrams; and Pareto charts.

Reengineering the radiology enterprise: a summary of the 2014 Intersociety Committee Summer Conference

The current initiative to reform health care from both a quality and a cost perspective has already had a profound impact on the radiology enterprise. We have seen a decrease in the utilization of imaging studies, a reduction in reimbursement, a declining payer mix, shrinking incomes, a proliferation of performance indices, creation of radiology mega-groups, growth of national radiology companies, and increasing turf incursions. Our cheese is clearly on the move, and we must take action to reengineer the radiology enterprise. In keeping with general health care reform, we must be patient-centric, data driven, and outcome based. We must create a radiology enterprise that adheres to the value equation of providing the highest quality health care, for the lowest possible cost, for all citizens.

Conducting a Successful Practice Quality Improvement Project for American Board of Radiology Certification

Practice quality improvement (PQI) is a required component of the American Board of Radiology (ABR) Maintenance of Certification (MOC) cycle, with the goal to "improve the quality of health care through diplomate-initiated learning and quality improvement." The essential requirements of PQI projects include relevance to one's practice, achievability in one's clinical setting, results suited for repeat measurements during an ABR MOC cycle, and reasonable expectation to result in quality improvement (QI). PQI projects can be performed by a group or an individual or as part of a participating institution. Given the interdisciplinary nature of radiology, teamwork is critical to ensure patient safety and the success of PQI projects. Additionally, successful QI requires considerable investment of time and resources, coordination, organizational support, and individual engagement. Group PQI projects offer many advantages, especially in larger practices and for processes that cross organizational boundaries, whereas individual projects may be preferred in small practices or for focused projects. In addition to the three-phase "plan, do, study, act" model advocated by the ABR, there are several other improvement models, which are based on continuous data collection and rapid simultaneous testing of multiple interventions. When properly planned, supported, and executed, group PQI projects can improve the value and viability of a radiology practice.

Blind spots at oncological CT: lessons learned from PET/CT

Improved accuracy in oncological computed tomography (CT) could lead to a decrease in morbidity and improved survival for oncology patients. Visualization of metabolic activity using the glucose analogue [¹⁸F]fluorodeoxyglucose (FDG) in combination with the high anatomic resolution of CT in an integrated positron emission tomography (PET)/CT examination has the highest sensitivity and specificity for the detection of primary and metastatic lesions. However, PET/CT costs are high and patient access is limited; thus CT remains the primary imaging modality in oncology patients. We have noted that subtle lesions are more easily detected on CT by radiologists with PET/CT experience. We aimed to provide a brief review of the literature with comparisons of multi-detector computed tomography (MDCT) and PET/CT in primary and metastatic disease with an emphasis on findings that may be overlooked on MDCT in cancer of the breast, lung, colon, and ovaries, and in melanoma, as well as thrombosis in oncology patients. We further reviewed our experience for illustrative comparisons of PET/CT and MDCT studies. Experience in interpreting conventional CT scans alongside PET/CT can help the reader develop an appreciation for the subtle appearance of some lesions on CT that might otherwise be missed. This could improve detection rates, reduce errors, and improve patient management.

Quality initiatives: Quality improvement in radiology: basic principles and tools required to achieve success

All imaging departments are expected to establish and maintain effective quality, safety, and performance improvement programs. Essential components of such programs include adherence to the basic principles of quality management and appropriate utilization of quality tools. The initial step is the gathering of relevant information, followed by the collection and analysis of quality and performance data; analysis and ranking of causes that likely contributed to a process failure, error, or adverse event; and prioritization and local implementation of solutions, with careful monitoring of newly implemented processes and wider dissemination of the tools when a process proves to be successful. Quality improvement requires a careful, dedicated, and continuously planned effort by a number of skilled and committed team members, with the goal being to do the right thing in a timely fashion in every case. This process can be sustained by offering rewards and celebrating successes, with all lessons learned disseminated throughout the department or organization.

Quality initiatives: measuring and managing the procedural competency of radiologists

Many regulatory and oversight groups require that the professional performance of radiologists be evaluated on an ongoing basis. Although the diagnostic accuracy of radiologists is routinely measured at most institutions by means of peer review processes, systems for evaluating procedural competency are not widely available. Consequently, technical skills are seldom, if ever, evaluated or managed. The key elements of a system for evaluating procedural competency include the following: (a) clear definition of all elements of a transparent evaluation process; (b) definition of standards for training and credentialing and options for maintenance of competency certification in interventional procedures; (c) collection and analysis of process and outcomes metrics; (d) multisource feedback on procedural, patient care, and safety skills; and (e) an effective, anonymous process for managing radiologists in whom deficiencies are identified. Although no ideal system for evaluating procedural competency currently exists, inclusion of these elements goes a long way toward facilitating the introduction of a simple process for providing appropriate feedback to procedural radiologists, acknowledging excellence, and identifying and managing deficiencies if they occur.

Intraoperative ultrasonography of the pancreas

Intraoperative ultrasonography (US) of the pancreas is a versatile technique that provides excellent spatial and contrast resolution and real-time imaging capabilities, making it useful for diagnostic imaging as well as for guidance of laparoscopic and open operative procedures. Intraoperative US may be used for applications such as staging and localizing tumors; performing regional metastatic surveys; documenting arterial and venous patency; identifying endocrine tumors; distinguishing pancreatitis from a neoplasm; and guiding biopsy, duct cannulation, and drainage of abscesses or cysts. The scanning approach and technique vary according to the application, with many different equipment and transducer options and sterilization methods available. With increasing clinical demands for intraoperative US, it is essential that radiologists be familiar with its uses and technique. In addition, to properly perform intraoperative US and accurately interpret the images, knowledge of normal and variant pancreatic and vascular anatomy and relevant landmarks is needed. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.307105051/-/DC1.

Application of failure mode and effect analysis in a radiology department

With increasing deployment, complexity, and sophistication of equipment and related processes within the clinical imaging environment, system failures are more likely to occur. These failures may have varying effects on the patient, ranging from no harm to devastating harm. Failure mode and effect analysis (FMEA) is a tool that permits the proactive identification of possible failures in complex processes and provides a basis for continuous improvement. This overview of the basic principles and methodology of FMEA provides an explanation of how FMEA can be applied to clinical operations in a radiology department to reduce, predict, or prevent errors. The six sequential steps in the FMEA process are explained, and clinical magnetic resonance imaging services are used as an example for which FMEA is particularly applicable. A modified version of traditional FMEA called Healthcare Failure Mode and Effect Analysis, which was introduced by the U.S. Department of Veterans Affairs National Center for Patient Safety, is briefly reviewed. In conclusion, FMEA is an effective and reliable method to proactively examine complex processes in the radiology department. FMEA can be used to highlight the high-risk subprocesses and allows these to be targeted to minimize the future occurrence of failures, thus improving patient safety and streamlining the efficiency of the radiology department.

Electronic messaging system for communicating important, but nonemergent, abnormal imaging results

PURPOSE

To evaluate the effectiveness of an electronic messaging system for accurately communicating important, but not emergent, abnormal radiology results to referring physicians.

MATERIALS AND METHODS

The Institutional Review Board deemed this proposal a quality improvement project that did not require formal approval. The electronic messaging system permits radiologists to submit online requests to communicate important, but not emergent, abnormal findings and recommended follow-up to two communications facilitators, who contact referring health care providers by e-mail or telephone. Of 10,510 electronic communications during a 3-year period, a representative sample of 500 communications were selected for detailed analysis. To eliminate bias associated with increased experience with the system, every 20th communication during the 3 years that the messaging system had been functional was examined. Parameters studied included the rate of successful communications with referring physicians, the frequency of these being accomplished within the goal of 48 hours from the time of radiologist submission, and the results of an e-mail survey of physicians to assess their satisfaction with the system.

RESULTS

The radiologic abnormality was successfully communicated to the referring physician in every communication. Overall, a mean of 82.2% ± 3.3 (standard deviation) of communications were accomplished within the goal of 48 hours, with this goal being met in 93.7% ± 2.3 of communications submitted Monday through 3 pm on Thursday. Satisfaction among referring physicians was high (79.0% ± 3.8 satisfied; 5.0% ± 2.0 dissatisfied), especially among those with the most experience with the system.

CONCLUSION

The electronic messaging system communicated important, but not emergent, abnormal radiology results to referring physicians in a timely, accurate, and relatively inexpensive manner.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10101015/-/DC1.

Quality initiatives: quality improvement grand rounds at Beth Israel Deaconess Medical Center: CT colonography performance review after an adverse event

As computed tomographic (CT) colonography is being used increasingly in clinical practice, an effective quality improvement process must be ensured. The quality improvement process is outlined for the reader by using an adverse event during CT colonography as an example. Components of this process are the approach to a sentinel event, performance of a root cause analysis, and development of strategies for minimizing errors after a serious adverse event. Important factors include indications and contraindications for the examination, proper imaging technique, training of personnel, complications of the procedure, and legal implications. Complications from CT colonography are rare. Attention must be paid to the correct technique for colonic insufflation, particularly in older patients and those who are symptomatic. Root cause analysis provides valuable tools for identification and implementation of improvements designed to avoid similar and other adverse events and to minimize damage.

Benign hepatic tumors and iatrogenic pseudotumors

Myriad benign tumors may be found in the liver; they can be classified according to their cell of origin into tumors of hepatocellular, cholangiocellular, or mesenchymal origin. Common benign hepatic tumors may pose a diagnostic dilemma when they manifest with atypical imaging features. Less frequently encountered benign hepatic tumors such as inflammatory pseudotumor or biliary cystadenoma demonstrate less specific imaging features; however, awareness of their findings is useful in narrowing differential diagnostic considerations. In addition, certain iatrogenically induced abnormalities of the liver may be confused with more ominous findings such as infection or neoplasia. However, knowledge of their common imaging appearances, in addition to the clinical history, is critical in correctly diagnosing and characterizing iatrogenic abnormalities of the liver. Familiarity with both expected and unexpected imaging appearances of common benign hepatic tumors, less commonly encountered benign hepatic tumors, and iatrogenic abnormalities potentially masquerading as hepatic tumors allows the radiologist to achieve an informed differential diagnosis.

Focal hepatic lesions: US-guided biopsy--lessons from review of cytologic and pathologic examination results

PURPOSE

To retrospectively assess factors affecting the success of ultrasonographically (US)-guided core liver biopsy of focal lesions on the basis of experience when both cytologic and pathologic examination results were available.

MATERIALS AND METHODS

This HIPAA-compliant retrospective study was granted an exemption from the institutional review board. All percutaneous US-guided biopsies of focal liver lesions performed at one institution from January 2000 through February 2006 for which both cytologic and pathologic examination results were available were included. Specimen adequacy was determined with on-site cytologic examination performed with a "touch prep" technique. Of 1910 liver biopsies, 240 (12.6%) revealed focal lesions, and cytologic and pathologic examination results were available for 208 (86.7%) of these 240 lesions. The number of biopsy passes and concordance between cytologic and pathologic findings were evaluated, and correlation between lesion size, type, and location and the number of passes was assessed. The Pearson correlation chi(2) test and the Wilcoxon test were used.

RESULTS

Biopsy specimens were diagnostic in 205 cases (98.6%) and were nondiagnostic in three cases (1.4%); 85.9% of the lesions were malignant. There was a single lesion in 89 patients (42.8%), and there were multiple lesions in 119 patients (57.2%). One biopsy pass was sufficient in 58 patients (27.9%); two passes were sufficient in 75 patients (36.1%); and three, four, five, and six passes were sufficient in 51 (24.5%), 17 (8.2%), five (2.4%), and two (1.0%) patients, respectively. There was no relationship between lesion size or location and the number of passes, according to the Pearson correlation and chi(2) test (P = .16 and P = .22, respectively). On average, 1.9 passes were required for metastatic lesions, versus 2.8 for nonmetastatic lesions (P < .001, Wilcoxon test). Cytologic and histopathologic findings were discordant in 25 cases (12.0%).

CONCLUSION

The size and location of liver lesions sampled for biopsy do not influence the number of passes needed, while metastatic lesions require fewer passes. Without the on-site cytologic examination service, a predetermined number of three passes would be diagnostic in almost 90% of all cases.