Leading change: examples from the front line

Transcription

1 Leading change: examples from the front line Alexander J. Towbin Vice-Chair of Radiology, Clinical Operations and Informatics Neil D. Johnson Chair of Radiology facebook.com/cincykidsrad

2 Disclosures Grant support Cystic Fibrosis Foundation Guerbet Siemens Consultant Guerbet Applied Radiology Shareholder Merge Healthcare (divested) Royalties Elsevier

3 Objectives Frame change management through series of projects Describe multiple methods for leading change

4 Project 1 Implementing department-wide standardized structured reports

5 Background Benefits of structured reporting Improved communication Consistency Interpretation Coding Decreased time Decreased errors Data mining

6 Resistance Lose autonomy Art of radiology Patients aren t structured

7 Methods to Encourage Change Recruit champions Encourage participation Strong leadership Systemize change Incentivize change Audit

8 Recruit Champions Committees Structured report committee Working group subcommittee

9 Encourage Participation Working group subcommittee Report structure Format Style Technical details Structured report committee Write individual reports Most common first Divisional feedback How-to checklist Editing/Standardizing

10 Strong Leadership Guidelines Concise Minimal data entry Answer common questions Language for reimbursement Larson D B et al. Radiology doi: /radiol

11 Encourage Participation Process Creation Revision Negotiation Distribution Comment Approval

12 Systemize Change Prepopulated Audits Format Normal Bonus goals

13 Incentivize Change Bonus goals Group goal Achievable Hard to do wrong thing

14 Audit Data 271 reports 99% studies ~100% compliant Larson D B et al. Radiology doi: /radiol

15 Success

16 Project 2 A Comprehensive Approach to Convert a Radiology Department from ICD-9 based Coding to ICD-10-based Coding

17 Background ICD-9 used for 30+ years Outdated Limited ability to expand

18 Background ICD-10 Greater specificity Allow for expansion of terms More streamlined billing

19 Resistance Not my job Someone else s job Extra work This is stupid

20 Methods to Encourage Change Education Rationale for change Systemize change Incentivize change Audit Encourage participation Test change Collect data Consensus

21 Methods: Risk Assessment Insufficient clinical history Insufficient detail in fracture reports

22 Education Lecture to technologists

23 Education Lecture to technologists Frame problem

24 Education Lecture to technologists Frame problem Define expectations

25 Education Lecture to technologists Frame problem Define expectations

26 Rationale for Change Asked our technologists to obtain history directly from the patients and families Why technologists Eyes and ears of the department Excellent rapport with patients and families Scope of practice

27 Systemize Change Technologist history Added as an end exam question Mapped to dictation system Automatically populated in every report

28 Systemize Change Technologist history Added as an end exam question Mapped to dictation system Automatically populated in every report

29 Incentive Change Group goal Set achievable target Define ground rules

30 Audit Random audit 200 histories per month per modality Group performance goal 95% of all studies containing a complete history Routine feedback

31 Results: Improving History At baseline, technologists obtained a complete history 57.8% of the time By October, 2014, technologists in all modalities were providing a complete history more than 95% of the time

32 Encourage Participation Leadership subgroup created to evaluate and modify the structured reports for extremity radiographs Online ICD-10 codebook ( Created four potential reports Range in complexity and structured content

33 Encourage Participation Leadership subgroup created to evaluate and modify the structured reports for extremity radiographs Online ICD-10 codebook ( Created four potential reports Range in complexity and structured content

34 Encourage Participation Leadership subgroup created to evaluate and modify the structured reports for extremity radiographs Online ICD-10 codebook ( Created four potential reports Range in complexity and structured content

35 Encourage Participation Leadership subgroup created to evaluate and modify the structured reports for extremity radiographs Online ICD-10 codebook ( Created four potential reports Range in complexity and structured content

36 Test Change Test each report option with two separate body parts Forearm Wrist Elbow Hand Leg Ankle Knee Foot

37 Results: Improving Reports Forearm Wrist Elbow Hand Leg Ankle Knee Foot Baseline 77.8% 64.9% 73.1% 43.3% Test % 60.2% 80.1% 47.7% Test % 46.2% 32.2% 42.1%

38 Consensus

39 Results: Improving Reports Baseline (ICD-9) 20% Total % reports with unspecified codes Baseline (ICD-10) 43% Oct/Nov %

40 Project 3 Quality control checking of CT scans by a radiologist

41 Background Prior to 2008 all CT s were checked twice Technologist Radiologist Process interrupted workflow of techs and radiologists

42 Resistance Safety Better patient care

43 Methods to Encourage Change Use data Addressing concerns Data transparency Systemize change

44 Use Data Collected data CT technologist Radiologist Body area imaged Reason for additional imaging Whether additional imaging was requested by the radiologist Length of time

45 Share Data 6028 total CT exams 224 total repeats (3.7%) 164 technologist repeats 28 radiologist repeats 13% 14% Average length of time for checking process = 3 minutes 73% Tech Rad Tech + Rad

46 Address Concerns Intervention Eliminating CT checking by radiologists was safe Exceptions Sedated patients Trauma patients Critically ill patients transported from ICUs Out of town patients HRCT exams

47 Data Transparency Gathered data over 6 months after change 14% 6106 total CT exams 22 total repeats (0.4%) 18% 68% Tech Rad Tech + Rad

48 Systemize Change

49 Results Expanded scope MRI Other sections

50 Project 4 Decreasing variability in turn-around time for radiography studies from the ED

51 Background Complaints from ED regarding radiology turnaround time (TAT) starting Spring, 2011 Made Radiology look at TAT In August 2011, mean TAT for ED radiographs was 23.8 minutes Problem was variability

52 Resistance Already world class Safety Shoot the messenger

53 Methods to Encourage Change Create awareness Set clear goals Share data Benchmarking Dashboard

54 Create Awareness Faculty meeting

55 Create Awareness Faculty meeting Describe rationale

56 Create Awareness Faculty meeting Describe rationale Share data

57 Set Clear Goals To increase the percentage of ED radiographs with a TAT of < 35 minutes from 82% to >90%

58 Share Data/Benchmarking Daily TAT report Daily TAT graph

59 Share Data/Benchmarking Daily TAT report Daily TAT graph n=49; mean 6.8; Median 6; 100% < 35 min

60 Data Transparency

61 Dashboard

62 Data Transparency Results 7/1-9/19 (Baseline) Mean TAT = 23.8 min Median TAT = 15 min % < 35 min = /17 1/13 (After) Mean TAT = 14.6 min Median TAT = 10 min % <35 min = 92.9

63 Conclusions Multiple methods to lead change Multiple methods needed for each project Combination unique to specific project

64 Conclusions Multiple methods to lead change Multiple methods needed for each project Combination unique to specific project

65 Thank facebook.com/cincykidsrad