Pitfalls: Question and Discussion (4)

Challenges in Private Practice and Academia

We were talking at lunch today that the relatively few people that I know who have been leaders in private practice, who have tried to spend a lot of time doing peer review and introducing other sorts of management issues that you've talked about in their private practices, have often met pushback from their colleagues saying, Hey, look, we're getting paid to read films. If you're, every hour you spend doing that is an hour, you're not spending reading films and there's pushback in academics as well.

I agree with you. I think that you have to have that vision and determination from on high to make this happen. It's a very difficult thing, I believe for a lot. If you've got 50 people in your practice, you're not gonna have 50 people who are expert on setting benchmarks and so forth. I think you need a real champion of this in your department with some staff that know how to get things done. Somebody says, Hey, I've got an idea for improving our throughput or efficiency or whatever, an ultrasound, but I don't know how to do these quality control projects. I think there needs to be sort of a standing team that can help them do that.

I wonder about your thoughts on that.

The Cost of Quality Teams and Organizational Leadership

I totally agree, but the problem of course is it costs money to have these teams and personnel and it all gets back in a way to leadership. How are you gonna run your organization? It's easy for me to say this 'cause we're a large organization and we do relatively well, but we have a quality management group. I think there's five or six of them for our department. And again, it's easy for me to say that 'cause we're a big organization, but we pay for it. It does cost us money.

And I would propose that if you work appropriately in a smaller organization, with whether it's private practice or otherwise, you make the case to your hospital administration, look, maybe we will go participate in the funding of some of this, but it's absolutely critical for us to do our job properly. We need what Mike has referred to because you are absolutely right. We can't do it ourselves. Not because necessarily we're just stuck reading cts all day. But that's because what we're good at, and ideally we should be, that's what we should be doing, but at least backfill the gap, if you will, with personnel who know what they're doing.

And too often that's neglected, both by the administrations by the way, and by radiology department. I think we need to recognize that and make the case to the administration to do that. But ultimately, I think it, we, I don't know how we go to bed at night, frankly, having read 78 cts, 14 MRIs and all the rest of it, and know that we're not doing any form of consistent peer review. I'm not saying I know what you should do in your organization, how to do it, et cetera, but you've gotta start asking the questions, how can we get there? And going back to administration, to your leadership to say, now's the time we have to have the personnel and maybe, maybe we do make a little less money. We've done pretty well, still doing very well, thank you. Despite the cuts, et cetera. It's the right thing to do.

Examples from University of Pittsburgh Medical Center (UPMC)

I can tell you two different approaches. The last two places I've worked, university of Pittsburgh Medical Center, which is a huge organization, and they, the lead was actually taken by the hospital and they have a large committee of people, physician leadership, but mostly non-physicians. There are nurses and others in there, and they are the ones who drive this. And I really liked the way that happened there, where again, every department was charged with regularly coming up with quality assurance projects. And you'd say, I've got an idea for something I think would be useful to do in my area, CT or Mr. Whatever. And then you'd talk to them, they'd say, okay, here's how you go about doing this sort of a study. But they had the resources to help you and there was a steady stream of really impactful quality improvement programs that came out every month. Yeah. At the University of Pittsburgh Medical Center.

Hand Washing Initiative at MGH

We had a similar thing at MGH in that they had a major drive. We got dinged big time by joint commission over hand washing of all things. It was out in the Boston, maybe made the New York Times and it was certainly the Boston Globe. Yep. So it's been known since about 1857 or something that if we wash our hands, that it actually might make a difference in terms of patient outcomes. Yet we did an appalling job, not just in radiology, but the whole hospital. It took about two years of a major initiative to get us to the point where we've got the Cal stats going around, so you just walk down the hallway and you just go ding. And it becomes part of what you do, which is a sort of a segue into the fact that this doesn't happen overnight, this history of this culture of safety in your organization.

Building a Culture of Safety

It's only through someone at the top, ideally in the hospital organization, setting that as the major agenda. And then time and time and time and time again reinforcing it such that it becomes part of your culture so that when they add the next quality initiative, you don't go, oh my God, I can't deal with this. It you actually expect it because it's part of the culture of safety. And so it's not like I'm looking forward to the next one. And part of the problem, of course, is some of these safety issues are kind of border on a little bit of banal or something. But if you get it as a well working machine, you can suggest them.

Feeding Tube Quality Improvement at UPMC

For instance, I'll give you a process. I had a hand in starting at UPMC, it really bothered me that on a regular basis, maybe half a dozen times a year, we would see a feeding tube inserted into the bronchus out in the lung with real measurable morbidity and mortality. I brought it to their attention, said, this is a big problem. Oh, that's not really a big problem. Yeah, it's a big problem. We went from, I don't remember the data right now. We've actually published it. There, it's a, there's an inescapable small number of cases where it's gonna go down into the bronchus, but you can prevent it from ever going out into the lung by doing a immediate film of the chest. I'll spare you the details, but we went from significant problem with measurable morbidity and mortality to 0% incidents of feeding tube induced pneumothorax and lung injury with this one quality assurance program.

Quality Control Recruitment at Stanford

We are recently at Stanford, we're suffering the same cutbacks in money and so forth. And as everyone else. And our chairman at the urging of several of us senior guys recently recruited an associate chair level person strictly for quality control processes. And you probably know him, David Larson. He's a terrific guy. See, that takes leadership, right? Yeah. Your leader saw that and hired them. Yep. But I mean, we are going to, I am sure we are going to have dozens of projects ongoing on a monthly basis with buy-in from the residents, the faculty, physicians and so forth.

And I fully realize that most of you are not in an academic practice, but at a level appropriate to your practices. We really must do these kinds of things at the risk of sounding preachy. And I do think there is gonna be a financial impetus for this, that you're gonna have to show to the third party payers that you have these mechanisms in place, or they're gonna say, we're gonna send patients elsewhere.

Audience Questions and Comments

Questions, comments from the audience. It's tough. I think we need some practical guidelines, workshops and so forth that things like the rs NA and so forth. Okay, finally, you've convinced me I don't really want to do it, but what do I do? Okay, now I realize it's important. Now how do we actually get this going? And I think that's really where we at Stanford said, you know what? We all know it's important. We finally have to bite the bullet, take the financial hit, bring somebody on board that actually knows how to do this, is enthusiastic about doing it, gonna be our champion, and lead us in this endeavor.