“Making Quality the
Differentiator in a Flat World”, © Tor Valenza, Imaging Economics,
February, 2007
In a flat world where a radiologist in Bombay can
interpret an x-ray from Buffalo for cents on the
dollar, Stephen Swensen, MD, is distinguishing the
Mayo Clinic’s radiology department with proven
quality and accountability.
So maybe a patient
waits 20 or 30 minutes for imaging an elbow. Perhaps there is a slight
variation in protocols for an MRI within a group practice. And, OK,
radiologists do make mistakes when reading an x-ray now and then;
radiologists are human, too. So is improving quality in radiology really
such a big deal? Stephen Swensen, MD, past chairman of radiology at the
Mayo Clinic, Rochester, Minn, and its current director for quality,
believes that quality in radiology is important not only to patients, but
also to the future of radiology in North America.
"Radiology as a commodity will crash and burn in this flat world,"
Swensen says. "Right now, for cents on a dollar, you can have images
interpreted in other parts of the planet using teleradiology. Unless we
can differentiate our product by quality—meaning quality as a combination
of outcomes, safety, and service—then why wouldn’t someone send their
images to Bangalore, India, for that dramatic savings in a commodity
market? We have to be able to not just say that we’re better; we have to
be able to prove it."
To avoid having radiology interpretations become an international
commodity, Swensen believes that radiology must significantly distinguish
itself through measurable benchmarks that are achieved through systems
engineering and science. Doing so will demonstrate that on-site radiology
services are so reliable, efficient, and convenient as to be almost
incomparable. In effect, Swensen’s theory is that if consumers are given
the choice between the Yugo of radiology with a questionable reputation,
and the Toyota of radiology with a stellar one, they will pay a markedly
higher price for the one that is verified as being accurate, safe,
convenient, and cost-efficient.
Forget the Moral
Imperative
Although the Institute of Medicine’s landmark
report, "To Err Is Human," published in 2000,
addresses the ethics and cost savings of quality
care in medicine, Swensen’s focus is on the business
case for quality—which is inevitably beneficial to
patients, as well.
In his presentation at the 2006 Annual Meeting of the Radiological
Society of North America (RSNA) entitled "The Business Case for
Quality," Swensen described radiology as a $100 billion industry that
is subject to the same quality control goals as other industries. He went
on to acknowledge that there is absolutely a moral imperative for better
quality in radiology; then he asked his audience to forget about it.
"Assume that 300 American and North American patients die in a plane
crash every day from medical errors," he said. "Forget about the 3,000
American patients on a cruise ship who are harmed by medical errors every
day. Let’s assume that we’re not concerned about it, or that there’s
variation in care in North America, or that 40% of what we do is wasteful
because of overutilization or mis-utilization. Let’s just talk about the
business case for quality and not the moral imperative."
For Swensen, the goals for quality in radiology should be based on
essentially the same principles that large manufacturers have been using
for decades—namely, reducing needless variation, waste, and defects.
"The 3Ms, GEs, and Toyotas of the world have [quality control] as a
business strategy, knowing that if you drive out waste, variation, and
defects, you save money," he says. "Well, medicine and radiology must do
it for patients because it’s the right thing for patients, and because we
find more cancers, we have fewer complications from strokes, infections,
and so on. But, by the way, if you do it with the right approach with
systems engineering, you’ll also save money and have a better bottom
line."
Why Quality Now?
Three Reasons
Few medical professionals would state that
quality care has not always been a goal in their
practices. However, Swensen says that now, more than
ever, there are three basic reasons why radiologists
must go further and accurately measure their level
of quality with science and systems engineering.
The first reason is the aforementioned threat of having radiology
become a one-size-fits-all product, thanks to the Internet and
international teleradiology. But Swensen also notes that this radiology
commoditization threat also comes from the radiologist across the United
States and even across town. "If you have two or three hospitals in a
city, you should be able to show that your results are better or why
someone should come there. Otherwise, we become a commodity, and people
will just go to the lowest price."
Swensen’s second reason why measuring and improving quality is
important today is the impending Medicare pay-for-performance (P4P)
initiatives that will become part of everyday medicine. The Deficit
Reduction Act of 2005 kept most Medicare reimbursements stable for
physicians until 2008, but only in exchange for voluntarily complying with
new P4P reporting measures. Consequently, P4P is a looming reality, and
Swensen believes that if radiologists do not create their own
evidence-based standards and measures for quality and outcomes, then the
government will do it for them.
Third, and perhaps most important, Swensen says that
taking responsibility for quality is part of the professionalism of being
a physician. "We’ve always said that quality was important, and genuinely
and sincerely, physicians thought that to be true," he says. "But as a
profession, we haven’t taken that to the level where we measure quality,
safety, service, and outcomes of most everything we do, and then making
those results transparent to whoever’s paying for it and to the patients."
So What’s Wrong with Radiology?
Swensen first became interested in quality in
radiology while studying for his master of medical management degree at
Carnegie Mellon University’s Heinz School of Public Policy and Management,
Pittsburgh. However, he credits his radiology colleague at the Mayo
Clinic, C. Daniel Johnson, MD, for bringing the program to Mayo, believing
that the clinic could not rest on its reputation and that it needed to be
the best it could be.
Together, Johnson and Swensen developed a
systems-based quality control program at Mayo. In an article they wrote
for the Journal of the American College of Radiology, Johnson and Swensen
outline where and when there are opportunities for improvement in
radiology.1
Johnson and Swensen’s radiology value map pinpoints
nine areas in radiology care that can be measured and improved, from the
referral (where referring physicians may prescribe an inappropriate
examination), to procedure protocols (where each radiologist within a
practice may have varying protocols for the same procedure), to
interpretation (where there are many opportunities for correcting errors).
(See Table 1 below.)
Within those nine areas, Johnson and Swensen outline
many opportunities for improvements leading to more efficient, safer
radiology care, including:
-
the appropriateness of an examination ordered by the
referring physician;
-
performing evidenced-based radiology;
-
overutilization and underutilization of procedures;
-
timely access to procedures based on urgency;
-
waiting room times;
-
procedure protocols that are standardized based on
evidence-based best practices;
-
patient safety during the examination (infections,
falls, mislabeled exams, contrast-induced nephropathy, wrong
procedure/site/side/patient, improper radiation doses);
-
better peer review and avoiding conflicts of
interest;
-
decreasing the number of radiologic errors caused by
poor perception, poor interpretation, lack of knowledge, or
miscommunication;
-
distributing prompt finalized reports to referring
physicians;
-
poor postprocedure communication with referring
physicians; and
-
lack of measured outcomes and transparency (to
payors and to the public).
Variation: The
Slippery Slope
Issues, such as wait times and variation in
protocols, might seem unimportant compared to errors in interpretation,
but Swensen believes variation becomes a slippery slope. In particular,
Swensen mentions technologists having to look up each radiologist’s
preference for protocols and radiologic dyes for the same procedure, which
can be confusing, be time-consuming, and lead to mistakes. "Variation is
an environment that predisposes you to defects, mistakes, and
inefficiency," he says. "So, it costs more that way."
Swensen believes that the short answer to variation
is picking evidence-based best practices and having set standards of care
that are based on clinical prediction rules.
As to who will ultimately choose the best practices,
Swensen admits that payors who dictate P4P requirements may have the last
word. But, he adds, "Individuals can start in their own practices, saying
that if we’re going to be looking at, for example, diffuse lung disease
with high-resolution CT, let’s pick a single protocol so that all of us do
it the same way. Then, when a patient comes back, we can compare the same
protocol exam to the one done 6 months ago, or 6 years ago, which is
better patient care."
Some may be concerned that having set standards will
restrict radiologists’ personal judgments and expose them to malpractice
suits, but Swensen thinks it might actually do the opposite.
"That’s the beauty of these clinical prediction
rules or having standards of care," Swensen says. "If you follow what’s
considered to be the best care, then you have an opportunity to say, ‘I
did not image this patient with CT because all the publications that lead
to this clinical prediction rule, which is the highest level of evidence
for appropriate use of imaging, say that this is the best way of doing it
if the patient has these clinical signs and symptoms.’ So, it’s actually a
help for that liability."
Swensen also notes that once these standards and
best practices are implemented, then innovation may be slowly tested
against the outcomes of the current standards.
Other Solutions
Other solutions for quality are simpler, but must
have a system in place for compliance. For example, technologists and
radiologists can reduce the risk of nosocomial infection by simply washing
their hands between examinations.
To reduce perception and interpretation errors,
Swensen and Johnson cite several studies where second readings,
computer-aided detection, and dual interpretations with specially trained
radiographers have reduced error rates—and also may be cost-efficient.2–6
Addressing overutilization, Swensen supports
radiologists and referring physicians consulting the American College of
Radiology’s Appropriateness Criteria, which suggest the appropriate
radiology procedures for a variety of imaging and treatment decisions. In
the future, if they were one day electronically linked into electronic
medical records and an office’s electronic examination-ordering tools,
they also could improve efficiency and reduce overutilization.
Swensen also says that radiologists should
"maximize" communications with referring physicians in order to decrease
postprocedure communication errors. Doing so may help reduce liability for
malpractice.
"When you look at the top four causes for
malpractice in radiology, one of them is failure to communicate results
clearly and effectively," he explains. "So, even if we find the cancer or
the pneumonia or the pneumothorax, and we don’t communicate that via our
report—or for urgent findings, via a phone call or page—to the ordering
health care provider, we have fallen short of our commitment to patients.
And we consistently fall short of that, and that’s one reason why [poor
communication] is one of the top malpractice causes."
To maximize the communication, Swensen recommends
that radiologists submit structured reports and establish a follow-up
mechanism that documents that the communication was made to the
appropriate provider in a timely fashion.
Consumers with X-Ray Vision
The last step in Swensen and Johnson’s radiology
value map is measuring outcomes. The metrics include patient satisfaction,
morbidity, mortality, and quality of life.
Having those postprocedure facts and figures may be
a useful tool for a radiology practice, but Swensen thinks this
information should be available to the public as well. Will that mean that
a patient can go to the Internet before a procedure and see how accurate a
particular radiologist or hospital has been for mammography or any other
procedure?
Swensen says yes. "When a woman is in a position to
make a choice about the three screening centers in her metropolitan area,
shouldn’t she know the accuracy rates of the three centers? Today, you
don’t have a clue," he says. "You probably can’t even tell how much the
places charge—but, more importantly, how much they charge is how good they
are. Why don’t we make that accurate or transparent?"
Furthermore, Swensen says that measuring outcomes
for particular procedures will allow payors to be aware of radiologists
who are performing poorly in a particular area. "Just because radiologists
are board certified doesn’t mean they have the same level of accuracy in
interpreting an exam," he notes. "In mammography screening, the current
median accuracy in the literature is 66%.7 If we want that median accuracy
in the United States to be 71%, we’d have to take the bottom 6,000
radiologists, which is about one third of the practitioners, and say, ‘You
have to improve your results, or you won’t be allowed to interpret
mammography and get reimbursed for it.’"
The Way to Quality: Systems
Engineering
Swensen does not believe that simply admitting
mistakes and promising to work harder can achieve improvements in quality.
Instead, solutions should be implemented with a scientific,
systems-engineering approach with many of the same quality control
theories used by manufacturing industries.
Mayo initially developed its quality management
program by working with The Baldrige Foundation. Later, Johnson and
Swensen developed another approach based on a combination of Lean, Six
Sigma, and the quality management principles of W. Edwards Deming. Swensen
also mentions being influenced by W. Chan Kim and Renée Mauborgne’s book,
Blue Ocean Strategy.8
Johnson and Swensen eventually used their knowledge
to develop Mayo’s value management software, a quality management program
that helps identify problems by tracking seminal events and specific
relevant measures. "You can measure everything from image labeling to
nephropathy to hand-washing compliance and compliance with appropriateness
criteria," Swensen says.
No matter what protocol is put into service, Swensen
says that the key to any value management tool is to use some sort of
consistent, process-based systems approach.
In terms of quality management manpower, Mayo
employs a core group of six individuals who exclusively manage quality
control for radiology. Other hospital departments have their own teams.
Although having a quality control team might be more
feasible to a large and well-funded facility like Mayo, Swensen says that
all practices should implement some system with costs that are
proportional to the size of the group.
Administrators should expect to employ or consult
with people who have expertise in systems engineering. Although the
initial capital for the program may be expensive, Swensen is confident
that the proper implementation of quality controls will have a return on
investment in the long run.
"If it is done right, and the department owns the
spectrum of activity—from technical activity and scanners to
radiologists—instead of just taking a piece of it, this is a business
strategy for increasing efficiency and saving money. Because as you have
less variation, less waste, and fewer defects, your malpractice rates will
go down, and your efficiency will go up. So, if you use a systems
approach, driving out waste, variation, and defects, and you are in charge
of the whole radiology enterprise, it is absolutely a cost-saving
environment."
P4P? Not at Mayo. P4P may have the final say on
whether a radiologist is typically rewarded or penalized for performance.
As for Mayo, Swensen says that the clinic currently does not reward
physicians for quality improvements. "All of Mayo Clinic’s staff is
salaried—unique in medicine today," he notes. "There are no financial
incentives for anything from productivity to academic rank. Socialism
works very well and is absolutely the most patient-centered model."
