Enter Your Email Address to Receive a
Copy of MedicExhange Member Demograhpics

The ever-present issue of patient safety in radiology was given star billing earlier this month with a keynote presentation from Dr. William R. Brody, president of Johns Hopkins University. The ever-present issue of patient safety in radiology was given star billing earlier this month with a keynote presentation from Dr. William R. Brody, President of Johns Hopkins University in Baltimore, at the European Congress of Radiology.

Delivering the Wilhelm Conrad Röntgen – Honorary Lecture, entitled 'Healthcare and the Ford Model T: Unsafe at any speed. How to make hospitals safer places for patients' Brody drew on the lessons learned at Hopkins' Center for Innovation in Quality Patient Care, themselves based on quality systems used in the automotive industry:

"Improvements in safety represent the greatest opportunity to improve patient care. They also represent the best way to substantially lower healthcare costs," said Brody.

Adopting what amounts to a 'whole systems' approach Brody added that the generic root of the problem was "not an individual, but the 'system'. Our current attention is focused upon assigning blame rather than fixing the system that creates the problems".

Variability in the delivery of care leads to unavoidable systemic errors with medical errors causing between 44,000 and 98,000 deaths a year and an estimated $50bn in total costs, though because we don’t tally medical variability the costs are probably much greater, he said.

Drawing on the example of the automotive industry he made comparisons with the health care industry where health care is still based on a mass production mentality, where as per Henry Ford’s infamous dictum you can have "any color - so long as it’s black". In the old-style car industry teams worked with little communication among the silos, defects were inherently tolerated, and inspection was used to identify and select out defects. This was challenged in the 1980s with the Toyota Production System: with an intense focus on quality:

• 'Zero defect' mentality: no errors are acceptable.
• Everyone is responsible for quality.
• Each employee empowered to stop the assembly line when defects appear.
• Quality is ‘designed-in’ rather than ‘inspected out’.
• Silos are broken down & communication enhanced.
• ‘Bottom-up’ rather than ‘top-down’ process.

Brody’s made the point that the Toyota system is essentially very simple, involving setting the goal of zero defects, and simplifying processes (focusing on the steps in the process) to reduce variability & to achieve the desired goal. He added that a key part of this was a focus on team work which encouraged teamwork & communication.

He told the ECR audience that importing these lessons from Toyota at John Hopkins the aim was again to set an ambitious goal of zero errors in which everyone (from the housekeeping staff to the Board of Trustees) is responsible for patient safety. In the specific context of radiology Brody cited the work of Jonathan Lewin, M.D., Chair of Diagnostic Radiology who has identified several areas for improvement. One example is to reduce the cycle time for portable chest radiographs, in which teams are empowered to redesign processes, performance is measured monthly, resulting in reduced cycle time from average of three hours to 20 minutes!

But does Brody’s impressive approach really have all the answers? Doesn’t the messy reality of hospital mean that an industry-inspired approach, where the variables of manufacture are much easier to control, limit its validity in a clinical setting where in reality intuition plays a role alongside spreadsheets and pie-charts? And if so how can a system be designed to take account of that?

The ACE study (Information Appliances in Clinical Environments) in the UK (with a health system internationally ranked highly in terms of patient safety ¹) undertaken by City University however did find similar value in importing approaches in industry, in their case in the complexity involved in the design of shift handover systems, into the hospital setting:

"There is a larger body of work on handover in other industries. Patterson et al (2004) compare strategies in space shuttle mission control, nuclear power, ambulance and railroad dispatching. Grusenmeyer (1995) looks at paper mills. HSE (1996) compares shift handover in the chemical, nuclear, paper, and oil-refining industries as well as nursing. These papers suggest a number of successful strategies of potential benefit also to healthcare.

"For example, many other critical systems have a readily available and up-to-date representation of the state of the system. In contrast, the lack of such a representation on medical wards appears to be an impediment to effective handover." (http://hcid.soi.city.ac.uk/research/Ace.html)

Perhaps the growth in simple online tools such as wikis and blogs offers radiologists a fruitful source for designing safety systems which balances the need for precision with the necessary simplicity such software can deliver as a whole team/state of the ward system?

This would certainly fit in with the importance of a bottom-up approach, keeping the software simple so all are able to use it without too much technical know-how. It would also allow a greater degree of customization, dealing with the need for adaptation of such key patient safety systems to the working operation of individual wards, while allowing XML feeds to aggregate the data at a management level. Maybe it’s too early to say whether such 'web 2.0' approaches will make inroads into radiology patient safety, though with the recent launch of a wiki for radiologists based on wikipedia the climate is warming up to these possibilities.

Written by Stuart Hall

References
¹Commonwealth Fund. From a presentation by Dame Gill Morgan, chief executive of the UK NHS Confederation.