An Urgent Case for Quality
Gary Becker, MD, outgoing president of the RSNA, read members the equivalent of the riot act in his presidential address on November 29 in Chicago, Illinois, kicking off the 2009 meeting and jump-starting the quality-improvement movement in radiology. Gary Becker “One of the most vital priorities for our profession is the adoption of a new focus on quality improvement,” Becker says. He cites demands for individual physician transparency from patients and families, insurers, employers, hospitals, quality groups, accrediting organizations, regulators, and government. “Identifying quality and our commitment to it will be a key factor in determining our future. Fundamental to this vital priority is a habit many of us don’t yet have: the habit of measurement,” he says. Three significant hurdles currently stand in the way of meeting the quality challenge for radiologists, Becker says: ignorance of quality-improvement principles, preconceived notions and attitudes, and the lack of a culture of improvement. Radiologists have precious little time in which to embrace quality improvement, as Becker believes that the quality hourglass is running out of sand. It’s been 10 years since the Institute of Medicine1 reported that as many as 100,000 patients die each year in US hospitals from preventable medical errors, and the Joint Commission documented more than 5,600 sentinel events in 2008. Becker also cites a RAND Corp study2 that found only half of the health care delivered in the United States meets evidence-based quality standards. As the population ages and the government assumes a growing share of the national health expenditure, it will also have greater voice in all aspects of delivery, Becker says. Even if Congress doesn’t pass a reform bill with a new public option, more than 50% of our national health expenditure will be publicly funded by 2014. “Ponder, for just a moment, what will happen in a predominantly publicly funded system: If we radiologists and all physicians wish to avoid ceding all medical regulation to government and other external stakeholders, we must earn the public’s trust,” he warns. The Ultimatum If radiologists wish to maintain a portion of their privilege to self-regulate, they will have to deliver high-quality, affordable care; engage in physician assessment and improvement; and demonstrate their competence through public reporting, Becker says. While the Physician Consortium for Performance Improvement, the National Committee for Quality Assurance, CMS, and the Joint Commission are currently measuring and assessing care delivery, other (less rigorous) outfits such as HealthGrades and Angie’s List stand in the wings. “When price is the differentiator, quality fades from view, and we must not let that happen,” Becker says “As stewards of the profession, we must not permit radiology to succumb to commoditization. Instead, we must safeguard professionalism, develop our quality focus, and take control of radiology’s destiny by delivering value.” In health care, quality improvement depends on making measurement an integral part of the work routine. Becker cites a RadioGraphics paper3 published in 2009 that distilled radiology’s quality-improvement goals into four objectives: safety, process improvement, professional performance assessment and improvement, and satisfaction. Physicians, in general, are likely to be surprised by the results of performance assessment, Becker says. “We physicians tend to have very little insight into how well (or more correctly, how poorly) we are actually doing in practice,” he says. He shared the example of the American Board of Internal Medicine’s experience in launching its practice improvement modules (PIMs). As part of its maintenance and certification program, practicing internists were, for the first time, required to evaluate their compliance with established practice guidelines by reviewing the charts of 25 of their patients with a given condition, such as diabetes, asthma, or hypertension. Before completing the PIMs, physicians commonly complained that they were already doing this well, or that their patients with diabetes were doing just fine, “but after the baseline measurements, many internists were astonished in the gaps they discovered in their own practices,” Becker says. “What they had not previously measured, they could not have known. Following implementation of improvement measures and completion of PIMs, 73% said they had changed their practice and 82% said they would recommend the PIM to a colleague.” The two biggest barriers to radiologist participation in quality-improvement initiatives are lack of knowledge and preconceived notions and attitudes. Add to those barriers erroneous beliefs or perceptions about personal-practice quality, such as the statement, “my patients are doing just fine”; concerns that these efforts will take extra time and add another unfunded practice expense; and the fear of reprisals for mistakes, and it is no wonder that physicians have not embraced quality improvement. “In a culture of blame, every adverse event has a responsible person,” Becker says. “In a culture of improvement, we work to make the system better.” It is Becker’s contention that a decisive commitment to a culture of quality improvement is not only a good idea; it is imperative: “The nation has awakened to medical error; it has grown intolerant of waste, weary of fragmented health-care delivery, and impatient with a system that not only doesn’t serve it well, but often seems designed to serve the providers,” he says.