| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Perspective |
Department of Radiology, Indiana University, 702 N Barnhill Dr., Rm. 1053, Indianapolis, IN 46202.
Received September 30, 2004; accepted after revision November 23, 2004.
Address correspondence to R. B. Gunderman
(rbgunder{at}iupui.edu).
OBJECTIVE. Radiologists often regard risk management as a burden or even a threat. This article examines some of the most important reasons every radiologist should regard managing risk as an opportunity.
CONCLUSION. There are short-term risks and costs to a program of risk management, but they are far less than the long-range costs of inaction. More importantly, managing risk well is an opportunity to excel as a physician and leader.
Risk management is one of those subjects with which every radiologist needs to be familiar, yet to which relatively few radiologists have ever devoted much attention. It is not a topic covered in most medical school or residency curricula, and few continuing medical education courses include it in their programs. When risk management does receive attention, it is often in response to a medicolegal issue: Either a radiologist has been named in a lawsuit or a malpractice insurer has attempted to prevent future losses by requiring that radiologists undergo risk management training. In fact, however, risk management is about much more than merely avoiding or successfully defending lawsuits [1]. Properly understood, risk management addresses the very core of what it means to be a physician and a radiologist. Those who understand its principles enjoy a substantial advantage in providing high-quality service to patients and referring physicians.
One commercial risk management company suggests that every organization needs to understand the role risk management plays in our day-to-day work [2]:
Risk in itself is not bad; risk is essential to progress, and failure is often a key part of learning. But we must learn to balance the possible negative consequences of risk against the potential benefits of its associated opportunity.
Definitions
There are a number of dangerous misconceptions about risk management. Here are some examples: What patients and families don't know won't hurt them. Physicians, technologists, and nurses don't care about risk management. We are fully insured, so we need not worry about risk management. If you haven't been sued, your risk management program must be fine. Serious adverse outcomes are so infrequent that we can safely ignore them. Patients and families are incapable of understanding risks. Telling people about risks only increases the probability of adverse outcomes. Communicating with patients about risk is not my job.
Such misconceptions may be more widely distributed among the staffs of radiology departments than many radiologists suppose, and it is vital that education efforts address them head on. The Accreditation Council for Graduate Medical Education (ACGME) now includes such system issues as part of the six core competencies that all residents in medicine must study [3]. The following brief discussion of risk management in radiology is intended to dispel these misconceptions.
To understand risk management, it is first necessary to understand risk [4]. The dictionary states that risk is the possibility of suffering loss (or a negative outcome) [5]. Risk management provides us with processes, methods, and tools for managing risks in our health care system. It provides a disciplined environment for proactive decision making to assess continuously what can go wrong (anticipate risks), determine what risks are important to deal with, and implement strategies to deal with those risks.
CT and MRI Examinations as Examples of Risk
To manage risk in radiology, we first need to identify the errors and adverse outcomes that can occur [6]. What are some of the more important risks faced by a radiology department and the patients for whom it cares? Let us consider what can go wrong for patients undergoing CT and MRI examinations. The most obvious risks concern bodily harm. Immediate adverse outcomes include death, bleeding, infection, adverse reactions to contrast material, displacement of ferromagnetic objects such as metal in the eye, pain, and so on. Other adverse outcomes may be detected only years or decades later, such as radiation-induced malignancies or cataracts.
Yet this is not a complete list. Other adverse outcomes that radiology departments cannot afford to ignore involve patient dissatisfaction and include long waiting times, patient anxiety, difficulty scheduling examinations, and staff behavior that offends patients. Clerical errors can cause the wrong examination to be performed or the wrong patient to be examined and the results of an examination can be lost, sent to the wrong patient or referring physician, or arrive too late to be used in clinical care. Another class of adverse outcomes is more strictly radiologic, including interpretive errors such as failures to detect a lesion, to consider the appropriate diagnosis, and to make the appropriate management recommendations [7].
Risk management involves anticipating such adverse outcomes and taking steps to prevent or ameliorate them. It is an extension of the Hippocratics' prime directive of medicine: "First do no harm" [8]. It is not the same thing as insurance. Insurance assumes risk, attempts to pool risk, and compensates those who suffer losses. Risk management focuses on reducing the risk up-front. This requires not only identifying and assessing risks, but also making trade-offs between the benefits and costs of risk reduction. In some cases, it may make more sense to live with a risk than try to reduce it. For example, each of us is at risk for being struck by a meteor, but few of us would modify our daily lives to reduce it.
Most of our decisions are characterized by uncertainty, and risk management is an effort to improve the quality of our decision making under that condition. Some risks can be reduced unilaterally by the radiology department, but others require the participation of health care providers, patients, and families. For example, radiologists can unilaterally reduce the dose of ionizing radiation their CT scanners deliver to patients, but they cannot premedicate patients against adverse reactions to contrast material without their cooperation.
The assessment of risk is not purely a matter of measurement in the way that physicists can simply measure radiation dose. Science alone does not know the whole story. Our assessments of risk are inevitably shaped by our past experiences, culture, and general world-view. A radiologist who only yesterday saw a patient go into cardiorespiratory arrest after the administration of IV contrast material is likely to assess its risks differently as a result. Being partially disrobed for an imaging procedure may mean something different to a Muslim woman than to a Scandinavian woman. Patients for whom death is the greatest fear may regard informed consent differently from those who place greatest store by the preservation of their personal dignity.
Physicians, like most people, are poor estimators of risk. Take for example our understanding of the risks of CT examinations for children. We are well educated about and expend considerable resources to avoid the risk of severe contrast reactions from iodinated contrast CT examinations. This risk in children is less than in adults; in fact, the risk of a severe allergic reaction from low-osmolar IV contrast material is estimated at less than 1 in 100,000 children. In contrast, the risk of fatal cancer induction from one (adult dose) abdominal CT scan has been estimated to be as high as 1 in 1,000 children [9]. When we understand the greater potential risk of cancer induction, we can implement risk management policies to reduce the radiation dose to which children are exposed.
These aspects of risk have an important bearing on the risks from which we automatically protect patients and those we believe patients should be at liberty to assume. There is an art and a science to determining the appropriate degree of precaution. One important implication is that patients and families should generally have a voice in the design and implementation of risk management programs that affect them or others like them.
Shared Decision Making
Patients and families should be involved in risk management for a number of reasons. First, as the doctrine of informed consent indicates, patients have a moral right to participate in decisions about the benefits they will pursue and risks they will take. Pretending that patients are not up to this task is patronizing. Moreover, without the input of patients and families, we do not really understand the nature of the risks or what such adverse outcomes would mean in the context of their lives. It is well known, for example, that adverse outcomes tend to look worse to those who are unaffected by them than those who live with them.
Blind people tend to appraise the loss of sight in less catastrophic terms than sighted people. On the other hand, people who have undergone placement of a nasogastric tube tend to rate the experience as more unpleasant than people who have only placed them on others. In addition, getting patients and families involved in these discussions helps to foster trust by showing that radiology department staff take their point of view seriously [10]. Finally, it is entirely possible, and perhaps even probable, that getting patients involved can help us make better decisions and learn to provide better care.
Radiologists should be aware that a number of factors tend to shape risk tolerance, including our innate personalities, our life experiences, and the culture in which we are raised [11]. Generally speaking, risks that are voluntarily assumed are more tolerable than those that are imposed. Risks that are under the control of the patient are more tolerable than those that are under the control of others. Risks with clear benefits are better tolerated than those without. Fairly distributed risks are more tolerable than those that are unfairly distributed. Risks generated by a trusted source are better tolerated than those generated by an unknown or untrusted source. Risks that subjects are familiar with are more tolerable than unfamiliar risks. Finally, risks that affect adults are more tolerable than those that affect children. Bearing these factors in mind can help radiology department staff develop more patient-friendly and effective approaches to risk management.
Patients are concerned about a number of risks beyond objective ones such as pain, injury, and death. Although subjective, they are no less important. For example, patients want to know the possible effects of a procedure on their functional status, such as their ability to work, to perform activities of daily living, and to engage in favorite recreational activities. They may wonder how they might feel after this procedure and how long will it be before they will feel normal again. Another major concern is economics. The cost of a procedure is only part of the equation. Other important considerations in the minds of patients are indirect costs, such as lost income, child care expenses, and even the cost of travel and parking.
Patients are also concerned about fairness. Is the quality of care in this institution stratified by patients' ability to pay? Are some people getting better treatment than others simply because they are prominent figures in the community? Finally, physicians are not the only people concerned with the legalities of health care. Patients and families sometimes want and need to know the legal implications of their choices. For example, what are the implications of a decision to withdraw treatment on their inheritance rights?
Radiologists as Risk Managers
Risk management is not a subject radiologists can simply ignore based on the presumption that the risk managers are taking care of it. If risk management is to function effectively, radiologists need to be involved as well. What do we need to do? At least one radiologist in a group practice should be involved in the health system's risk management program. Obviously, we need to help control adverse outcomes that lead to financial losses to our departments, but there is much more.
If radiologists understand risk management well, we can use it as a tool to increase the satisfaction of referring physicians and health care payers and patients. We can improve clinical outcomes, enhance referrals, and generate more revenue. It is not necessary or even advisable to be the lowest-price provider because quality of care and patient satisfaction turn out to be important considerations when people choose a provider [12]. In the most enlightened practices, risk management plays an integral role in marketing by showing that we really care about our patients and referring physicians.
The ripple effects of our approach to risk management can extend far beyond our probability of being named in a lawsuit. The development and implementation of risk management programs can serve as important opportunities for team building. All the stake-holders involved in health care can be represented in the risk management team, including not only radiologists and administrators, but also physicians in other specialties, nurses, technologists, clerical staff, and even patients and families.
Instead of physicians imposing rules on the rest of the radiology department, everyone can be involved in anticipating risk, responding to adverse outcomes, and tracking the results of new risk management initiatives. Radiologists who adopt such approaches take advantage of their associates' knowledge about crucial aspects of patient care. Moreover, they reap the fruits of an improved esprit de corps throughout their department.
The Chinese character for crisis, Wei ji, is made up of two component characters. One is the character for danger, but the other is the character for opportunity. This spirit should exemplify our attitude toward risk management. Where many see only dangers they would prefer to avoid, we should strive to see opportunities to express our regard for our colleagues and the patients for whom we care.
References
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  D. I. Bulas, M. J. Goske, K. E. Applegate, and B. P. Wood Image Gently: Why We Should Talk to Parents About CT in Children Am. J. Roentgenol., May 1, 2009; 192(5): 1176 - 1178. [Full Text] [PDF]
|
|
|
|
|
|
D. B. Larson, S. B. Rader, H. P. Forman, and L. Z. Fenton Informing Parents About CT Radiation Exposure in Children: It's OK to Tell Them Am. J. Roentgenol., August 1, 2007; 189(2): 271 - 275. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
