Video Transcript: A Good First Step to Any Improvement Project

Don Goldmann, MD, Chief Medical and Scientific Officer, Institute for Healthcare Improvement

I remember very well my first days as medical director of quality improvement at my hospital and I was certainly wet behind the ears and green as can be and I read a few books and I went to a course Don Berwick taught and it was all good, I was ready to go. And I went out to talk to my friends and colleagues in the hospital about how we were going to together improve care of their patients and I went to the radiology department and there was a crusty senior radiologist there who is the best radiologist I know. You give him a chest x-ray and he will teach you like you’ve never been taught before and you’ll go away understanding what that patient really has. So I went in to the office and we are sitting there and there he is sitting across from me and I’m figuring this is going to be a great conversation. I said “so I’m the medical director of quality improvement and I’m here to help you…” and he interrupts me and uses words, which on camera I can’t use these words actually, but they were 4 letter words and he basically says that quality improvement was a bunch of ___ and I was wasting his blah blah blah time. And I’m sitting there saying “wow, you really have feelings about this” and I won’t use the actual language I used with him but I said “since we are talking this way, what really, when you get up in the morning and come to this hospital and you walk in this door, what ticks you off?” And he said “what really blah blah blah ticks me off is the emergency room. The ER sends me children with head trauma for a CT scan of the head and I get one line on the requisition that says CT of the head, trauma. He said you know I am a clinical person. I went to medical school, I was trained. I am capable of not just technically reading a scan, but I know something about medicine and in fact I will read the scan better if I know something about the patient.” I said “oh, that’s a reasonable request, right. He wants more information.”

My next visit coincidentally was to the ER and there was a colleague, a friend somebody I like and trust. Almost the same reaction. He didn’t use quite the same level of language that id experienced in radiology but basically I said what ticks you off and he said “it’s the radiology department. We have kids here, they are screaming and crying, the mother’s anxious and they need a CT of the head and we get all these questions and delays. Why can’t we just get our CT done and read?” I said “oh, this sounds like there’s a quality improvement problem here around communication in process.” So with the help of a volunteer who was a visiting scholar and the people from both departments, we devised a new system where the requisition for a CT scan had all the criteria in a checklist. This is before the checklist you’ve all read about, and Peter Pronovost’s checklist, I mean its obvious checklists are useful. The checklist was for all the criteria for a head CT in a child. And if you check these off and it didn’t meet the criteria, then you are wasting your time getting a CT and the CT reader will then be able to look at the checklist and say “well this looks like a really high risk case” or “no this is kind of iffy but I can see why they did it” and they get the clinical information they need.

We ended up writing this up and it wasn’t in a high profile journal, but it was an interdepartmental, interdisciplinary paper, got published, everybody was happy and the checklist made care better. That’s really important and I think there are some real lessons there. Where are the pain points? Get people to express them and then immediately go out and help them find the solution instead of putting it in a desk drawer someplace and saying that’s another complaint from that department, they always complain.