The Turn-Around-Time Caucus Race
Is producing radiology reports more quickly a means to an end or an end itself?
"Turn-Around Time" by Julianna Czum (adapted from "Alice in Wonderland," with apologies to Lewis Carroll):
"What is the value of ever-faster turn-around time?" said a radiologist; not that she much wanted to know, but the accountant had paused as if he thought that somebody ought to speak, and no one else seemed inclined to say anything.
"Why," said the accountant, "the best way to explain it is to do it." (And, as you might like to try the thing yourself, some winter day, I will tell you how the accountant managed it.)
First he marked out a quality metric, in a sort of circle ("the exact shape doesn't matter," he said), and then all the party were placed at workstations, here and there.
There was no "One, two, three, and away!" but they began interpreting images as the studies appeared on their queues and stopped reading whenever there were none, so that it was not easy to know when measuring was over. However, when they had been interpreting images as quickly as possible for half an hour or so, and were quite unsure of the impact of their reads, the accountant suddenly called out, "The race is over!" The radiologists all crowded round him, panting and asking, "But is patient care improved?"
This question the accountant could not answer without a great deal of thought, and he stood for a long time with one finger pressed upon his forehead (the position in which you usually see Shakespeare, in the pictures of him), while the rest waited in silence.
At last the accountant said, "Everybody has won, and all must have performance bonuses."
In the caucus race scene in "Alice in Wonderland," Lewis Carroll critiques turn-of-the-century English politicians for accomplishing little while deflecting criticism with pandering giveaways. Alice finds the caucus race nonsensical but reluctantly participates. At the end of the race, everyone is rewarded for their efforts, like participation trophies being handed to children on sports teams. Reading this, I could only think of the deafening diagnostic imaging interpretation need-for-speed drumbeat, with radiologists having little choice but to read faster though not always knowing why and administrators pointing to success in meeting performance targets with kudos all around.
Faster, faster, faster! Faster imaging interpretation accomplishes the intended purpose of...well, faster image interpretation. If we meet our turn-around-time performance targets, have we achieved more than speed for speed's sake?
In this month's Radiology Firing Line podcast, recorded at RSNA 2015, regular contributor Saurabh (Harry) Jha, MBBS, moderates the discussion between his collaborator C. Matthew Hawkins, MD, and guest Seth Trueger, MD, MPH, an emergency department physician at the University of Chicago. The conversation centers on image interpretation speed, the impact of faster reporting, and the associated trade-offs.
No one disputes the need for timely image interpretation. But timely ("happening at the correct or most useful time") and fast are not synonymous. Some patients are sick enough that every minute matters. In these cases, image interpretation is truly a rate-limiting step to getting the patient the right care. But not every patient is in the emergency department or inpatient critical care unit.
Currently, nothing prevents a provider from ordering any study STAT. If STAT studies require a specific turn-around time but there is no hurdle to ordering any study STAT at any time for any reason, radiologists will have little choice but to read faster (when turn-around time is the only thing being measured), possibly resulting in more errors and omissions. By ordering studies STAT, the ordering providers improve patient throughput in their clinics, so their performance target is met.
The sad truth is that if a radiologist's performance target is effectively pitted against a clinician's performance target, there are likely other instances in which well-intentioned but simplistic or ill-conceived quality measures are in place, inadvertently putting other providers in a quasi-adversarial position, rather than creating an environment that supports and rewards collaboration. We are following Alice down the rabbit hole, competing in a caucus race run by accountants and administrators where everyone gets a prize for meeting performance targets, but nobody (including patients) actually wins.
Here is one recently-published idea to replace the simplistic turn-around-time metric with a more meaningful performance measure agreed upon by key stakeholders that better captures the timeliness of reporting, incorporates some measure of impact, and effectively promotes collaboration in a multidisciplinary team.