John-Paul J. Yu

The Radiologist's Workflow Environment: Evaluation of Disruptors and Potential Implications

Workflow interruptions in the health care delivery environment are a major contributor to medical errors and have been extensively studied within numerous hospital settings, including the nursing environment and the operating room, along with their effects on physician workflow. Less understood, though, is the role of interruptions in other highly specialized clinical domains and subspecialty services, such as diagnostic radiology. The workflow of the on-call radiologist, in particular, is especially susceptible to disruption by telephone calls and other modes of physician-to-physician communication. Herein, the authors describe their initial efforts to quantify the degree of interruption experienced by on-call radiologists and examine its potential implications in patient safety and overall clinical care.

Big Data and the Future of Radiology Informatics

Rapid growth in the amount of data that is electronically recorded as part of routine clinical operations has generated great interest in the use of Big Data methodologies to address clinical and research questions. These methods can efficiently analyze and deliver insights from high-volume, high-variety, and high-growth rate datasets generated across the continuum of care, thereby forgoing the time, cost, and effort of more focused and controlled hypothesis-driven research. By virtue of an existing robust information technology infrastructure and years of archived digital data, radiology departments are particularly well positioned to take advantage of emerging Big Data techniques. In this review, we describe four areas in which Big Data is poised to have an immediate impact on radiology practice, research, and operations. In addition, we provide an overview of the Big Data adoption cycle and describe how academic radiology departments can promote Big Data development.

Disruption of Radiologist Workflow

The effect of disruptions has been studied extensively in surgery and emergency medicine, and a number of solutions-such as preoperative checklists-have been implemented to enforce the integrity of critical safety-related workflows. Disruptions of the highly complex and cognitively demanding workflow of modern clinical radiology have only recently attracted attention as a potential safety hazard. In this article, we describe the variety of disruptions that arise in the reading room environment, review approaches that other specialties have taken to mitigate workflow disruption, and suggest possible solutions for workflow improvement in radiology.

Radiology Workflow Dynamics: How Workflow Patterns Impact Radiologist Perceptions of Workplace Satisfaction

RATIONALE AND OBJECTIVES The study aimed to assess perceptions of reading room workflow and the impact separating image-interpretive and nonimage-interpretive task workflows can have on radiologist perceptions of workplace disruptions, workload, and overall satisfaction. MATERIALS AND METHODS A 14-question survey instrument was developed to measure radiologist perceptions of workplace interruptions, satisfaction, and workload prior to and following implementation of separate image-interpretive and nonimage-interpretive reading room workflows. The results were collected over 2 weeks preceding the intervention and 2 weeks following the end of the intervention. The results were anonymized and analyzed using univariate analysis. RESULTS A total of 18 people responded to the preintervention survey: 6 neuroradiology fellows and 12 attending neuroradiologists. Fifteen people who were then present for the 1-month intervention period responded to the postintervention survey. Perceptions of workplace disruptions, image interpretation, quality of trainee education, ability to perform nonimage-interpretive tasks, and quality of consultations (P < 0.0001) all improved following the intervention. Mental effort and workload also improved across all assessment domains, as did satisfaction with quality of image interpretation and consultative work. CONCLUSION Implementation of parallel dedicated image-interpretive and nonimage-interpretive workflows may improve markers of radiologist perceptions of workplace satisfaction.

Isolated intracerebral light chain deposition disease: novel imaging and pathologic findings☆

Light chain deposition disease (LCDD) is a rare clinicopathologic entity first described in 1976 and is characterized by a monoclonal gammopathy resulting in nonamyloid immunoglobulin light chain tissue deposition. Only four cases of intracerebral LCDD have been previously reported, all in the setting of a known plasma cell dyscrasia or in the presence of local mature plasma cells. We present the first case of intracranial LCDD in the absence of a known plasma cell dyscrasia or local mature plasma cells.

Workflow Dynamics and the Imaging Value Chain: Quantifying the Effect of Designating a Nonimage-Interpretive Task Workflow

PURPOSE To assess the impact of separate non-image interpretive task and image-interpretive task workflows in an academic neuroradiology practice. MATERIALS AND METHODS A prospective, randomized, observational investigation of a centralized academic neuroradiology reading room was performed. The primary reading room fellow was observed over a one-month period using a time-and-motion methodology, recording frequency and duration of tasks performed. Tasks were categorized into separate image interpretive and non-image interpretive workflows. Post-intervention observation of the primary fellow was repeated following the implementation of a consult assistant responsible for non-image interpretive tasks. Pre- and post-intervention data were compared. RESULTS Following separation of image-interpretive and non-image interpretive workflows, time spent on image-interpretive tasks by the primary fellow increased from 53.8% to 73.2% while non-image interpretive tasks decreased from 20.4% to 4.4%. Mean time duration of image interpretation nearly doubled, from 05:44 to 11:01 (p = 0.002). Decreases in specific non-image interpretive tasks, including phone calls/paging (2.86/hr versus 0.80/hr), in-room consultations (1.36/hr versus 0.80/hr), and protocoling (0.99/hr versus 0.10/hr), were observed. The consult assistant experienced 29.4 task switching events per hour. Rates of specific non-image interpretive tasks for the CA were 6.41/hr for phone calls/paging, 3.60/hr for in-room consultations, and 3.83/hr for protocoling. CONCLUSION Separating responsibilities into NIT and IIT workflows substantially increased image interpretation time and decreased TSEs for the primary fellow. Consolidation of NITs into a separate workflow may allow for more efficient task completion.

Persistent Perceptual Disturbances After Lithium Toxicity: A Case Report and Discussion

Received July 8, 2014; revised August 9, 2014; accepted August 11, 2014. FromSchool ofMedicine, University of California San Francisco, San Francisco, CA (WBF); Department of Psychiatry, University of California San Francisco, San Francisco, CA (ADB, JJD, JAB); Department of Radiology andBiomedical Imaging, University of California San Francisco, San Francisco, CA (J-PJY). Send correspondence and reprint requests to William B. Feldman, D.Phil., School of Medicine, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA 94143; e-mail: william.feldman@ucsf.edu & 2015 The Academy of PsychosomaticMedicine. Published by Elsevier Inc. All rights reserved. Introduction

Cardiac arrest with impending circulatory collapse

An old patient was brought to the emergency department with cardiac arrest following blunt traumatic injury. After successful cardiopulmonary resuscitation, the patient underwent CT scan which revealed dependent layering of contrast and severe venous reflux (figure 1) as well as lack of forward flow into the left heart (figure 2), indicating impending circulatory collapse. Moments later, the patient became pulseless and severely …

Characteristics of Durable Quality Improvement: A 6-Year Case Study

Quality improvement processes are central to efforts to deliver higherquality health care [1]. Despite the dynamic political and economic forces reshaping paradigms of health care delivery and reimbursement [2], high-quality— and high-value—health care remains a common denominator and underscores the vital role practice quality improvement will play in realizing our collective quality and value goals [1,3]. Toward these ends, prompted by the American Board of Medical Specialties [4-6] and by changes to the ABR CORE examination [7-9], quality improvement and other systems-based practices are now routinely incorporated into the radiology residency training programs. These system-based learning opportunities ensure that radiologists are introduced to and are well versed to a critical facet of their future practice [7,10] and a major component of their maintenance of certification. Quality improvement work, however, is not easy. To assist and fulfill efficiency and patient care goals, many individuals and organizations have begun incorporating process methodologies adopted from business and industry, including Lean Six Sigma and the Model for Improvement [11-14], which have

Process improvement methodologies uncover unexpected gaps in stroke care

Background The diagnosis and treatment of acute stroke requires timed and coordinated effort across multiple clinical teams. Purpose To analyze the frequency and temporal distribution of emergent stroke evaluations (ESEs) to identify potential contributory workflow factors that may delay the initiation and subsequent evaluation of emergency department stroke patients. Material and Methods A total of 719 sentinel ESEs with concurrent neuroimaging were identified over a 22-month retrospective time period. Frequency data were tabulated and odds ratios calculated. Results Of all ESEs, 5% occur between 01:00 and 07:00. ESEs were most frequent during the late morning and early afternoon hours (10:00–14:00). Unexpectedly, there was a statistically significant decline in the frequency of ESEs that occur at the 14:00 time point. Conclusion Temporal analysis of ESEs in the emergency department allowed us to identify an unexpected decrease in ESEs and through process improvement methodologies (Lean and Six Sigma) and identify potential workflow elements contributing to this observation.