CHICAGO — Work harder?

Well, you can, but that doesn't mean you will get better results, according to Stephen Swensen, MD, professor of radiology at Mayo Clinic (Rochester, Minnesota).

Speaking at the opening plenary session of this year's meeting of the Radiological Society of North America (Oak Brook, Illinois), Swensen used the analogy of a schooner that was developed two centuries ago with more masts than the standard in the hope that it would travel faster — but then crashed within a year — to suggest that, at least in radiology, pouring on more sails won't get the industry to quality faster.

Rather, Swensen focused on building a "market case" for quality in the profession and to "forget about any moral imperative" in medicine. The moral imperative, he said, has served to drive higher patient utilization throughout while not paying enough attention to how the technology is best used.

"Forty percent of what we do is [over-utilization] or mis-utilization," he said — an unhappy statistic for both patients and practitioners.

While noting that healthcare service is the largest business segment in America, Swensen also pointed out that it has the highest error ratio of any business in America.

And the economic imperative for quality is growing.

For example, Swensen posed the possibility — and the possible implications — of someone in Bangalore, India, using advanced technology to read an X-ray for 10 cents on the dollar of the cost of reading it in the U.S. In such a circumstance, the possibilities of that "flat world" scenario will make the field exponentially more competitive.

The answer in this market, he said, is process, or systems engineering, the same way that the U.S. has achieved its competitive status in worldwide retail banking.

And Swensen asked, "Why will we do it in radiology?"

In answer, he said that it will be done by being "safer and better for our patients."

He noted the rise of the pay-for-performance imperative, saying that this is one strong indicator that the "trust me" approach in medicine is turning to "show me." In other words, more regulators — and many patients — will be asking why a particular healthcare provider offers a superior product or service.

There are many opportunities for radiology in this value proposition, Swensen noted, those opportunities beginning as soon as a physician orders a scan.

For example, he pointed to studies showing that if a patient lives in the state of New York, he or she is four times more likely to get an MRI of the head. Swensen called this "Just do it" radiology, borrowing from the Nike tagline.

But he also cited 30% of over-utilization in radiology care as due to "liability concerns" by physicians and "self-referral" by patients.

As basic pushback, the profession should move to more frequent and rigorous use of evidence-based imaging standards, he said.

For example, what he found at Mayo was that an evaluation of its practices showed there were 23 "best ways" that radiology administered oral contrast media for CT scans. After that discovery, radiology narrowed that list down to "one best practice."

The delivery of quality healthcare also comes down to very simple and basic practices as simple, for example, as hand hygiene. Hand hygiene, Swensen noted, is considered so important in the fast food industry that some employees are fitted with RFID devices to ensure that they are following proper procedures.

"[Hand hygiene] is more important in healthcare than fast food, but how many physicians practice hand hygiene?" — another rhetorical question providing obvious criticism.

He cited an executive at JCAHO who suggested he had never been to a hospital where more than 35% of the healthcare providers practice hand hygiene, just one indicator of why there is such a high rate of hospital-acquired infections.

Other problems he noted include wrong-site surgery or other medical errors.

And radiology is part of that unfortunate mix.

"Hospital radiology has the highest error rate in [a] hospital every day," he said, noting that of those errors, 12% resulted in "harm to the patient," with interpretation of scans being one of the big areas for errors.

Swensen suggested that — as other areas in healthcare have done — to "limit the level of risk allowed."

Swensen cited the example of the current median accuracy rate in screening mammography of 66%, as of 2003. And he projected that if the profession wanted to increase that rate to 71%, it would have to collectively prohibit about 6,000 radiologists from practicing, something that would be a "hard decision."

One of the biggest complaints in radiology malpractice cases is the failure to communicate results effectively and clearly, he said. Thus, he advised the profession to get serious about improvements in quality, an effort that he said would require a dedication to systems engineering and guidelines that standardize quality of care.