The Health Quality & Safety Commission is a partner in the Council of Medical College’s Choosing Wisely campaign. The campaign encourages health professionals to question current practice and to talk to patients about the potential risks and benefits of undergoing tests, treatments and procedures.
Canterbury District Health Board (DHB) has a number of Choosing Wisely projects, and has found that supporting doctors to question the necessity of a particular test, treatment or procedure has been key to implementing a Choosing Wisely approach across many services.
'In terms of establishing Choosing Wisely projects, we’ve been quite doctor-focused on the basis that doctors are making most of the decisions about ordering investigations and tests,' says the DHB’s Service Improvement Lead, Carol Limber, who has responsibility for Choosing Wisely implementation.
'Doctors can be under pressure to do tests and investigations – partly to make sure they don’t miss something – but also because of patient expectations.
'Junior doctors can often feel under pressure to ensure all available investigations are performed which can sometimes result in over investigation or duplication of tests for that patient. We’re working hard to ensure senior medical officers support junior doctors to question whether a test is really necessary and support them with underpinning documented pathways.'
Ms Limber says implementing Choosing Wisely has had a focus on radiology testing, but it has not been limited to this. The Choosing Wisely programme also has projects looking at blood tests, prescribed medications and pathways for follow up and surveillance.
A recent area of focus in the Choosing Wisely campaign is perioperative care and pre-surgery assessments.
'We’re looking at the concept of routine chest x-rays, urinalysis, ECGs and blood tests. For example, if the patient is under 70 years old and has no previous history of a cardio pulmonary disorder, do they need a chest x-ray? We’re asking people to think about the patient’s risk factors, the surgery risk factors and what investigations are needed for that patient, rather than have a blanket approach of tests that we do on everyone.
'Everything we do carries some risk and Choosing Wisely is all about balancing that risk.'
Ms Limber says communication has been essential in supporting a culture change. This has included incorporating Choosing Wisely into CEO briefings, regular stories about examples of applying its principles in different departments in hospital newsletters, a Choosing Wisely focus in grand rounds and GP education sessions.
Canterbury’s Community and Hospital HealthPathways are also being updated as a result of the Choosing Wisely approach.
'We’re currently going through all the HealthPathways and highlighting where they link to the Choosing Wisely recommendations from each medical college.
'We have been pleased to find that all but one of about 100 Choosing Wisely recommendations are the same or very similar to the existing recommendations in HealthPathways.'
The latest tool in the Choosing Wisely initiative is the Health Care Analytics System (HCAS) which sits over the data warehouse and allows the team to query unstructured as well as structured data fields.
'It means we can look at, say, the impact of complete pathways of care including referrals, outpatient appointments, radiology testing and discharge summaries to enable us to explore and audit pathways in a way that we’ve never had the ability to do before. We have recently applied this tool to investigate our use of CT pulmonary angiography to audit and review current practice.
'We’re really mindful that this is about doing the right thing and balancing risk for the patient. Undoubtedly, if we reduce the amount of unnecessary and duplicate testing, there will be a system benefit, but that’s not our starting point.
'In some areas we might be under investigating, or doing the wrong test, or not doing the most appropriate test, so it’s about making sure we’re doing the right test at the right time for that patient.'