Table 2. Using the framework for real life examples of overuse to identify practical ways in which overuse can be addressed.
| Example of overuse | Possible drivers/domains | Feasible approaches to improvement |
|---|---|---|
| A hospitalist on a general medical service wants to reduce use of routine lab testing |
Culture of health care: expectation of all clinicians (including attendings, consultants, nursing) for daily lab testing Clinician factors: belief that more is better, poor knowledge of evidence Practice environment: ease of daily ordering in the EMR Patient factors: expectation for frequent testing (likely a minor factor) |
Culture: broad campaign across the medical center Clinician: education about evidence/guidelines43,44 Practice environment: EMR alert35 |
| A physician hospital leader wishes to reduce inpatient opioid prescribing |
Clinician factors: misperception of patient/parent desires, discomfort with pain treatment81 Practice environment: pressure to discharge patients leading to aggressive pain treatment Patient factors: poor understanding of the potential harms of opioids, demand Patient-clinician interaction: poor communication regarding pain itself and the benefits/harms of therapy |
Clinician: education about guidelines/evidence43,44 Patient: provide information about options for treating pain and potential opioid harms Patient-clinician interaction: physician-directed tool for communicating about the issue49 |
| A palliative care fellow seeks to reduce imaging tests in end-of-life (EOL) hospitalized patients |
Culture of health care: need to define clinical problems even if there is no intervention, discomfort with doing nothing Clinician factors: belief that more information helps patients, belief that patients desire testing Patient factors: poor knowledge or acceptance of prognosis Patient-clinician interaction: poor communication regarding prognosis and EOL preferences |
Clinician factors: education about harms of testing in these patients Patient-clinician interaction: specific tools to improve communication about EOL preferences49,78 |
EMR = electronic medical record; CMO=Chief Medical Officer