Abstract
While there is an expanding body of literature on Point-of-Care Ultrasound (POCUS) pedagogy, administrative elements that are necessary for the widespread adoption of POCUS in the clinical environment have received little attention. In this short communication, we seek to address this gap by sharing our institutional experience with POCUS program development and implementation. The five pillars of our program, selected to tackle local barriers to POCUS uptake, are education, workflow, patient safety, research, and sustainability. Our program logic model outlines the inputs, activities, and outputs of our program. Finally, key indicators for the monitoring of program implementation efforts are presented. Though designed for our local context, this approach may readily be adapted toward other clinical environments. We encourage others leading the integration of POCUS at their centers to adopt this approach not only to achieve sustainable change but also to ensure that quality safeguards are in place.
Main text
Though Point-of-Care Ultrasound (POCUS) program leaders are generally well versed in POCUS education, they may lack the tools to support the broader implementation of POCUS in the clinical environment. While there is an expanding body of literature on POCUS pedagogy [1–3], administrative and logistical elements that are necessary for the widespread adoption of POCUS have received little attention [4, 5]. Considering the value proposition of POCUS to enhance patient care [6], we set out to increase the uptake of POCUS by general internists at the Ottawa Hospital, a tertiary care academic center. Using concepts from the literature on change management, quality improvement, and program evaluation, we developed a comprehensive approach to program development and implementation. In this paper, we share our approach as a model to support others looking to achieve the safe uptake of POCUS at their institution.
Understand your local environment
The first step to any change initiative is to gain an understanding of the operational environment [7]. A thorough understanding of local barriers and enablers, including stakeholder perceptions and readiness for change [8–10], organizational culture, and infrastructure is crucial [7].
Our program stakeholders include senior management, divisional leadership, content experts, non-clinical partners (biomedical engineering and information technology services), and end users. Stakeholder engagement was achieved using different mediums including informal interviews, divisional meetings, and online surveys.
The Ottawa Hospital has established programs in Emergency Medicine Ultrasonography (EMUS) and Critical Care Ultrasonography (CCUS). In addition to offering a wealth of experience in program development, these programs have a mature POCUS infrastructure, including hospital-based archiving, that can readily be expanded to other departments. Our environmental survey also showed that there is strong leadership support both at the senior management and divisional level for the implementation of POCUS in General Internal Medicine (GIM).
In addition to these enablers, we identified barriers to the broader uptake of POCUS in our division. Similar to barriers that have previously been described [11], lack of training, lack of time, lack of quality safeguards, and lack of evidence were quoted as being prohibitive. Finally, we identified that previous attempts to integrate POCUS in the division had been unsuccessful due to the lack of sustained efforts.
Develop and communicate a vision of change
Once we had developed a good understanding of our local barriers and enablers, we set out to establish our mission, values, and vision (Table 1) [12]. These are aligned with our organization’s strategic goals [13] and will give direction to our change efforts [14, 15].
Table 1.
Mission, values, and vision
| Mission | Leverage POCUS to provide better value care, enhance patient and provider experience, and achieve better health of populations |
| Values |
Quality and patient safety Educational excellence Sustainability |
| Vision | To achieve widespread safe use of POCUS by general internists at the Ottawa Hospital |
Remove obstacles [14]
Our next step was to identify strategies that would address each barrier (Table 2). This exercise allowed us to come up with the five overarching pillars of our program.
Table 2.
GIM POCUS program goals and pillars
| Barrier | Goals | Program pillars |
|---|---|---|
| Lack of training | Deliver educational activities to allow internists to gain the cognitive and psychomotor competencies required to perform and integrate POCUS clinically | Education |
| Lack of time | Establish a seamless POCUS workflow that is adapted to the high clinical volumes faced by internists | Workflow |
| Lack of quality safeguards | Establish a quality and patient safety program | Patient safety |
| Lack of evidence | Generate local data on clinical effectiveness, efficiency, and relevance of POCUS | Research |
| Lack of sustained efforts | Build capacity within the division and foster strong interdepartmental collaboration | Sustainability |
Plan program resources, activities, and outputs
Once we had identified the key elements of our program, we set out to plan our specific deliverables [16]. We present a logic model for our program (Table 3). A logic model is a systematic and visual way to outline the different elements of a program, from the inputs required to operate the program, the activities the program will deliver, and the outputs that will result from program implementation [17].
Table 3.
GIM-POCUS program logic model: resources, activities, and outputs
| Resources/Inputs | Activities | Outputs | Pillars |
|---|---|---|---|
|
Early adopters1 Infrastructure: 1. Ultrasound machines on wheels on medical wards 2. Hand held devices that allow for portability 3. Archiving capabilities Funding: 1. POCUS leads -Protected teaching, administrative and research time 2. Non-clinical partners -Biomedical engineering department -Information system department 3. Academic grants to support research, quality improvement and innovation |
POCUS academic half days | Establish a POCUS curriculum imbedded within the GIM residency training program | Education |
| POCUS rotation | |||
| Asynchronous feedback on archived scans | |||
| GIM POCUS rounds | Continuous professional development for practicing attendings | ||
| POCUS course (interdepartmental) | |||
| Bedside scanning sessions | |||
| Optimize the physical location of US machines | Optimize the physical environment | Workflow | |
| Optimize the US to user ratio | |||
| Integrate an archiving platform with US machines and the hospital information system | Onboard users to an archiving platform | ||
| Training sessions on the use of the archiving platform | |||
| Establish a system failure reporting process for US machines and the archiving platform | Maintenance of infrastructure | ||
| Establish standards for what constitutes an adequate scan2 | Quality assurance of scans | Patient safety | |
| Establish and implement a credentialing process3 | |||
| Establish a mechanism by which a proportion of scans performed by credentialed users are reviewed | |||
| Adopt patient safety policies4 | POCUS quality improvement program | ||
| Conduct morbidity and mortality rounds for POCUS-related adverse events | |||
| Implement an adverse event reporting and reviewing process | |||
| Develop questions and set up projects that are specific to the use of POCUS in GIM | Research program with a focus on quality improvement and implementation science | Research | |
| Develop an IM POCUS fellowship | Capacity building | Sustainability | |
| Recruit and retain credentialed users | |||
| Interdepartmental rounds | Cross-departmental collaboration | ||
| Interdepartmental delivery of teaching activities (course, academic half days) |
US = ultrasound
1Locally, the early adopter groups are POCUS-trained internists who have completed dedicated POCUS training (ranging from 3 to 6 months) as part of their GIM subspecialty residency training.
2Including standards for image acquisition, image interpretation, clinical integration, and documentation
3There is currently no standardized credentialing process for Internal Medicine POCUS in Canada. We, therefore, developed a dedicated POCUS Entrustrable Professional Activities (EPA) using consensus methodology. To be considered credentialed, learners must achieve entrustment on 50 EPAs, including a minimum attributed to each core application.
4Including learner policy, incidental findings policy, infection prevention policy
Monitor
Finally, we planned for monitoring of our implementation efforts. We selected indicators that could feasibly be collected, would adequately signal change, and would be actionable (Table 4) [18–20].
Table 4.
Indicators to monitor program implementation
| Pillar | Indicator | Frequency |
|---|---|---|
| Education | # of credentialed GIM trainees | Annually |
| # of credentialed GIM attendings | Annually | |
| Workflow | # of archived scans by credentialed users | Quarterly |
| # of system failures reported to IS and biomed | Quarterly | |
| Level of agreement with “Our POCUS infrastructure (machines and archiving) facilitates the safe use of POCUS in patient care” | Annually | |
| Patient safety | % of scans performed by credentialed users that meet quality assurance standards | Quarterly |
| # of reported POCUS-related adverse events | Quarterly | |
| Research | # POCUS publications with GIM as principal investigator | Annually |
| # POCUS grants with GIM as principal investigator | Annually | |
| Sustainability | # of POCUS-fellowship trained internists in the division | Annually |
| # of credentialed internists participating in the delivery of the training program | Annually | |
| # of non-internists participating in the delivery of the training program | Annually |
IS = information services
Conclusion
In this paper, we have—through sharing our institutional experience—sought to address a gap in the literature regarding POCUS implementation in the clinical environment. A strength of our program is its focus on quality and patient safety. Our program is designed specifically for our local context but may readily be adapted toward other clinical environments. As such, we encourage others leading the integration of POCUS at their centers to adopt this approach not only to achieve sustainable change but also to ensure that appropriate quality safeguards are in place.
Acknowledgements
Not applicable.
Author contributions
All authors read and approved the final manuscript and have agreed both to be personally accountable for their contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
Funding
Open access publishing was supported by The Ottawa Hospital Academic Medical Organization (TOHAMO) Innovation Grant.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors have no competing interests.
Footnotes
Publisher's Note
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Data Availability Statement
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.