The power of video recording: taking quality to the next level.

IN MEDICINE, THE PROBLEMS OF WIDE VARIATIONS IN quality and poor compliance with evidence-based care are well known. More education is not the solution for these problems. Knowledge is abundant, but implementation of knowledge often lags. This Viewpoint explores whether use of an existing technology, video recording of medical procedures, can improve quality of care. Although the World Health Organization’s hand washing declaration and aggressive global awareness campaign has been long established, behavior change among health care workers remains a persistent struggle. For instance, at Long Island’s North Shore University Hospital, hand washing compliance rates were consistently low despite educational efforts. In response to these low rates, the hospital took an assertive approach to solving the problem by installing cameras to monitor hand washing rates. The outcome data were reported to the staff and as a result, compliance increased from 6.5% to 81.6%, demonstrating the potential power of this technology in the medical setting. The concept of measuring quality for learning is not a proposal to rewire hospitals and install cameras, but rather, a consideration that many applicable activities and procedures are already video based. For example, procedures ranging from cardiac stent placement to arthroscopic surgery are performed using sophisticated video equipment; however, the record button is often turned off. The potential to harness the data in these videos and drive quality improvement may be substantial. At Indiana University, Rex et al decided to use the recording feature of colonoscopy video equipment to address the long-standing problem of quality variations in colonoscopies. Over several months, the investigators performed a blinded review of 98 colonoscopy videos performed by 7 gastroenterologists who were unaware that their procedures were being recorded. Procedure quality scores and mucosal inspection time data were collected based on established criteria. Wide variations in quality were found. The researchers then informed the gastroenterologists that their procedures were being video recorded and peer reviewed. Following the announcement, mean inspection time during colonoscopy increased by 49% and quality of mucosal inspection improved by 31%, suggesting a substantial improvement in quality because of the Hawthorne effect. Peer review of videos can also enhance existing quality improvement efforts. For example, procedure videos can better inform morbidity and mortality conferences and sentinel event root-cause analyses that have traditionally relied on the notes of clinicians, which can be limited and even biased. Moreover, the exportability of video files can facilitate external review, allowing a peer reviewer removed from a local department’s politics to advise on what could have improved. In addition to reviews triggered by patient harm, video recording also offers a valuable opportunity for coaching. In the same way that athletes learn from coaches when jointly watching videos of past games, physicians can also learn from their performance by viewing with a coach. At the Brigham and Women’s Hospital, a coaching program was developed in which surgeons spent 1 hour reviewing their procedure videos with an expert. The video-based peer review informed the surgeons about alternative approaches to problems they encountered during their operations and how they could be more efficient. The expert reviewer also suggested ways to better position the patient, surgical assistants, the surgeon, as well as the surgical retractors for optimal exposure. All of the surgeons who participated in the program found the personalized feedback to be valuable. Such video-based quality improvement intiatives could be offered remotely and even draw on the collaborative efforts among multiple institutions in a patient safety organization. Developing independent coaching networks will require an investment by hospitals, professional physician associations, and a new infrastructure, but the potential reward of improving procedure quality and safety may be substantial. According to the 2012 Institute of Medicine Best Care at Lower Cost report, unnecessary medical care may account for as much as 30% of US health care expenditures. Unnecessary procedures represent an important component of this problem, with major potential for reducing both pre-