High-value care, stewardship and avoiding low-value interventions — branching viva

Opening (candidate)

I would treat this as a de-implementation project, not a single instruction. First I would confirm the practice is genuinely low-value using Choosing Wisely guidance, then measure the baseline, diagnose the drivers, engage the team and families, de-implement with combined levers, and sustain and monitor to prevent re-adoption. [9] [15]

Branch A — Definition and why it is low-value

Examiner: Why is routine pre-operative testing in a healthy child low-value? [1]

Candidate: Low-value care is a test whose likely harm or cost exceeds its likely benefit. In a fit, asymptomatic child before low-risk surgery, routine blood tests and a chest radiograph rarely change management, so they carry the burden of needles, false positives, delay and cost without offsetting benefit. [1] [15]

Branch B — Measurement

Examiner: How will you know whether your effort works? [6]

Candidate: I would audit the baseline rate of routine pre-operative testing, quantify the variation between surgeons and the downstream cascade and cost, and set a tractable, measurable target. Measurement turns a vague impression into a problem I can move and prove. [6]

Branch C — Drivers and levers

Examiner: The team is proud of being thorough. How do you change a habit? [9]

Candidate: I would first name the drivers: clinician habit and fear of an intra-operative surprise, family expectation that preparation means testing, and the system default that lets a test be ordered with a click. Then I would match a lever to each — changing the default order set, audit and feedback with peer comparison, and a family decision aid that reframes preparation. [9] [13]

Branch D — Engagement and trust

Examiner: A family complains that you are cutting corners. Your response? [13]

Candidate: I would not be defensive. I would explain that omitting unnecessary testing is good medicine that protects their child from needles, false alarms and delay, share the evidence and the safety-net, and make clear that any test that would change the plan is still done. Stewardship succeeds only when families trust that restraint is care, not cost-cutting. [13] [8]

Branch E — Sustainability and the failure mode

Examiner: Six months on, the rate is creeping back. What went wrong? [6]

Candidate: Re-adoption is an expected threat once the guardrails relax, so the sustain and monitor step was likely underdone. I would reinstate ongoing measurement and feedback, keep the low-value option off the default order set, and treat the drift as a signal to re-engage rather than a defeat. [6] [13]

Close

Confirm understanding with the team, leave a written summary of the campaign's aim, the measured baseline and outcome, and the plan to sustain and re-audit, and name the next review point so the gain outlives the individuals who made it. [6] [8]