cqiperiop

American Society of EchocardiographySociety of Cardiovascular Anesthesiologists

Recommendations and Guidelines forContinuous Quality Improvement in

Perioperative EchocardiographyJoseph P Mathew MD FASE Kathryn Glas MD FASE Christopher A Troianos MD

Pamela Sears-Rogan MD FASE Robert Savage MD Jack Shanewise MD FASEJoseph Kisslo MD FASE Solomon Aronson MD FASE and Stanton Shernan MD FASE

for the Council for Intraoperative Echocardiography of the American Society ofEchocardiography Durham North Carolina Atlanta Georgia Pittsburgh Pennsylvania

Washington DC Cleveland Ohio New York New York and Boston Massachusetts

The American Society of Echocardiography (ASE)established in 1975 has long encouraged the assess-ment of quality in the practice of echocardiographyTo that end it has published and continues todevelop documents establishing guidelines for thepractice of echocardiography1-8 In 1995 the ASEpublished a series of recommendations specificallyfor continuous quality improvement (CQI) in echo-cardiography9 The accelerated growth of the clini-cal application of echocardiography combined withthe complexity of ultrasound technology conductof examinations and interpretation of results werecited as some of the reasons for developing a CQIprogram In the following document the ASE andthe Society of Cardiovascular Anesthesiologists(SCA) seek to establish recommendations and guide-lines for a CQI program specific to the perioperativeenvironment Using the prior ASE publication onCQI as the foundation we will (1) present a ratio-nale for CQI in the perioperative period (2) definethe components of a perioperative echocardiogra-phy service (3) establish the principles of CQI asthey relate to the practice of perioperative echocar-

From Duke University Medical Center Durham North Carolina(JPM JK SA) Emory University Atlanta Georgia (KG)The Western Pennsylvania Hospital Pittsburgh Pennsylvania(CAT) Washington Hospital Center Washington DC (PS-R)Cleveland Clinic Foundation Cleveland Ohio (RS) ColumbiaUniversity College of Physicians and Surgeons New York NewYork (JS) and Brigham and Womens Hospital Boston Massa-chusetts (SS)Members of the Council for Intraoperative Echocardiography arelisted in the appendixReprint requests American Society of Echocardiography 1500Sunday Dr Suite 102 Raleigh NC 27607 (E-mail apratherasechoorg)J Am Soc Echocardiogr 2006191303-13130894-7317$3200Copyright 2006 by the American Society of Echocardiography

doi101016jecho200608039

diography and (4) assess whether CQI programs areeffective in the perioperative period The recom-mendations and guidelines set forth in this docu-ment are to be applied to any echocardiographicprocedure performed in the intraoperative periodand to any in the immediate preoperative or post-operative period when it is performed indepen-dently of the CQI program of an established Level IIIechocardiographic service

RATIONALE FOR ASSESSING QUALITY

The integration of continuously evolving and com-plex scientific principles and technology into thehealth care environment can sometimes be challeng-ing In the last decade the use of echocardiographyin the perioperative period and in particular intra-operative transesophageal echocardiography (TEE)has expanded rapidly The conduct interpretationand clinical application of echocardiography in theperioperative environment are complex and requireappropriate knowledge technical skills and com-plete familiarity with operative concerns Moreoverdiagnostic interpretation of these examinations hasbeen reported to vary widely especially duringcongenital heart surgery10 CQI programs are there-fore equally necessary in the perioperative environ-ment CQI is recommended for physicians perform-ing and interpreting perioperative studies to ensurecomprehensive data acquisition and accurate inter-pretation In addition a CQI program may be usedto assess and prevent underuse overuse or misuseof perioperative echocardiography

In the last 5 years the goal of improving quality inhealth care has gained national prominence trig-gered in large part by a publication on medicalerrors from the Institute of Medicine (IOM)11 This

report galvanized the public and private sectors and

1303

Journal of the American Society of Echocardiography1304 Mathew et al November 2006

the medical profession into a collaborative effort atbuilding a safer health care system A centerpiece ofthat strategy has been the assessment and improve-ment of quality in health care delivery Recently theCenters for Medicare and Medicaid Services haveinitiated several programs to improve quality inhealth care services that can best be described asldquopay for performancerdquo12 The first of these initiativesaims to improve quality of inpatient care to Medi-care beneficiaries by providing financial incentivesGiven the purported early success of this program13

expansion of the program to all health care servicesincluding echocardiography should be anticipatedPerioperative echocardiographers who establishCQI programs and demonstrate improvements inquality measures of their practice are likely to bewell positioned for this future

DEFINITIONS FOR CQI

Perioperative Echocardiography

Perioperative echocardiography involves the use ofcardiac ultrasound in surgical patients immediatelybefore during or after their operation and includestransesophageal epicardial epiaortic and transtho-racic approaches Practice locations may include theoperating room recovery room intensive care unitand echocardiography laboratory The various mo-dalities that comprise perioperative echocardiogra-phy include M-mode and 2- and 3-dimensional imag-ing and pulsed wave continuous wave color flowand tissue Doppler The echocardiographic data areobtained in real time and interpreted by a physicianin a timely manner to direct the clinical treatment ofsurgical patients These techniques may be com-bined with a variety of adjuncts such as contrastagents and may be used during a variety of physio-logic conditions including pharmacologic stress

CQI

The IOM has defined quality as ldquothe degree to whichhealth services for individuals and populations in-crease the likelihood of desired health outcomes andare consistent with current professional knowl-edgerdquo14 CQI is a management methodology adaptedby health care providers from business and industrythat is designed to identify and analyze problems inhealth care delivery More importantly once a prob-lem is identified CQI encourages the developmenttesting and implementation of solutions withoutassigning blame The essential elements of CQIinclude an ldquoorientation towards customers and sys-tems (processes) a commitment to understandingand minimizing process variations and the develop-ment of teams that can broaden vision and imple-

ment solutionsrdquo15 CQI in perioperative echocardi-

ography is a continual process characterized by 3assumptions about quality (1) technologic advance-ments in echocardiography may redefine qualityand therefore the ensuing recommendations(2) assessments of quality often require compari-sons and (3) quality is enhanced by repetitivepractice9

COMPONENTS OF PERIOPERATIVEECHOCARDIOGRAPHY

Equipment and Recording

An ultrasound machine with full diagnostic capabil-ities is required to provide a comprehensive periop-erative echocardiographic examination At a mini-mum the system should be equipped with thecapacity for 2-dimensional Doppler (pulsed wavecontinuous wave and color flow) and M-modeimaging Each console should have a video screenthat can be made visible either directly or by anothermonitor screen to the surgeon and other cliniciansresponsible for the patientrsquos medical care All ultra-sound systems must also possess a system for per-manently recording data onto a media format thatallows for offline review or analysis Recently theASE made an unequivocal recommendation for anall-digital capture storage and review process7 Allperioperative echocardiographers are thereforeurged to move toward this digital standard by incor-porating the Digital Imaging and Communications inMedicine (DICOM) format high-speed networkingand permanent storage with built-in redundancy7

TEE probes used in the perioperative period shouldbe capable of multiplane imaging

Request for Echocardiographic Services

In nonemergency settings outside of the operatingdepartment a request for an echocardiographicexamination should be activated by an order in thepatientrsquos hospital chart The intraoperative settinghowever is unique in that medical therapy deliveredtherein does not require individual and specificorders recorded on an order sheet Because deliv-ered therapy is always documented on the anesthe-sia record intraoperative echocardiographic ser-vices may be requested by the anesthesiologist anddocumented on the anesthetic record In manyinstitutions requests for intraoperative therapy aremade by the surgeon and thus requests for intra-operative echocardiographic services may also belisted on the posted surgical schedule In all in-stances the indications for performing periopera-tive echocardiography should be documentedclearly in the patientrsquos medical record either in theanesthesia record or on the report of echocardio-

graphic findings

Journal of the American Society of EchocardiographyVolume 19 Number 11 Mathew et al 1305

Patient Interactions

The decision to perform perioperative echocardiog-raphy begins with a careful clinical history andphysical examination that is used to detect relativeor absolute contraindications to performing theexamination (eg unstable neck injuries esophagealtrauma varices strictures cancer dysphagia activeupper gastrointestinal bleeding or a history of chestradiation) Clinical information such as heart failurecoronary artery disease atrial fibrillation strokestructural heart disease or active endocarditis mayhelp in evaluating the natural history of the patientrsquosdisease and assist the echocardiographer in guidingperioperative clinical decisions An explanation ofthe echocardiographic procedure including the in-dications risks and benefits should be provided toevery patient andor legal guardian whenever possi-ble (ie elective procedures) It is also recommendedthat informed consent in which the specific risksand benefits to the patient from the procedure arediscussed with the patient before the examina-tion be obtained and documented in the patientrsquoschart either separately or as part of the generalanesthetic consent

Role of the Physician and the Sonographer

The cardiac sonographer in the echocardiographylaboratory plays a well-respected and integral role inacquiring comprehensive echocardiographic exam-inations by applying independent judgment andproblem solving skills He or she has specific train-ing in obtaining accurate images and integratingdiagnostic information during the performance ofthe examination However the role of the sonogra-pher in the performance of TEE is limited to maxi-mizing image quality by the manipulation of thecontrols on the ultrasonography system as stated inthe ldquoGuidelines for Cardiac Sonographer EducationRecommendations of the ASE Training and Educa-tion Committeerdquo16 In addition the American Col-lege of CardiologyAmerican Heart Association Clin-ical Competence Statement on Echocardiographystates that ldquotraining for the performance and inter-pretation of TEE is best obtained during a formalfellowship in cardiovascular medicine or its equiva-lent (ie cardiology cardiovascular anesthesiologycardiovascular surgery or critical care medicine)rdquo2

Furthermore the Intersocietal Commission for theAccreditation of Echocardiography Laboratories(ICAEL) Standards do not recognize sonographerperformance of a TEE and specifically states ldquoTEE isa semi-invasive test which if performed incorrectlycan lead to serious harm to patients and thereforeshould be performed by appropriately trained per-sonnelrdquo TEE is generally safe but insertion andmanipulation of the TEE probe can produce pharyn-geal andor laryngeal trauma dental injuries esoph-

ageal andor gastric trauma or bleeding arrhythmias

respiratory distress and hemodynamic effects1718

In addition performing procedures on patients whoare sedated or anesthetized requires special trainingthat sonographers do not receive Thus a sonogra-pher may assist the physician in manipulation of thecontrols on the ultrasonography system howeverthe physician must always be present to insert theTEE probe perform a perioperative TEE (PTEE)examination interpret the echocardiographic dataand assist the surgeon by providing information perti-nent to surgical decisions

Performance and Interpretation Time

The time needed to complete a comprehensiveperioperative examination will vary depending onthe complexity of the case No minimal time hasbeen established to perform a comprehensive eval-uation however initial study time may last 10 to 45minutes including time for discussion between car-diologists surgeons and anesthesiologists Addi-tional time may be needed for important Dopplercalculations and complementary evaluations (egcontrast echocardiography or pharmacologic stresstesting) It is also recognized that the entire durationof an intraoperative examination may total severalhours as repeated sequential examinations are con-ducted to assess acute hemodynamic changes or theadequacy of surgical repair

Echocardiographic data that will influence thesurgical plan should be interpreted and reported tothe surgeon in an ongoing and timely manner Averbal report must be provided throughout and inparticular at the completion of the initial examina-tion to both the surgical and anesthesia care teamsA written or electronic description of the findingsshould be left in an obvious location within theoperating room on completion so that it is availablefor immediate reference Furthermore a written orelectronic report (preliminary or final) outlining keyfindings should be included in the medical record bythe end of the procedure Official reports of all theintraoperative data may be generated after comple-tion of the surgical procedure and should be con-sistent with the real-time interpretation provided tothe surgeon Such a report should be legible placedin the patientrsquos medical record within 24 hours ofoperation and include (1) a description of theechocardiographic procedure (2) indications forthe procedure and (3) important findings

Comprehensive Versus Limited PerioperativeExamination

A comprehensive echocardiographic study is ldquoonethat examines all cardiac chambers valves and greatvessels from multiple views then uses the availableinformation to define completely any recognizedabnormalitiesrdquo9 For PTEE we recommend that peri-

operative echocardiographers follow the guidelines


previously outlined for performing a comprehensiveintraoperative TEE examination6 Although not allcomponents of the comprehensive examinationmay be needed in every patient the practitionershould attempt to acquire all 20 of the recom-mended views accompanied by appropriate Dopp-ler data in the event they are needed for remoteconsultation19 We also recommend that echocar-diographers strive to derive all the hemodynamicdata that are pertinent to each patient from theavailable Doppler techniques

Although a comprehensive examination is alwaysrecommended a limited or focused study may beoccasionally indicated Typically these patientshave had a recent comprehensive examination withno expected interval change other than in the areabeing re-examined A limited intraoperative TEEexamination may also be warranted after a requestto determine the cause of acute hemodynamic com-promise such as during an intraoperative cardiacarrest

Specialized Echocardiographic Procedures

Epiaortic and epicardial echocardiography are sepa-rate procedures that may be used to obtain addi-tional echocardiographic data not acquired byTEE2021 They may also serve as a substitute for TEEimaging when TEE probe insertion is contraindi-cated or cannot be performed Additional probeswith varying ultrasound frequencies are required toperform echocardiography with these approachesGuidelines for the use of epicardial and epiaorticechocardiography are forthcoming from the ASECouncil for Intraoperative Echocardiography

PRINCIPLES OF CQI

Acquisition of Primary Trainingand Technical Skills

Minimal competence required for performing andinterpreting perioperative echocardiography inadult patients requires basic cognitive and technicalknowledge of ultrasound physics as well as instru-mentation and transducer manipulation for imageand data acquisition and a fundamental understand-ing of cardiac and great vessel anatomy physiologyand pathology In addition an appreciation of theinteraction between surgical techniques and thepathophysiology of the disease process under studyis essential A comprehensive perioperative echocar-diographic examination is performed predominantlythrough the TEE approach although epicardial andepivascular techniques continue to have a role dur-ing surgery particularly for the echocardiographicassessment of the ascending aorta or rarely when

TEE probe insertion can not be accomplished or is

contraindicated17 Training guidelines for less fre-quently used procedures in the perioperative periodsuch as transthoracic echocardiography22 stressechocardiography23 echocardiography for pediatricpatients1 and echocardiography using hand-carriedultrasound devices22 have been previously detailedBecause TEE is the dominant perioperative proce-dure the remainder of this document will focus onthe use of TEE TEE evaluation of the patient withcongenital heart disease is more complex and prac-titioners in this arena require special expertise Wetherefore endorse the recommendations publishedby the Pediatric Council of the ASE1

Training requirements represent the minimaltraining experience that is considered necessary toachieve the skills for performing perioperative echo-cardiography The essential components of traininginclude independent work directly supervised ac-tivities and assessment programs2224 Through astructured independent reading and study programtrainees must acquire an understanding of the prin-ciples of ultrasound and indications for perioperativeechocardiography This independent work should besupplemented by regularly scheduled didactics such aslectures and seminars designed to reinforce the mostimportant aspects of perioperative echocardiogra-phy192224

Specific guidelines on training in perioperativeechocardiography have been published by an ASESCA task force19 These recommendations whichwere initially developed mainly for anesthesiologistsand cardiologists recognized that perioperativeechocardiography can be practiced at different lev-els Both basic and advanced levels of perioperativeechocardiographic training refer to specialized train-ing that typically extends beyond the minimumexposure to echocardiography that occurs duringnormal residency training The knowledge and skillsnecessary to practice perioperative echocardiogra-phy at the basic and advanced levels are summarizedin Tables 1 to 3192225

Trainees undergoing basic training should learnindications and contraindications and how to place

Table 1 Fundamental cognitive skills required forcompetence in perioperative echocardiography19

Knowledge of physical principles of echocardiographic imageformation and blood flow velocity measurements

Knowledge of instrument settings required to obtain anoptimal image

Knowledge of normal cardiac anatomy Knowledge of pathologic changes in cardiac anatomy caused

by acquired heart disease and CHD Knowledge of fluid dynamics of normal blood flow Knowledge of pathologic changes in blood flow caused by

acquired heart disease and CHD

CHD Congenital heart disease

the TEE probe operate the ultrasound machine and


perform a TEE examination all under direct super-vision by another physician who has already ac-quired advanced training Trainees should be en-couraged to master the comprehensive examinationdefined by the ASE and SCA6 A basic practitionershould be able to acquire all 20 of the recommendedcross sections Thus basic training does not preparethe practitioner to influence the surgical plan with-out the assistance of a physician with advancedtraining in perioperative echocardiography19 Forbasic training 150 complete examinations should bestudied under appropriate supervision These exam-inations must include the full spectrum of com-monly encountered perioperative diagnoses and atleast 50 comprehensive PTEE examinations person-ally performed interpreted and reported by eachtrainee (Table 4)192225

Advanced training should take place after basictraining in a program designed specifically to accom-plish comprehensive training in perioperative echo-cardiography192225 Physicians with advanced train-ing are able to use the full diagnostic potential ofPTEE In this regard cardiovascular lesions are diag-nosed and the information is used to influence thepatientrsquos perioperative treatment including assistingthe surgeon in planning the surgical procedure Foradvanced practice the comprehensiveness of train-ing is paramount2224 The ASESCA Task Forcerecommends that 300 complete examinations be

Table 2 Cognitive and technical skills needed to perform p

Cognitive skills Basic knowledge outlined in Table 1 Knowledge of the equipment handling infection control and e Knowledge of the indications and the absolute and relative con General knowledge of appropriate alternative diagnostic modal Knowledge of the normal cardiovascular anatomy as visualized Knowledge of commonly encountered blood flow velocity prof Detailed knowledge of the echocardiographic presentations of Detailed knowledge of the echocardiographic presentations of Detailed knowledge of the physiology and TEE presentation o Knowledge of native valvular anatomy and function as displaye Knowledge of the major TEE manifestations of valve lesions an Knowledge of the principal TEE manifestations of cardiac mass

sions of the great vesselsTechnical skills Ability to operate the ultrasound machine including controls a Ability to perform a TEE probe insertion safely in the patient w Ability to perform a basic TEE examination Ability to recognize major echocardiographic changes associate Ability to detect qualitative changes in ventricular function and Ability to recognize echocardiographic manifestations of air em Ability to visualize cardiac valves in multiple views and recogniz Ability to recognize large intracardiac masses and thrombi Ability to detect large pericardial effusions Ability to recognize common artifacts and pitfalls in TEE exam Ability to communicate the results of a TEE examination to pa

sults cogently in the medical record

TEE Transesophageal echocardiography

studied under direct supervision of another physi-

cian who has already acquired advanced training19

These examinations must include a wide spectrumof cardiac diagnoses and at least 150 comprehensivePTEE examinations that are personally performedinterpreted and reported by the trainee (Table 4)Physicians should also take the Examination of Spe-cial Competence in PTEE and aspire to achieveboard certification in perioperative echocardiogra-phy through the National Board of Echocardiogra-phy (wwwechoboardsorg)

The director of the training program must be aphysician with advanced training and proven exper-tise in perioperative echocardiography who hasperformed at least 450 complete examinations in-cluding 300 PTEE examinations or has equivalentexperience (Table 4)19 As advanced trainees ac-quire more experience they may be allowed towork with more independence but the immediateavailability and direct involvement of an advancedsupervisor during the examination is an essentialcomponent of advanced training

Training requirements represent the minimaltraining experience that is considered necessary toachieve the skills for performance at a particularlevel Such training is expected to occur under thedirect supervision of a practitioner who has alreadyacquired advanced training and for the most partoccurs during formal fellowship training in eithercardiovascular medicine cardiovascular anesthesiol-

rative echocardiography at a basic level19

al safety recommendations associated with the use of TEEcations to the use of TEEpecially transthoracic and epicardial echocardiography

easured by Doppler echocardiographydial ischemia and infarctionand abnormal ventricular functionbolizationEEe TEE techniques available for assessing lesion severitymbi emboli cardiomyopathies pericardial effusions and le-

the quality of the displayed datanesthetized and intubated

myocardial ischemia and infarctionynamic statusionvalvular lesions and dysfunction

snd other health care professionals and to summarize these re-

eriope

lectrictraindiities esby TEEiles as mmyocarnormalf air emd by Td of thes thro

ffectingho is a

d withhemodbolizate gross

inationtients a

ogy cardiovascular surgery or critical care medi-

ediatric


cine2224 However physicians trained before thedevelopment of these techniques may have properlylearned their use while in practice and can achieveappropriate training in perioperative echocardiogra-phy without enrolling in a formal training pro-gram2224 Nonetheless the same prerequisite med-ical knowledge medical training and goals forcognitive and technical skills apply to them as theyapply to physicians in formal training programsThey should work with other physicians who haveadvanced TEE training or equivalent experience toachieve the same training goals and case numbers asthe training levels previously delineated Physiciansseeking basic training by this pathway should also

Table 3 Cognitive and technical skills necessary to perform

Cognitive skills All the cognitive skills defined for the basic level (Table 2) Knowledge of the principles and methodology of quantitative e Detailed knowledge of native valvular anatomy and function Knowledge of prosthetic valvular structure and function detail

and dysfunction Knowledge of the echocardiographic manifestations of CHD Detailed knowledge of echocardiographic manifestations of p

rysms hypertrophic cardiomyopathy endocarditis intracardiapericardial disorders and postsurgical changes)

Detailed knowledge of other cardiovascular diagnostic methoTechnical skills All the technical skills defined for the basic level (Table 2) Ability to perform a complete TEE examination Ability to quantify subtle echocardiographic changes associated Ability to use TEE to quantify ventricular function and hemod Ability to use TEE to evaluate and quantify the function of all

gradients and valve areas regurgitant jet area effective regurgitlar function

Ability to use TEE to evaluate congenital heart lesions ability t Ability to detect and assess the functional consequences of pa

rysms hypertrophic cardiomyopathy endocarditis intracardiaand pericardial disorders) and ability to evaluate surgical inte

Ability to monitor placement and function of mechanical circ

CHD Congenital heart disease TEE transesophageal echocardiographyRequires additional training as outlined in the Guidelines for Training in P

Table 4 Training recommendations for basic and advanced

Minimum number of examinationsinterpreted and reported under appropriatesupervision

Minimum number of examinations personallyperformed interpreted and reported underappropriate supervision

Program director qualifications Advanced perioechocardiogr

Program qualifications Wide variety ofof echocardio


have at least 20 hours of Continuing Medical Educa-

tion (CME) devoted to echocardiography Physiciansseeking advanced training by this pathway shouldhave at least 50 hours of CME devoted to echocar-diography The CME in echocardiography should beobtained during the time that trainees are acquiringthe requisite clinical experience in TEE

The supporting surgical program must have thevolume and diversity to ensure that trainees willexperience the wide spectrum of diagnostic chal-lenges encountered in perioperative echocardiogra-phy and learn to use TEE effectively in all itsestablished perioperative applications The periop-erative echocardiography training program shouldideally have an affiliation with an echocardiography

perative echocardiography at the advanced level19

diography

ledge of the echocardiographic manifestations of valve lesions

ic conditions of the heart and great vessels (eg cardiac aneu-es cardioembolic sources aortic aneurysms and dissections

orrelation with TEE findings

yocardial ischemia and infarctionsvalves including prosthetic valves (eg measurement of pressurefice area) ability to assess surgical intervention on cardiac valvu-

s surgical intervention in CHDic conditions of the heart and great vessels (eg cardiac aneu-es cardioembolic sources aortic aneurysms and dissectionsn in these conditions if applicableassistance devices

Echocardiography 1

perative echocardiography19

Advanced

300

150

eaining

Advanced perioperative echocardiographytraining plus at least 150 additionalperioperative TEE examinations

rative applications Full spectrum of perioperativeapplications of echocardiography

perio

chocar

ed know

athologc mass

ds for c

with mynamiccardiacant ori

o assesthologc massrventioulatory

perio

Basic

150

50

perativaphy tr

periopegraphy

laboratory so that trainees can gain regular and

iography


frequent exposure to teaching and clinical resourceswithin that laboratory

Both basic and advanced trainees must be taughthow to convey and document the results of theirexamination effectively Formal and informal evalu-ations of the progress of each trainee should beconducted during training at a minimum of twice ayear All trainees should document their experiencein detail in a log of the examinations they per-formed and should be able to demonstrate trainingequivalent in depth diversity and case numbers tothe training levels previously delineated The expe-rience and case numbers acquired during basictraining may be counted toward advanced training ifthe basic training was completed in an advancedtraining environment

Proof of competence consists of a set of require-ments that provide some assurance that physicianshave gained the expertise needed to perform ac-cording to recognized standards Documentation ofcompetence can be achieved by means of letters orcertificates from the director of the perioperativeechocardiography training program (Table 5) Thisdocumentation should state the dates of trainingand that trainees have successfully achieved orsurpassed each of the training elements All echo-cardiographic facilities should have on file appropri-ate documents attesting to the adequacy of physi-cian training The file should be kept up to date withthe addition of a new record for additional physi-cians as they arrive Records of individuals leaving afacility should be kept for at least 10 years9

Maintenance of Technical Skills

Clinical competence in perioperative echocardiog-raphy requires continued maintenance of cognitiveand technical skills in perioperative echocardiogra-phy On completion of the above training require-ments a minimum of 50 examinations per year withat least 25 personally performed is required toremain proficient in performing perioperative echo-cardiography (Table 5)2224 In addition CME inPTEE is essential to keep pace with technical ad-vances refinements in established techniques andapplication of new methods Physicians practicingperioperative echocardiography should obtain a

Table 5 Documentation and maintenance of competence

Documentation of competence

NBE certification or Letter or certificate from the director of the periopera-

tive echocardiography training program

CQI Continuous quality improvement NBE National Board of Echocard

minimum of 15 hours every 3 years of Category I

CME credits in echocardiography as recommendedrecently by the ICAEL26 (Table 5)

Periodic Review

Periodic review is the cornerstone of any CQIprogram and consists of a review of caseloadperformance interpretation record keeping andequipment In many areas of medicine caseloadand experience have been directly associated withoutcome2728 Minimal caseload requirements fortraining at the basic and advanced level designa-tion as program director and maintenance ofskills are outlined in Tables 4 and 5 In addition tothese a minimum of 25 intraoperative TEE studiesper month should be performed by a periopera-tive echocardiographic service An inability tomeet these requirements and plans to addressdeficiencies should be documented monthly aspart of the CQI process For the purpose ofverifying caseloads limited studies are not in-cluded A case is defined as a single patientencounter resulting in a complete 2-dimensionaland Doppler echocardiographic examination

In addition to minimal caseloads CQI requiresintermittent review of study performance and inter-pretation This review should include all types ofprocedures performed by members of the perioper-ative echocardiography team including but notlimited to transesophageal transthoracic epiaorticand epicardial examinations Ideally this review isconducted by an immediate repetition of the studyby a second echocardiographer However becauseintraoperative echocardiography is relatively inva-sive the performance review by a second physicianskilled in echocardiography may be conducted by areview of stored images Components of this reviewinclude an assessment of (1) the documentation ofthe indications for the procedure and patient con-sent (2) appropriate use of ultrasound system tech-nology and controls (3) the adequacy and presen-tation of the imaging planes and (4) concurrencebetween the recorded images and the written report(ie do the recorded images document the echocar-diographic findings provided in the written report)It is recommended that a minimum of 5 cases foreach echocardiographer in a service be subjected to

operative echocardiography19

Maintenance of competence

t 50 examinations per year with 25 of these being personallymed

a minimum of 15 hours every 3 years of Category I Continu-edical Education credits in echocardiographypation in CQI program

in peri

At leasperforObtainous MPartici

such review every 12 months In a similar fashion


Table 6 Summary of continuous quality improvement recommendations

Equipment Ultrasound machine with full diagnostic capabilities 2D Color PW and CW Doppler and M-mode imaging Video imaging screen Digital capture review and permanent storage of data with redundancy and using DICOM format Multiplane TEERequest for echocardiographic services Order for ultrasound study must be documented on surgical schedule anesthesia record or permanent medical recordPatient interactions Determine relative or absolute contraindications to examination Use clinical history in conjunction with echocardiographic data to guide decisions Review risks and benefits of procedure Document informed consentExamination components Comprehensive 2D echocardiographic and Doppler examination with pertinent hemodynamic data should be performed in most pa-

tients Limited or partial examination may be performed

In those with a recent examination in whom no interval change is expected other than in the specific area being re-examined or In those with intraoperative hemodynamic instability such as cardiac arrest (ie ldquorescuerdquo echocardiography)

Performance and interpretation time Acquisition interpretation and dissemination of data should occur in a timely fashion for use in surgical decision making Report of echocardiographic findings available to OR staff in easily accessible manner Written or electronic report (preliminary or final) outlining key findings included in the medical record by the end of the procedure Legible formal report in patientrsquos medical record within 24 hours of operation and should include

A description of the echocardiographic procedure Indications for the procedure Important findings

Formal report should be consistent with findings presented to OR teamTraining requirements Program director with advanced training (450 TEEs) and certification Surgical caseload with adequate volume and diversity of cases Affiliation with echocardiography laboratory 150 TEEs for the basic level and 300 for advanced level 50 Hours of CME in echocardiography for individuals seeking advanced certification outside fellowship training Review of traineersquos progress at least twice per year Trainee case logs Provide documentation of successful completion of training to trainee Maintain records of training for 10 yearsMaintenance of technical skills 50 Examinations per year 25 of these should be personally performed Average of 5 hours Category I CME credits in echocardiography per year Didactic monthly conference of at least 30 minutes Completion of 25 comprehensive TEE studies per month to be designated as a perioperative echocardiographic servicePeriodic review Performance review to occur every 12 months on 5 cases from each echocardiographerrsquos caseload and include

Documentation of the indications for the procedure and patient consent Appropriate use of ultrasound system technology and controls Adequacy and presentation of the imaging planes Concurrence between the recorded images and the written report

Interpretive review to occur every 12 months on 5 cases from each echocardiographerrsquos caseloadEquipment review Electrical systems should be checked for current leakage according to industry standards TEE probes should be checked for leakage at a minimum of every 3 months Regular preventive maintenance service should be conducted according to manufacturerrsquos recommendations Ultrasound system and ECG cables should be wiped carefully with an antiseptic solution after each patient use TEE probes cleaned according to institutional guidelinesUse review Yearly review Indication for the study Appropriate use of technology Comprehensiveness of the study

tation o


an interpretation review should be conducted everyyear on 5 of the cases for each physician in theservice Here the focus is not on the performancevariables but rather on whether the examination hasbeen accurately interpreted The two interpreta-tions should be compared and any differences dis-cussed with the primary physician Changes to theechocardiographic report that occur as a result of aninterpretation review should be made only afterconsultation with and the agreement of the physi-cian responsible for the initial report Documenta-tion of the occurrence of performance and interpre-tation reviews and the feedback provided to thosesubjected to review is to be maintained as part of theCQI process

A final component of the periodic review pro-cess is that of equipment review All electricalsystems should be checked for current leakageaccording to industry standards TEE probesshould be checked for leakage at a minimum ofevery 3 months Regular preventive maintenanceservice should be conducted according to manu-facturerrsquos recommendations In the intraoperativeenvironment it is critical that echocardiographicequipment such as the TEE probes be cleanedaccording to institutional guidelines In additionthe ultrasound system and electrocardiographiccables should be wiped carefully with an antisep-tic solution after each patient use A review of theadequacy and safety of the cleaning process withappropriate documentation should be conductedevery 6 months

Continuing Education

As discussed previously an average yearly mini-mum of 5 hours of Category I CME dedicated toechocardiography is necessary for the mainte-nance of skills In addition every perioperativeechocardiographic service should conduct a ser-vice conference lasting between 30 and 60 min-utes at least once a month This conference shouldcover a wide assortment of echocardiographictopics and may range in format from case reviewsto formal didactic presentations Category I CMEmay be obtained from this activity but should not

Table 6 Continued

Timely completion of the interpretive report Note whether the examination answered the question for whicCQI documentation Review compliance with JCAHO guidelines Obtain hospital review of CQI process Make official policy manual available to all service members Document all aspects of CQI process including compliance and

CME Continuing Medical Education CQI continuous quality improvemedicine ECG electrocardiogram JCAHO joint commission on accreditransesophageal echocardiography 2D 2-dimensional

account for more than 2 hours of the average

annual total of 5 Certification of adequate CMEfor each physician in the perioperative echocardi-ography service is to be collected on a yearly basisand should total 15 hours over 3 years

Documentation of CQI Process

The measures outlined in this document andsummarized in Table 6 are the necessary compo-nents of an acceptable CQI program Practitionersare strongly encouraged to develop and partici-pate in the CQI processes to enhance individualand departmental growth Accreditation agenciessuch as Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) have estab-lished guidelines regarding many aspects of pa-tient care and these guidelines should be consid-ered when building the CQI process for aperioperative echocardiography service Hospitalor departmental quality assurance committeesshould also be involved in the review and ap-proval of developed documents Finally the pro-posed CQI process should be readily available toall members of the echocardiography team forreview

Use Review

Indications for perioperative echocardiographychange as surgical techniques are developed and asimaging modalities are enhanced Criteria for acomprehensive transesophageal transthoracic epi-cardial and epiaortic examination are available2621

and should be followed Moreover a periodic re-view of the indications for perioperative echocardi-ography should be undertaken to improve use ofechocardiographic services A yearly use reviewincludes not only the components defined in thesection on ldquoPeriodic Reviewrdquo but also an evaluationof the appropriateness of the indication for a studyand whether the use of technology was appropriatethe study was comprehensive the interpretive re-port was completed in a timely manner andwhether the examination answered the question for

rocedure was ordered

tive action

W continuous wave DICOM digital imaging and communications inf healthcare organizations OR operating room PW pulsed wave TEE

h the p

correc

ment C

which the procedure was ordered


CQI IN PRACTICE

Few perioperative services have reported on theirexperience with a CQI program but the limitedliterature indicates that incorporating CQI into dailypractice can be beneficial In 2002 a report from anintraoperative service examined the interpretiveskills of a group of 10 cardiac anesthesiologistspracticing in an academic environment29 Theseinvestigators determined that the intraoperative in-terpretation of a comprehensive TEE examinationcompared favorably with the offline interpretationprovided by two physicians whose primary practicewas echocardiography Through the CQI processthey were also able to identify areas where addi-tional training was required Similarly the provi-sion of educational aids and performance feed-back to anesthesiologists increased their ability torecord a basic intraoperative TEE examination30

These authors concluded that their attempt toassess compliance with published guidelines forbasic intraoperative TEE produced marked im-provement in practice

Conclusion

Aside from being a mandate of various accreditationagencies CQI is a process that will aid perioperativeechocardiographers in improving the delivery ofcare to patients Although no set of guidelines willguarantee an improvement the guidelines and rec-ommendations presented in this document and sum-marized in Table 6 should serve as a foundation onwhich each perioperative service can build a futuredefined by the consistent delivery of a high-qualityproduct CQI in the perioperative environment isfeasible but must move from the periphery to thecore of the echocardiography service

REFERENCES

1 Ayres NA Miller-Hance W Fyfe DA et al Indications andguidelines for performance of transesophageal echocardiogra-phy in the patient with pediatric acquired or congenital heartdisease report from the task force of the pediatric council ofthe American Society of Echocardiography J Am Soc Echo-cardiogr 20051891-8

2 Cheitlin MD Armstrong WF Aurigemma GP et al ACCAHAASE 2003 guideline update for the clinical applicationof echocardiography summary article a report of the Ameri-can College of CardiologyAmerican Heart Association taskforce on practice guidelines (ACCAHAASE committee toupdate the 1997 guidelines for the clinical application ofechocardiography) Circulation 20031081146-62

3 Gottdiener JS Bednarz J Devereux R et al American Societyof Echocardiography recommendations for use of echocardi-ography in clinical trials J Am Soc Echocardiogr 2004171086-119

4 Quinones MA Otto CM Stoddard M Waggoner A Zoghbi

WA Recommendations for quantification of Doppler echo-

cardiography a report from the Doppler quantification taskforce of the nomenclature and standards committee of theAmerican Society of Echocardiography J Am SocEchocardiogr 200215167-84

5 Rychik J Ayres N Cuneo B et al American Society ofEchocardiography guidelines and standards for performanceof the fetal echocardiogram J Am Soc Echocardiogr 200417803-10

6 Shanewise JS Cheung AT Aronson S et al ASESCA guide-lines for performing a comprehensive intraoperative multi-plane transesophageal echocardiography examination recom-mendations of the American Society of Echocardiographycouncil for intraoperative echocardiography and the Society ofCardiovascular Anesthesiologists task force for certification inperioperative transesophageal echocardiography J Am SocEchocardiogr 199912884-900

7 Thomas JD Adams DB Devries S et al Guidelines andrecommendations for digital echocardiography J Am SocEchocardiogr 200518287-97

8 Zoghbi WA Enriquez-Sarano M Foster E et al Recommen-dations for evaluation of the severity of native valvular regur-gitation with two-dimensional and Doppler echocardiogra-phy J Am Soc Echocardiogr 200316777-802

9 Kisslo J Byrd B Geiser E et al Recommendations for con-tinuous quality improvement in echocardiography J Am SocEchocardiogr 19958S1-28

10 Stevenson JG Adherence to physician training guidelines forpediatric transesophageal echocardiography affects the out-come of patients undergoing repair of congenital cardiacdefects J Am Soc Echocardiogr 199912165-72

11 Kohn LT Corrigan J Donaldson MS To err is humanbuilding a safer health system Washington (DC) NationalAcademy Press 2000

12 Medicare ldquopay for performance (P4P)rdquo initiatives In Centers forMedicare and Medicaid Services Available from URLhttpwwwcmshhsgovmediapressreleaseaspCounter1343Accessed September 16 2005

13 Medicare pay-for-performance demonstration shows significantquality of care improvement at participating hospitals In Cen-ters for Medicare and Medicaid Services Available from URLhttpwwwcmshhsgovmediapressreleaseaspCounter 1441 Accessed September 16 2005

14 Institute of Medicine (US) Division of Health Care Ser-vices Lohr KN Institute of Medicine (US) Committee toDesign a Strategy for Quality Review and Assurance inMedicare (US) Health care financing administrationMedicare a strategy for quality assurance Washington(DC) National Academy Press 1990

15 Applegate KE Continuous quality improvement for radiolo-gists Acad Radiol 200411155-61

16 Ehler D Carney DK Dempsey AL et al Guidelines forcardiac sonographer education recommendations of theAmerican Society of Echocardiography sonographer train-ing and education committee J Am Soc Echocardiogr20011477-84

17 Kallmeyer IJ Collard CD Fox JA Body SC Shernan SK Thesafety of intraoperative transesophageal echocardiography acase series of 7200 cardiac surgical patients Anesth Analg2001921126-30

18 Lennon MJ Gibbs NM Weightman WM Leber J Ee HCYusoff IF Transesophageal echocardiography-related gastro-intestinal complications in cardiac surgical patients J Cardio-

thorac Vasc Anesth 200519141-5


19 Cahalan MK Abel M Goldman M et al American Society ofEchocardiography and Society of Cardiovascular Anesthesiol-ogists task force guidelines for training in perioperative echo-cardiography Anesth Analg 2002941384-8

20 Davila-Roman VG Phillips KJ Daily BB Davila RM Kou-choukos NT Barzilai B Intraoperative transesophageal echo-cardiography and epiaortic ultrasound for assessment of ath-erosclerosis of the thoracic aorta J Am Coll Cardiol 199628942-7

21 Eltzschig HK Kallmeyer IJ Mihaljevic T Alapati S ShernanSK A practical approach to a comprehensive epicardial andepiaortic echocardiographic examination J Cardiothorac VascAnesth 200317422-9

22 Quinones MA Douglas PS Foster E et al ACCAHAclinical competence statement on echocardiography a re-port of the American College of CardiologyAmericanHeart AssociationAmerican College of Physicians-Ameri-can Society of Internal Medicine task force on clinicalcompetence J Am Coll Cardiol 200341687-708

23 Rodgers GP Ayanian JZ Balady G et al American College ofCardiologyAmerican Heart Association clinical competencestatement on stress testing a report of the American Collegeof CardiologyAmerican Heart AssociationAmerican Col-lege of Physicians-American Society of Internal Medicine taskforce on clinical competence J Am Coll Cardiol 2000361441-53

24 Thys DM Clinical competence in echocardiography AnesthAnalg 200397313-22

25 Thus DM Abel M Bollen BA et al Practice guidelines forperioperative transesophageal echocardiography a report bythe American Society of Anesthesiologists and the Society ofCardiovascular Anesthesiologists task force on transesopha-geal echocardiography Anesthesiology 199684986-1006

26 Intersocietal commission for the accreditation of echocardiog-raphy laboratories newsletter Available from URLhttpwwwicaelorgicaelapplystandardshtm Accessed June14 2005

27 Ellis SG Weintraub W Holmes D Shaw R Block PC King

SB III Relation of operator volume and experience to proce-

dural outcome of percutaneous coronary revascularization athospitals with high interventional volumes Circulation1997952479-84

28 Jenkins KJ Newburger JW Lock JE Davis RB Coffman GAIezzoni LI In-hospital mortality for surgical repair of congen-ital heart defects preliminary observations of variation byhospital caseload Pediatrics 199595323-30

29 Mathew JP Fontes ML Garwood S et al Transesophagealechocardiography interpretation a comparative analysis betweencardiac anesthesiologists and primary echocardiographersAnesth Analg 200294302-9

30 Miller JP Lambert AS Shapiro WA Russell IA Schiller NBCahalan MK The adequacy of basic intraoperative trans-esophageal echocardiography performed by experienced anes-thesiologists Anesth Analg 2001921103-10

APPENDIX

MEMBERS OF THE COUNCIL FORINTRAOPERATIVE ECHOCARDIOGRAPHY

Chair Joseph P Mathew MD FASEVice-Chair Stanton K Shernan MD FASEMark Adams RDCS FASESolomon Aronson MD FASEAnthony Furnary MDKathryn Glas MD FASEGregg Hartman MDLori Heller MDLinda Shore-Lesserson MDScott T Reeves MD FASEDavid Rubenson MD FASE

Madhav Swaminathan MD FASE

American Society of Echocardiography Society of Cardiovascular Anesthesiologists Recommendations and Guidelines for Continuous Quality Improvement in Perioperative Echocardiography


DEFINITIONS FOR CQI


CQI

COMPONENTS OF PERIOPERATIVE ECHOCARDIOGRAPHY






Comprehensive Versus Limited Perioperative Examination


PRINCIPLES OF CQI

Acquisition of Primary Training and Technical Skills


Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX

MEMBERS OF THE COUNCIL FOR INTRAOPERATIVE ECHOCARDIOGRAPHY


the medical profession into a collaborative effort atbuilding a safer health care system A centerpiece ofthat strategy has been the assessment and improve-ment of quality in health care delivery Recently theCenters for Medicare and Medicaid Services haveinitiated several programs to improve quality inhealth care services that can best be described asldquopay for performancerdquo12 The first of these initiativesaims to improve quality of inpatient care to Medi-care beneficiaries by providing financial incentivesGiven the purported early success of this program13

expansion of the program to all health care servicesincluding echocardiography should be anticipatedPerioperative echocardiographers who establishCQI programs and demonstrate improvements inquality measures of their practice are likely to bewell positioned for this future

DEFINITIONS FOR CQI


Perioperative echocardiography involves the use ofcardiac ultrasound in surgical patients immediatelybefore during or after their operation and includestransesophageal epicardial epiaortic and transtho-racic approaches Practice locations may include theoperating room recovery room intensive care unitand echocardiography laboratory The various mo-dalities that comprise perioperative echocardiogra-phy include M-mode and 2- and 3-dimensional imag-ing and pulsed wave continuous wave color flowand tissue Doppler The echocardiographic data areobtained in real time and interpreted by a physicianin a timely manner to direct the clinical treatment ofsurgical patients These techniques may be com-bined with a variety of adjuncts such as contrastagents and may be used during a variety of physio-logic conditions including pharmacologic stress

CQI

The IOM has defined quality as ldquothe degree to whichhealth services for individuals and populations in-crease the likelihood of desired health outcomes andare consistent with current professional knowl-edgerdquo14 CQI is a management methodology adaptedby health care providers from business and industrythat is designed to identify and analyze problems inhealth care delivery More importantly once a prob-lem is identified CQI encourages the developmenttesting and implementation of solutions withoutassigning blame The essential elements of CQIinclude an ldquoorientation towards customers and sys-tems (processes) a commitment to understandingand minimizing process variations and the develop-ment of teams that can broaden vision and imple-

ment solutionsrdquo15 CQI in perioperative echocardi-

ography is a continual process characterized by 3assumptions about quality (1) technologic advance-ments in echocardiography may redefine qualityand therefore the ensuing recommendations(2) assessments of quality often require compari-sons and (3) quality is enhanced by repetitivepractice9

COMPONENTS OF PERIOPERATIVEECHOCARDIOGRAPHY


An ultrasound machine with full diagnostic capabil-ities is required to provide a comprehensive periop-erative echocardiographic examination At a mini-mum the system should be equipped with thecapacity for 2-dimensional Doppler (pulsed wavecontinuous wave and color flow) and M-modeimaging Each console should have a video screenthat can be made visible either directly or by anothermonitor screen to the surgeon and other cliniciansresponsible for the patientrsquos medical care All ultra-sound systems must also possess a system for per-manently recording data onto a media format thatallows for offline review or analysis Recently theASE made an unequivocal recommendation for anall-digital capture storage and review process7 Allperioperative echocardiographers are thereforeurged to move toward this digital standard by incor-porating the Digital Imaging and Communications inMedicine (DICOM) format high-speed networkingand permanent storage with built-in redundancy7

TEE probes used in the perioperative period shouldbe capable of multiplane imaging


In nonemergency settings outside of the operatingdepartment a request for an echocardiographicexamination should be activated by an order in thepatientrsquos hospital chart The intraoperative settinghowever is unique in that medical therapy deliveredtherein does not require individual and specificorders recorded on an order sheet Because deliv-ered therapy is always documented on the anesthe-sia record intraoperative echocardiographic ser-vices may be requested by the anesthesiologist anddocumented on the anesthetic record In manyinstitutions requests for intraoperative therapy aremade by the surgeon and thus requests for intra-operative echocardiographic services may also belisted on the posted surgical schedule In all in-stances the indications for performing periopera-tive echocardiography should be documentedclearly in the patientrsquos medical record either in theanesthesia record or on the report of echocardio-

graphic findings





















PRINCIPLES OF CQI



































eriope


ffectingho is a


inationtients a


ediatric























diography






Echocardiography 1


Advanced

300

150

eaining



perio

chocar

ed know

athologc mass

ds for c



perio

Basic

150

50

perativaphy tr

periopegraphy


iography














Periodic Review







in peri













tation o






Table 6 Continued







Use Review




tive action


h the p

correc

ment C



CQI IN PRACTICE



Conclusion


REFERENCES





































APPENDIX






DEFINITIONS FOR CQI


CQI









PRINCIPLES OF CQI



Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX






















PRINCIPLES OF CQI



































eriope


ffectingho is a


inationtients a


ediatric























diography






Echocardiography 1


Advanced

300

150

eaining



perio

chocar

ed know

athologc mass

ds for c



perio

Basic

150

50

perativaphy tr

periopegraphy


iography














Periodic Review







in peri













tation o






Table 6 Continued







Use Review




tive action


h the p

correc

ment C



CQI IN PRACTICE



Conclusion


REFERENCES





































APPENDIX






DEFINITIONS FOR CQI


CQI









PRINCIPLES OF CQI



Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX





















eriope


ffectingho is a


inationtients a


ediatric























diography






Echocardiography 1


Advanced

300

150

eaining



perio

chocar

ed know

athologc mass

ds for c



perio

Basic

150

50

perativaphy tr

periopegraphy


iography














Periodic Review







in peri













tation o






Table 6 Continued







Use Review




tive action


h the p

correc

ment C



CQI IN PRACTICE



Conclusion


REFERENCES





































APPENDIX






DEFINITIONS FOR CQI


CQI









PRINCIPLES OF CQI



Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX


ediatric























diography






Echocardiography 1


Advanced

300

150

eaining



perio

chocar

ed know

athologc mass

ds for c



perio

Basic

150

50

perativaphy tr

periopegraphy


iography














Periodic Review







in peri













tation o






Table 6 Continued







Use Review




tive action


h the p

correc

ment C



CQI IN PRACTICE



Conclusion


REFERENCES





































APPENDIX






DEFINITIONS FOR CQI


CQI









PRINCIPLES OF CQI



Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX


iography














Periodic Review







in peri













tation o






Table 6 Continued







Use Review




tive action


h the p

correc

ment C



CQI IN PRACTICE



Conclusion


REFERENCES





































APPENDIX






DEFINITIONS FOR CQI


CQI









PRINCIPLES OF CQI



Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX












tation o






Table 6 Continued







Use Review




tive action


h the p

correc

ment C



CQI IN PRACTICE



Conclusion


REFERENCES





































APPENDIX






DEFINITIONS FOR CQI


CQI









PRINCIPLES OF CQI



Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX



CQI IN PRACTICE



Conclusion


REFERENCES





































APPENDIX






DEFINITIONS FOR CQI


CQI









PRINCIPLES OF CQI



Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX

















APPENDIX






DEFINITIONS FOR CQI


CQI









PRINCIPLES OF CQI



Periodic Review



Use Review

CQI IN PRACTICE

Conclusion

REFERENCES

APPENDIX


cqiperiop

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