Primer in quality improvement in radiology department

Dr/Ahmed BahnassyConsultant Radiologist

• Why hospitals should fly ?

In 1914, Dr. Codman said:You hospital superintendents are too easy. You work hard and faithfully reducing your expenses here and there—a half-cent per pound on potatoes or floor polish. And you let the members of the [medical]staff throw away money by producing waste products in the form of ill-judged operations and careless diagnoses.

IOM pivotal reports

• The first report, To Err is Human, estimated that nearly 44,000 Americans die each year as a result of medical errors.

• The second IOM report, Crossing the Quality Chasm, asked for a fundamental change based on 6 key dimensions :

Think STEEEPSafety—avoid injury to patients from the care that is intendedto help themTimeliness—reduce waits and harmful delaysEffectiveness—provide services based on scientific knowledgeto all who could benefit and refrain from providing servicesto those not likely to benefit (avoiding overuse andunderuse, respectively)Efficiency—avoid wasteEquitability—provide care that does not vary in quality becauseof personal characteristics such as gender, ethnicity,geographical location, and socioeconomic statusPatient centeredness—provide care that is respectful of andresponsive to individual patient preferences, needs, and values

signposts in the road of quality NHS experience

Radiology department and quality

The initial step is the gathering of relevant information, followedby the collection and analysis of quality and performance data; analysisand ranking of causes that likely contributed to a process failure,error, or adverse event; and prioritization and local implementationof solutions, with careful monitoring of newly implemented processesand wider dissemination of the tools when a process proves to be successful

Analysis of current state(brain storming )

SWOT analyses allow a department or organizationto identify major internal and externalstressors as well as opportunities for improvement. Internal factors to consider include the strengths and

weaknesses of a product or service. External factors include possible new opportunities and any

threats, limitations,or competition that may exist.

Fishbone diagram analysis (ishikawa)

actual problem

long waiting list of ultrasound

Road to SolutionsIn generating solutions to an identified problem,consideration must be given not only to minimizingthe effect or impact that introducing suchsolutions has on a department and its personnel,but also to defining, achieving, and maintaininga so-called preferred (ideal) state.

A brainstorming session may be required to define the preferred

state. In defining this state, it is important to seek input from all customers. Once the preferred state has been defined, a strategy must be mapped out for optimal achievement of the desired goals.

P-D-S-A• The Plan-Do-Study-Act (PDSA) cycle is

integral to rapid-cycle change methodology with emphasis on the “S” or study part of the cycle. Once data is collected, study is the analysis and interpretation phase, and when it is completed, an organization can proceed to “A” or acting on the data.

P-D-S-A In planning to implement change, one shoulddevelop a time line, assign ownership, monitorand measure the consequences and impact, andconsider contingencies in case not everythinggoes as expected.

If the solution is not working, it is importantto consider the following questions: (a) Was the plan for implementation properly

executed?(b) Was the selected solution the correct one?(c) Was the initial problem attributed to the wrongcause? In such a setting, one should reanalyze theinitial problem

In addition, it is important to consider whether the educational plan was

adequate and whether all staff were adequately informed, trained, and prepared for the change. Each of these domains offers possible reasons why an implemented “improvement” is not having the intended consequences.

The QI Plan is a detailed, and overarching organizational work plan for the health care organization's clinical and service quality improvement activities

A QI Project is born out of the QI Plan.

How to write a quality improvement plan

The process for developing and implementing a quality improvement plan incorporates the following:

1.An issue is identified through a variety of sources (e.g., member complaints, providers, over or under utilization, clinical quality or safety, or administrative quality indicators).

2.The issues with the greatest impact on the enrolled population are identified based on demographics, utilization and cost of care. Quality indicators are then selected (i.e., it is determined what will be measured and how it will be measured). Through this step, it is determined what data is appropriate for measurement.

3.Data is collected and reviewed for performance and/or outcomes.

4.Targets for improvement are set.

5.A specific work plan is developed that will lead to improvement in performance and/or outcomes.

6.The plan is approved or modified as necessary and implemented.

7.After an appropriate time period, new data may be gathered to assess the success of the plan for improvement or data may be gathered at regular intervals on an ongoing basis for continuous assessment of performance.

8.Through analysis of the data, barriers to improvement are identified.

9.Based on the analysis, a decision is made regarding the next step:a.Continue the process as is with the same indicators/data monitoringb.Continue the process with modifications (i.e., implement additional interventions to remove identified barriers)c.Add new monitors/quality indicatorsd.Stop monitoring.

10.New thresholds are developed or current targets are maintained.

11.A new work plan is developed.

Sources..ACRhttp://www.acr.org/Quality-Safety/Quality-Measurement/Quality-in-Practice/PQI-Projects

sources..ABRhttp://www.theabr.org/moc-dr-pqiguides

sources..personal

http://radiologyquality.com/(S(hyzd4055rgy5ujzimi2bwobg))/default.aspx

Example 1 Standardized Reporting of Lumbar Spine

MRI FindingsPurpose and RationaleThis project aims to increase utilization of the standard lexicon in MRI reports of the lumbar spine.There is enormous variability in the terms used in reporting lumbar spine MR findings. Various phrases and words used are confusing to clinicians reading the reports. There is no standardization in the various terms used to describe the same process, (e.g. herniated disc versus disc extrusion).The ASNR has come up with a standard lexicon to be used for pathologic findings on lumbar spine MRI reports. That lexicon has been incorporated into the comprehensive radiology lexicon, RadLex. Utilization of this lexicon by all radiologists reading MRI scans of the lumbar spine would standardize the reporting and make it easier for clinicians to understand the implications of the findings.

Resources : Consensus Nomenclature and

classification of Lumbar Disc Pathology – recommendations of the combined taskforce of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology www.asnr.org/spine_nomenclature.

http://www.rsna.org/Informatics/radlex.cfm

Measure: Numerator Number of MRI reports of the lumbar spine

utilizing the appropriate lexicon /Denominator total # of MRI reports of the lumbar spine

Collecting baseline data Review the lexicon and make a determination about

which of the terms you wish to make the focus of your project. It may be all of the lexicon terms, or it may be a subset of particular importance to your practice (e.g., disc herniation descriptions including the terms of extrusion, protrusion, sequestration).

Example 2Appropriate Management of Indeterminate Pulmonary

Nodules Found on CTPrimary Authors: Jeffrey P. Kanne, M.D. Ella A. Kazerooni, M.D. M.S.Purpose and Rationale This project focuses on adherence to appropriate recommendations for follow-up of

small, indeterminate pulmonary nodules detected on thoracic CT. Incidental pulmonary nodules are found on 30-50% of thoracic CT studies.

Radiologists’ recommendations for follow-up may be inconsistent. Individual practices or institutions may or may not have an existing policy for follow-up of incidentally detected indeterminate pulmonary nodules.

The Fleischner Society has released guidelines for management of small pulmonary nodules detected on CT scans.1 Practices may have a policy that is based on these guidelines or may have estab lished their own. The goal of this project is to monitor and improve adherence to the practice policy.

Project Resources Guidelines for management of small pulmonary nodules detected on CT scans: a

statement from the Fleischner Society. MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, Patz EF Jr, Swensen SJ; Fleischner Society. Radiology 2005 Nov;237(2):395-400.

Data Analysis The goal is to achieve high compliance

with the policy. There may always be cases for which some deviation from the policy is medically appropriate, so 100% compliance may not be reasonable or desirable. It is reasonable, however, to set a goal of 0 cases containing no follow-up recommendation.

anayzing causes of low performance

1. Lack of radiologist knowledge/awareness of current Fleischner Society guidelines or your institution policy.

2. Lack of a standard reporting template.3. Lack of familiarity with or use of reporting

templates. Here, work with IT staff or colleagues to integrate the templates into the practice workflow and promote their use.

4. Lack of a transcriptionist template for nodule follow-up. Here, work with the transcription staff or company to adopt a pulmonary nodule follow-up template.

Other examples of quality projects

• Standardizing thyroid ultrasound report.• Pulmonary embolism report template.• Turn around time decrease from A&E.• Decrease of exposure of pediatric patient

in fluoroscopy ,CT .• Accuracy of ultrasound brain in neonates.• PIRADS• LIRADS The list is endless..