Kanne, Jeffrey P. MD
Modern quality management originated in the years following World War II and focused on manufacturing. W. Edwards Deming, an American industrial engineer and statistician, brought his ideas of quality control (QC) to Japan in the early 1950s when large American industrial companies showed no interest.1,2 Subsequently, Japan's weak economy was bolstered by efficient production of high-quality products, and Japan became a major competitor of the United States in the world economy, now with one of the largest economies in the world. Not until the 1970s, with growing overseas competition, did American companies begin implementing Deming's quality management programs.3 Health care is a latecomer to the quality management arena. Major articles on the topic were not published until 1989,4,5 and a national survey of US hospitals in 1993 indicated that more than two-thirds of the institutions had begun implementation of some type of quality management program, most within the past couple of years. However, most of these programs were focused on administrative and operational functions, such as document archiving and billing.6
Recently, quality management has become a focus of the practice of radiology. This is exemplified by the American Board of Radiology incorporating practice quality improvement (PQI) into its requirements for the maintenance of certification.7 Although still in its infancy, PQI has become a focus, and to some degree a concern, for individual radiologists, academic and private institutions, and professional radiologic societies. Already within the early years of maintenance of certification, PQI requirements have increased from 1 project to 3 projects within the 10-year cycle beginning with diplomates certifying in 2008.8 To support these requirements, the American Board of Radiology and other radiologic organizations have increased content, including templates for PQI projects.9
The purpose of this article is to provide an overview of quality management as it pertains to cardiopulmonary imaging and describe specific areas of cardiopulmonary radiology in which the components of a quality management program can be integrated. Specific quality components are discussed, and examples of quality initiatives are provided.
TERMINOLOGY IN QUALITY MANAGEMENT
A number of terms and abbreviations pertaining to quality management frequently are encountered in daily practice as well as in departmental, hospital, and professional organizational meetings. Terms such as QC, quality assurance (QA), and quality improvement (QI) may be used interchangeably when, in reality, each represents a very different component of quality management (Table 1). The most extreme example encountered in the author's professional experience is the common use of the moniker “QA guy” by colleagues to refer to the person responsible for quality management and improvement within the department.
QC has been a part of radiology for most of its history. QC establishes and maintains a range of standards that are considered acceptable for practice (Fig. 1). QA is more encompassing than QC and focuses on systematic data collection and evaluation with the goal of improving patient care through establishing and maintaining a certain level of quality. Although QC is an integral part of any QA program, QA focuses more on specific metrics thought to influence the quality of services provided.10
In contrast to QC and QA, QI has evolved more into a philosophy or culture in health care rather than a purely methodologic quality management program.6 The goal of QI is to step beyond what is perceived to be a consistent level of acceptable quality in order to continuously improve quality through a comprehensive system-wide approach.11 First, problems are identified, and solutions are proposed and implemented. Second, measurements are obtained to assess the effectiveness of solutions. Finally, the solutions are further modified, and results measured again. This process continues again and again until no further improvements are deemed possible.
Like QC and QA, QI initiatives can be developed and managed by an individual or small group of individuals in a practice. However, unlike QC and QA, QI requires all members of a practice to ascribe to the QI values and goals selected and to actively participate in a QI project.
QUALITY IN CARDIOPULMONARY RADIOLOGY
Quality management programs in cardiopulmonary radiology can include aspects of QC, QA, and QI, and they can be the purview of a single radiologist, all members of the cardiopulmonary section in a subspecialty-based practice, or an entire department. Projects and programs can be comprehensive or focus on a particular area such as image acquisition, accuracy of interpretation, or report turnaround time (Table 2).
QUALITY MANAGEMENT TEAM
A quality management team (Fig. 2) provides an optimal approach to developing and implementing a radiology quality management program. Centralization of quality management has the potential to effect more change in a practice, as this group enables input from all members of the health care team to be integrated into QC, QA, and QI projects. In addition, the quality team can serve as the liaison between the radiology department and referring physicians as well as hospital leadership. Coordination of quality projects allows focusing of resources, including personnel and financial, to achieve the greatest gains.
The makeup of a quality management team will vary among practices and depends on practice setting, operational structure, and size of practice. For example, a small radiology practice operating out of an outpatient imaging center may have one radiologist designated to supervise quality in conjunction with a supervising technologist. In contrast, a large hospital-based practice in an academic medical center may have a quality team composed of physician leadership, radiology residents and fellows, informatics support, modality managers, as well as hospital support staff. No matter what the composition of a quality team, each member needs to both serve and be received as an active and valued member who shares the common goal of improving patient care.
QC in chest radiography has 2 components. The first component of QC in chest radiography includes routine testing and maintenance of imaging equipment, usually performed through service contracts and oversight by medical physicists.12 QC also applies to routine digital radiography hardware calibration, cleaning and replacing phosphor plates, and software upgrades. The second component focuses on the quality of images submitted for interpretation. Each radiologist has a certain threshold of image quality deemed acceptable for interpretation and reporting based on factors such as proper labeling, image contrast, and patient positioning. Radiographs that fall outside these standards are usually considered unacceptable, and a repeat examination may be requested. Today, with an ever-increasing number of examinations performed, a supervising technologist often is responsible for QC in a general imaging department, minimizing the number of unacceptable images submitted to the radiologist for interpretation. This “gatekeeper” role serves as the transition to a QA approach to chest radiography.
QA, as it pertains to the performance of chest radiography, aims to minimize the number of inadequate radiographs obtained. This occurs through technologist training and continuing education. QA for the interpretation of chest radiographs generally centers on peer review and report turnaround time.
QI in chest radiography receives less attention than it does for computed tomography (CT) or magnetic resonance imaging (MRI) because chest radiography has been a part of daily practice in radiology for over a century and has changed very little following the transition from film screen to digital equipment. A QI program in chest radiography can involve the participation of other clinical services such as the intensive care unit or emergency department, with the goal of reducing the number of “routine” or unnecessary chest radiographs using tools such as the American College of Radiology's Appropriateness Criteria13 or other hospital-based protocols.
Although CT scanning of the chest has been a part of radiologic practice for a few decades, advances in CT technology have resulted in the development and implementation of new applications such as volumetric high-resolution CT, 3-dimensional dynamic airway imaging with virtual bronchoscopy, and CT pulmonary angiography.
QC for chest CT is similar to that of chest radiography and includes equipment maintenance such as routine scanner calibration, scheduled maintenance, and software upgrades. QA programs for performance chest CT include standardized acquisition protocols across a practice to minimize acquisition errors, technologist training and continuing education, and monitoring nondiagnostic rates for CT pulmonary angiography. Radiologist QA for chest CT includes activities such as peer review, report turnaround time, and radiology-pathology correlation.
One example of a QI project for chest CT is selecting, implementing, measuring, and re-evaluating standard recommendations for follow-up of incidentally detected lung nodules. The recently published Fleischner Society guidelines for the management of incidentally detected small lung nodules could be adopted by an individual or, more commonly, a cardiopulmonary section or entire radiology practice.14,15 The success of this activity requires that all components of quality management be addressed. The QC component of this initiative is having these (or other agreed on) guidelines readily available to all radiologists. Measuring and reporting the percentage of reports where a radiologist made appropriate follow-up recommendations based on these guidelines comprise the QA component. The QI initiative goes to the next step and identifies why the selected criteria are not used or used consistently and correctly, and attempts to establish methods that improve the frequency and appropriate use of these guidelines.
Potential barriers that may lead to inappropriate use of such guidelines include some radiologists being uncomfortable or unfamiliar with the selected guidelines, incomplete understanding of the selected guidelines (eg, how to measure a nodule or what defines “high risk”), or lack of standardized reporting templates facilitating the use of these guidelines. QI aims to overcome these barriers by proposing solutions to recognized shortcomings, implementing these solutions, and reevaluating performance following implementation, making further modifications as needed.
As cardiac CT is a newer tool in the cardiopulmonary radiologist's armamentarium, expertise in image acquisition and interpretation is more limited than with noncardiac chest CT.
QC for cardiac CT is similar to that of routine chest CT. QA is somewhat more involved because some patients receive drugs such as β-blockers and nitrates to optimize image quality. The QA facet of cardiac CT is usually handled by standardized protocols for medication administration based on heart rate and underlying cardiopulmonary conditions such as asthma, conduction defects, and valvular disease. A simple QI initiative in cardiac CT could include instituting a program that cross-trains all CT technologists to perform an electrocardiogram (ECG)-gated cardiac CT scan, including selecting and producing additional image reformations as prescribed by the departmental protocol. Cross-training could be supplemented with regular in-services and ready access to appropriate continuing education. The 2 goals of this QI project are to ensure that cardiac CT is performed at the highest level possible and to ensure that this service is available regardless of technologist staffing schedules.
A comprehensive quality program is essential for operating a successful cardiopulmonary MRI program. As a result of the development of new image acquisition sequences, the number of clinical and research applications in cardiopulmonary MRI continues to grow. Thus, quality management of a cardiopulmonary MRI program requires constant review and updating.
QC in cardiopulmonary MRI centers primarily on scanner hardware and software maintenance, including routine upgrades. QA programs for performing cardiopulmonary MRI include developing and maintaining standard image acquisition protocols and technologist training and continuing education. Training all technologists in ECG placement and performing cardiac MRI is an example of a QA program that can increase the availability of cardiac MRI.
Because of the high magnetic field strengths used in MRI, a comprehensive safety program as part of QA needs to be in place.16 A standardized screening form for patients and other individuals who may accompany the patients into the MRI suite is an excellent tool to minimize the risk of ferromagnetic foreign bodies entering the bore or causing injury. Furthermore, medical personnel should also undergo MRI safety training when applicable.
QI projects in cardiopulmonary MRI can focus on image acquisition or patient safety. One sample project includes developing a method to provide feedback to technologists about the studies performed. For example, some picture archiving and communications systems or radiology information systems have built-in quality management functions allowing radiologists to provide feedback to technologists regarding the technical quality of studies. This type of feedback allows supervising technologists to identify common problems, identify individuals who require additional training, or even identify hardware or software issues. Metrics can be exam-type specific, technologist specific, or error specific. The goals of this project should focus on reducing the number of studies with suboptimal image quality or missing sequences through positive feedback, additional training when necessary, or refining of image acquisition protocols.
Image-guided procedures are a logical start for any quality management program, as data including complication rates and diagnostic yield can be easily measured for each radiologist and compared with peers as well as published data. Many cardiopulmonary radiologists perform fluoroscopic or CT-guided transthoracic needle biopsies. QC for transthoracic needle biopsy includes routine maintenance of imaging equipment, availability of previous studies for review before biopsy, maintaining a stock of necessary supplies, and observing institutional or departmental standards for informed consent. Rates for pneumothorax and other complications, as well as diagnostic yield, timeliness of scheduling, and proper specimen labeling are the primary focus of QA.
Although robust QC and QA programs for lung biopsy can ensure a high level of patient care, QI initiatives can be put into place to improve the patient experience. Potential QI projects for lung biopsy include reducing time from request to biopsy through schedule optimization, reducing the number of nondiagnostic biopsies by having onsite cytologic evaluation or performing core needle biopsy at the time of the initial procedure if the fine needle aspirate is insufficient, and developing a video or electronic presentation explaining the procedure and making it available to patients through departmental or hospital web sites to reduce anxiety related to the procedure. As with any QI project, problems are identified, changes are made, results are measured, data are evaluated, and modification is undertaken to further improve these processes. This cycle is repeated until the process is fully optimized, after which acquisition and analysis of selected metrics are performed periodically to ensure that the highest quality level is maintained.
Radiation safety is an essential component of the practice of radiology. Both technologists and radiologists play very active roles in minimizing patient exposure to ionizing radiation. This is particularly important in light of recent reports suggesting that overutilization of CT in the United States may result in radiation-induced cancer.17,18 The European Union established the concept of clinical audits for radiology practices in 1997.19 Although costly and time consuming, these audits can identify potential changes in practices that reduce patient exposure to unnecessary ionizing radiation. For example, a follow-up audit undertaken in Southwest Finland in 2007 showed improvement in various quality metrics, including decreased patient radiation exposure, after changes were implemented based on results of the initial audits between 2003 and 2005.20
QC for radiation safety includes designating a radiation safety officer for the practice or institution. Medical physicists can perform phantom studies and equipment assessment to ensure normal function and acceptable x-ray tube output. Depending on state and local requirements, operators of x-ray equipment should have the appropriate certification and continuing education.
QA in radiation safety centers around preventing patients from being exposed to excessively high levels of radiation by monitoring metrics such as dose-length product (DLP) and volume CT dose index. Dose-area product or fluoroscopy time can be documented for patients undergoing fluoroscopic procedures. Examinations resulting in patients receiving higher than expected doses for a particular diagnostic imaging study should be investigated for underlying causes such as technologist error, hardware or software malfunction, or patient factors such as metallic fixation hardware or obesity.
Radiation safety is an excellent and timely opportunity to design and participate in a QI project. An example of a QI project for cardiopulmonary imaging is to reduce patient radiation exposure in cardiac CT angiography (CTA). Several techniques are available on newer multidetector CT scanners, such as tube current modulation, using a lower kVp in smaller patients, and prospective ECG gating. DLP and volume CT dose index can be recorded before and after protocol modification to quantify overall dose reduction. If possible, collaboration with a medical physicist who has expertise in cardiac CTA may be of great value to achieve the optimal balance between image quality and radiation exposure.
Depending on one's practice pattern and workflow, quality management programs may focus only on the interpretation and reporting of diagnostic imaging studies. This may be a typical scenario with a teleradiology service that has little or no control over image acquisition. In addition, image interpretation and reporting are radiologist-specific activities and are a practical place to begin an individual or small group QI project.
QC measures in interpretation fall into the categories of image presentation, examination reporting, and the individual radiologist. QC for image presentation includes maintaining an operational picture archiving and communications system or film panel alternator for hard copy examinations, either of which is essential for proper image interpretation. Furthermore, the physical environment for diagnostic imaging interpretation needs to have appropriate lighting and privacy. QC for examination reporting focuses on the maintenance of dictation equipment, whether a dedicated dictation system or voice recognition (VR) software. QC for the radiologist is standardized at most institutions and includes board certification, state licensure, and specific privileges granted by credentialing committees.
Peer review dominates in the QA arena with regard to image interpretation. Peer review programs can vary and can rely on an internally developed system or a commercially available product. Peer review involves a second independent interpretation of an imaging study and documenting the level of agreement of the reviewer with the initial interpretation. Metrics for each radiologist, examination type, and diagnosis can be obtained, and comparisons can be made across a section or department and compared with published data.
Applying QI principles to peer review greatly increases its, with the goal of continuously improving the diagnostic accuracy of each radiologist. The metrics obtained through the QA activities of peer review can be used to identify specific deficiencies, allowing for development of an educational program targeted to the individual needs of each radiologist. In addition to “missed” cases conferences, which aim to provide a forum for an open, nonpunitive group discussion of difficult cases, peer review data can help an individual radiologist identify further learning needs that can be addressed through continuing medical education, self-assessment modules, and other forms of independent study. Ongoing measurements of peer review data can provide insight into whether a specific education program is leading to improved diagnostic accuracy.
Peer review, however, has its limitations. Time constraints limit the number of examinations that can be reviewed. Peer review programs that require a radiologist to review a certain number of examinations per day or week may result in selection bias favoring less complex or normal examinations. Moreover, peer review in cardiopulmonary radiology can be particularly challenging, as the number of “peers” in a practice may be limited because of the relatively low number of subspecialized cardiopulmonary radiologists. Finally, a discordant interpretation may boil down to differences of opinions because true reference standards are not always available.21
The radiology report is the final product of the radiologist. It is a formal means of communicating the interpretation of a diagnostic imaging study to the referring physician and documenting these results in the patient's permanent medical record. Although increased use of VR dictation software has not been shown to significantly impact the efficiency of radiologists,22 VR can significantly decease report turnaround time.23 VR also facilitates creation and use of templates or structured reports, which can be implemented individually or throughout an entire practice. Another benefit of reporting templates is to reduce the number of addenda necessary for coding and billing requirements. For example, including the generation of 3-dimensional reformations can be incorporated into the standard reporting template for CT pulmonary angiograms or coronary CTA.
QC for radiology reporting focuses mainly on maintaining operational dictation equipment, such as microphones and VR software, and ensuring functional communication with hospital and radiology information systems. The cornerstone of a successful QC program for reporting is having adequate technology support, whether internal or through a contract with a third-party vendor.
QA programs for radiology reporting most commonly include measuring report turnaround time (Table 2). However, adherence to standard report templates and documentation of data such as DLP, fluoroscopy time, and medication administration (eg, β-blockers for cardiac CTA) can also be part of a QA program.
Some researchers propose uniform use of radiology reports to standardize and optimize communication between the radiologist and the referring physician.24 Furthermore, surveys of referring physicians have shown a preference for standardized formatting of radiologic reports.25,26 However, it is imperative to assess the preferences and needs of one's own referring physicians before adopting a standardized reporting template, as the perceptions of radiologists referring to the needs of physicians may be incorrect.27
Structured reporting can be part of any QA program. An example of a structured reporting template in cardiopulmonary imaging is one for reporting coronary CTA.28 The findings can be organized into subsections including coronary arteries, cardiac chamber morphology, pericardium, functional data if obtained, aorta and other major vascular structures, and extracardiac findings. This allows clinicians to easily find the data they need within each report, similar to echocardiography reports generated in many institutions.
Aside from decreasing report turnaround time, QI for radiology reporting is a relatively new concept. The author posits that most radiologists are satisfied with the style in which they report diagnostic imaging studies and any request to make substantial changes would likely be met with resistance. A simple QI project using a template for lung nodule follow-up can expand beyond follow-up recommendations and focus on a systematic method of labeling nodules in the radiology report, facilitating easier comparison on follow-up examinations, and facilitating understanding by other radiologists and referring physicians as to which nodule a particular measurement or description applies. Some third-party vendors offer similar reporting mechanisms on their advanced workstations as part of their lung nodule evaluation packages.
COMMUNICATION OF CRITICAL OR UNSUSPECTED RESULTS
Failure to communicate critical or unsuspected results can adversely affect patient care. Furthermore, failures to communicate these findings and to document the communication are leading causes of malpractice litigation for radiologists.29,30 Most institutions in the United States have adopted critical tests and critical results policies as a result of the mandate from the Joint Commission, an independent organization responsible for the accreditation and certification of the quality of health care organizations in the United States.
QC for communications includes ensuring that correct referring physician contact information is readily available for radiologists. A list of institution-defined critical results should also be readily available. Communication QA initiatives can include monthly or quarterly auditing of randomly selected reports to identify any critical results documented and whether they were communicated to an appropriate care provider in the designated amount of time from detection. The QI approach to communications leads to the implementation of programs that streamline communication and documentation of important results to referring physicians. These QI initiatives may include the use of integrated electronic solutions and carbon copying a designated individual in the emergency department for incidental but important findings such as indeterminate lung nodules or other lesions that require further outpatient evaluation and management.
A successful quality management program in cardiopulmonary radiology and medical practice generally depends on the adoption of a culture of quality and safety in which all members of the health care team are dedicated to continuous improvement in the delivery of health care. Although leaders with expertise and interest in QI can develop, implement, and manage a departmental quality management program, the participation by all individuals involved in patient care is key to the program's success. Taking on small quality initiatives such as improving report turnaround time or decreasing the number of suboptimal portable chest radiographs is the stepping-stone that can ultimately lead to a more comprehensive quality management program (Table 3). By shifting from a paradigm of QC and QA to one of continuous QI, the practice of radiology can meet the challenges of the everevolving practice of medicine.
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