Rationale and Objectives
As a component of the practice-based core competency of the Accreditation Council for Graduate Medical Education, all radiology residents must receive training to be able to evaluate and improve their patient care practices. To achieve this goal, our quality management section has implemented a comprehensive elective rotation in quality assurance.
Materials and Methods
We have designed a month-long structured resident elective in radiology quality assurance at the Beth Israel Deaconess Medical Center, Harvard Medical School. This elective provides a combination of didactic teaching, self-learning, and practical experience in the methodology, workings, and clinical applications of quality assurance as these relate to improving technical and clinical performance in a large academic radiology department.
Results
During this rotation, residents are exposed to the spectrum of commonly used tools and techniques used for performance improvement related to the practice of radiology. By actively participating in department and hospital quality assurance (QA) committee meetings, and through initiation of a mentored project coupled with didactic instruction, residents are exposed first hand to the practice and role of continuous quality monitoring and to the implementation and monitoring of action items.
Conclusion
Participation in our QA elective provides our residents with a comprehensive exposure to the spectrum of quality-related problems, and equips them with the necessary tools to resolve many of the clinical or technical problems they are likely to encounter in their future careers. It is thus an appropriate tool to instruct residents in the competency of “practice-based learning and improvement.”
Quality assurance (QA) is now widely recognized as an essential process for improving clinical and technical operations in radiology departments ( ). We anticipate that our performance as radiologists will be more closely monitored and linked to defined quality metrics and benchmarks. In some academic centers, radiologist performance-based assessments have been introduced ( ) to monitor diagnostic and procedural performance metrics. It is likely that individual radiologist performance will be tied in with assignment of hospital privileges, incentive systems, and accreditation ( ).
Mentored training of residents and fellows in the basic principles of QA and quality improvement (QI) are now mandated by the Accreditation Council for Graduate Medical Education (ACGME) ( ). (Please see Appendix I for glossary of terms.) As an essential core component of the curriculum for all graduate medical education training programs, residents are expected to receive training in the basic principles of QA. Furthermore, for residency programs to be accredited by the ACGME, a functioning QA process must actively exist in the department, and trainees should participate in this process ( ). As a component of the ACGME practice-based learning and improvement competency (competency #3), trainees must be able to evaluate their patient care practices, appraise, and assimilate scientific evidence and improve their patient care practices ( ).
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Goals of elective
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Table 1
Learning Objectives of Radiology QA Elective and Criteria for Resident Evaluation
Objectives Criteria for Evaluation 1. To familiarize residents with available tools and methodology of quality assurance Completion of online risk management modules 2. To illustrate how data collection can be translated into improved performance Adverse event investigation report 3. To illustrate how performance improvement relates to patient safety in radiology Performance improvement project report 4. To complete a mentored research project and present results at department QA rounds Presentation at department QA grand rounds
QA: quality assurance.
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Structure of the elective
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Table 2
Overview of Weekly and Daily Structure of the QA Elective for Radiology Residents
Theme Mentor for Week Monday Tuesday Wednesday Thursday Friday Week 1 QA/QC Radiology quality control officer Meet with mentor Meet with HCQ nurse, Review project options Choose project, ED M & M Interventional radiology M & M Present at Surgical M & M, Online PI tools site, Review selected articles Medicine M & M Update online QA database Meet with mentor Week 2 Patient safety Radiology patient safety officer Work on project PACE rounds, Hospital QI directors meeting ED M & M, RQMT meeting, Review selected articles Surgical M & M Prepare cases for abdominal M & M Medicine M & M Present cases at abdominal M & M Meet with mentor QA nurse: JCAHO safety audits Week 3 Performance improvement Radiology QA director Didactic RMF presentation ED M & M, Article for newsletter Surgical M & M Medicine M & M Update QA database Meet with mentor Week 4 Risk management Hospital risk management director Work on project Hospital QI directors’ meeting ED M & M, RQMT meeting Surgical M & M Work on project Medicine M & M Update online QA database Present at radiology QA rounds Review and evaluation
QA: quality assurance; QC: quality control; ED: emergency department; M & M: morbidity and mortality; PI: performance improvement; PACE: Promoting Advances in Clinical Excellence; RQMT: radiology quality management team; JCAHO: Joint Commission on Accreditation of Healthcare Organizations; RMF: risk management foundation.
Table 3
Independent Study Materials and Recommended Websites for the Radiology Resident Participating in a Quality Assurance Elective
Week Recommended Websites Handouts for Reading Modules on www.RMFCME.com Lectures Available for Review on DVD 1
Nature and causes of errors and injuries Patient safety in radiology at BIDMC 2
Articles (6–10)
Preparing for the JCAHO visit at BIDMC 3 www.apiweb.org Tools for process improvement
Tools for performance improvement 4
Articles on failure to diagnose cancer Disclosure of unanticipated outcomes RMF lecture “BIDMC radiology risk management”
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Review of Online Radiology QA Website
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Tools for Quality Assurance
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Monitoring of our Online Radiology QA Reporting System
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Prepare and Present Cases at the Monthly Abdominal QI Meeting
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Attend and Participate in M and M Meetings
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Attendance at Hospital QI Directors Biweekly Meeting
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Clinical Audits
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Prepare a Brief Article for our Monthly Radiology QA Newsletter
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Initiation and Completion of a Research Project
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Lecture Preparation
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Discussion
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Table 4
Resident Quality Assurance and Performance Improvement Elective Projects and Their Outcomes
Elective Project Topic Outcome Reducing the incidence and risk of contrast nephropathy New hospital guidelines for contrast use have been established Communicating critical radiology results Specific results have been defined, and new policy established Evaluation of incident reporting in radiology Presented at radiology grand rounds Root cause analysis of interpretive errors in abdominal CT scans Presented at RSNA 2006 Analysis of misses in oncology follow-up CT scans Presented at RSNA 2005; exhibit at reading stations Increasing patient throughput in ultrasound Identified factors slowing down scanning time Why do cases get “lost” in our PACS system Established a dashboard to detect undictated cases Appropriateness of studies ordered in the ED A new educational program for ED residents Who participates in the pre-procedure timeouts? New policy has been written, approved and implemented Root cause analysis of diagnostic misses in abdominal CT scans Presented at RSNA 2006 Improving reader expertise in virtual colonography Technical factors identified to improve reader confidence Significance of nonvisualized appendix on a CT scan for suspected appendicitis Study published in Radiology 2006 Increasing patient throughput in the CT section Development of online protocol system Managing intravenous contrast reactions Create neck cards for all staff An audit of factors associated with changes in provisional reports Ongoing analysis
CT: computed tomography; RSNA: Radiological Society of North America; PACS: pictorial archival communications systems; ED: emergency department.
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Appendix 1
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APPENDIX 1
Lexicon of Terms
Term Abbreviation Brief Description Reference Quality assurance QA An integrated system of management activities (planning, implementation, assessment, reporting, and quality improvement) that focuses on providing confidence in the data or product by ensuring that it is of the type and worth needed and expected by the client. www.isixsigma.com/dictionary Quality control QC The system or procedure used to check product quality throughout the acquisition process. www.isixsigma.com/dictionary Quality improvement QI A management program for improving the quality of operations. www.isixsigma.com/dictionary Morbidity and mortality meeting M & M A meeting held to review deaths and adverse outcomes in patients, often as a component of audit and peer reviews. www.isixsigma.com/dictionary Performance improvement PI The concept of measuring the output of a particular process or procedure then modifying the process or procedure to increase the output, increase efficiency, or increase the effectiveness of the process or procedure. www.isixsigma.com/dictionary Accreditation Council for Graduate Medical Education ACGME A private, nonprofit council that evaluates and accredits medical residency programs in the United States; accreditation is accomplished through a peer review process and is based on established standards and guidelines. www.acgme.org Joint Commission for Accreditation of Healthcare Organizations JCAHO An organization that continuously improves the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. www.jcaho.org
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