Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care. Focused educational curricula are necessary to teach quality and safety-related skills and behaviors to trainees, staff members, and physicians. The increasingly complex healthcare landscape requires that organizations build effective data infrastructures to support quality and safety research. Incident reporting systems designed specifically for medical imaging will benefit quality improvement initiatives by identifying and learning from system errors, enhancing knowledge about safety, and creating safer systems through the implementation of standardized practices and standards. Finally, validated performance measures must be developed to accurately reflect the value of the care we provide for our patients and referring providers. Common metrics used in radiology are reviewed with focus on current and future opportunities for investigation.
Introduction
The Institute of Medicine (IOM) brought much attention to medical errors and the quality of health care in the United States through their pivotal report “To Err is Human” in 1999. Two years later, in “Crossing the Quality Chasm,” the IOM recommended a strategy for improving quality by promoting patient-centered aims, aligning payment policieswith quality improvement, practicing evidence-based medicine, and developing an information technology infrastructure . Despite national efforts to drive these changes through meaningful use, national quality goals, and payment incentives such as the Practice Quality Reporting System, the effects on care quality and delivery have been limited in the face of rising costs.
As proposed by the IOM, recent legislation has sought to align quality improvement with new payment policies. Scheduled to begin as early as 2019, the Medicare Access and CHIP Reauthorization Act will increasingly tie quality to reimbursement through the Merit Based Incentive Payment (MIPS) program and Advanced Alternative Payment Models. Of the two, most physicians are expected to be reimbursed through MIPS, in which quality (50%) and clinical practice improvement activities (15%) comprise the majority of the reimbursement criteria . Although these measures have yet to be finalized, robust quality and safety programs will be necessary to improve patient care and will determine physician reimbursement going forward.
Given the need for change through quality improvement activities, the AUR Radiology Research Alliance convened a task force to explore this topic, with the results presented in this review. This article examines five key dimensions of a quality and safety program including an organization’s safety culture, incident reporting, education requirements, information technology infrastructure, and common performance measures in radiology. Opportunities for current and future research in each category are discussed in the following sections.
Culture of Safety
Health organizations that establish a culture of safety operate with fewer adverse safety events . A positive safety culture recognizes that medical errors are often caused by underlying systems-level issues, and that human error is inevitable within a highly complex and dynamic healthcare environment . Rather than blaming and punishing individuals for errors, individuals are encouraged to speak up and disclose both errors and near-misses, so as to uncover latent issues, learn from mistakes, and facilitate crafting solutions that will mitigate future events . A culture of safety embraces the role of all workers in reducing patient harm, decreases authority gradients, and empowers frontline staff to make changes toward improvements . Providing a work environment where staff feel comfortable and safe in disclosing errors, without fear of retribution, facilitates such a system .
The related concept of “just culture” balances the focus on systems-level issues with individual accountability . A just culture considers an individual’s intent, adherence to safety procedures, and history of unsafe acts in determining the level of responsibility and associated consequences . This model recognizes that safety problems are exacerbated and errors underreported if individuals with good intention are punished for errors that occur while following standard procedures . Individuals are thus disciplined only in the setting of unjustified reckless behavior.
Measuring Institutional Culture
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Creating a Culture of Safety
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Quality and Safety (QS) Education
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Incident Reporting in Imaging
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IT Infrastructure
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Radiology Quality and Safety Performance Metrics
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TABLE 1
Individual and Group Performance Indicators by IOM Quality Aims
IOM Aim Example of Individual Radiologist PI Example of Group PI Safe Adherence to patient safety policies, participation in incident reporting, critical results reporting Institutional dose reduction programs, facility design, call to order process for procedures Timely Critical results reporting, report turnaround time, daily management huddle participation Patient wait time, time from order to study completion Efficient Application of ALARA principles, incidental findings management Room turnaround times, reducing system overutilization, RVU per FTE, and measuring value-added work Effective Standardized reporting, use of subspecialty guidelines, evidence-based use of imaging techniques, radiology-pathology correlation participation Measuring adverse events within department, use of ACR appropriateness criteria, clinical decision support Equitable Practicing within the promoted local diversity culture Providing uniform access to imaging services/follow-up across socioeconomic status, adjusting waiting areas and consent procedures to be gender and culturally sensitive Patient centered Number of patient counseling sessions, named positively in patient satisfaction surveys, knowledge of patient history when selecting the imaging protocol and interpreting the imaging studies Providing patient radiology information through online portals, adjusting procedure consent, and reporting information to lay terms
ACR, American College of Radiology; IOM, Institute of Medicine; RVU, relative value unit; FTE, full time employee; ALARA, as low as reasonably achievable.
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TABLE 2
Performance Metrics Grouped by Elements of Patient Care
Element of Care Definition Examples Structure Setting of healthcare delivery to the patient Professional certification, maintenance of certification, licensure, advanced certification, other professional skills, daily management huddle participation Process Delivery of care to the patient Use of appropriateness criteria, critical results reporting, report turnaround times, adherence to ALARA principles, adherence to local patient safety policies, participation in incident reporting, providing a patient-centered experience Outcome Contribution to the patient’s health outcome and satisfaction Infection rates, wrong site events, procedural complication rates, biopsy yields
ALARA, as low as reasonably achievable.
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Individual Versus Group Performance Metrics
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Benchmarking and Overview of National Efforts
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Commonly Used Quality and Safety Performance Indicators
Radiation Dose Monitoring and Optimization
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Decision Support for Ordering Providers
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Critical Results Reporting
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Report TATs
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Peer Review
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Procedural Competency
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Conclusion
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