Nearly all the published articles on quality improvement initiatives in radiology fall into one of two categories: articles outlining different approaches to quality improvement and articles describing successful quality improvement projects . Largely missing from the literature are examples of the trials and tribulations of quality improvement efforts, including accounts of how such efforts have failed. In this article, we briefly summarize some of the key features of a quality improvement program, describe a particular quality improvement effort in which we participated, and then discuss in greater detail how this quality improvement fell short and lessons to be learned going forward.
Kruskal et al. have identified key features of successful quality improvement programs. These include institutional leadership and support, just culture of safety and quality, an effective process for managing “customer” relations, a well-functioning quality management team, continuous engagement of all staff in the quality process, and the use of appropriate tools for measuring results. As this list makes clear, many of these factors are often not under the control of any radiologist or even any radiology department, at least when it comes to larger-scale projects such as hospital-wide initiatives, and this proved crucial in the case we are describing.
We refer to this quality improvement project as the magnetic resonance imaging (MRI) Safety Initiative. It grew out of a convergence of two factors. First, beginning in the summer of 2013, MRI technologists at a large urban hospital had expressed concern about a number of “near misses” that had occurred in the MRI suite, including security staff approaching the MRI suite with their belts and holsters on, housekeeping staff rolling their cleaning carts toward the magnet, and patients being brought to the waiting room with various non–MRI-safe apparatuses in place, such as wound vacs. Second, both a radiology resident and an attending radiologist on the abdominal imaging service in the facility were seeking to define a quality improvement project.
During the fall of 2013, the resident and attending met multiple times to develop an online, MRI safety, education module that could be shared with all hospital employees to help them better understand the key principles and practices of interacting safely with MRI. With a draft of this educational module in hand, they contacted the clinical education department of the hospital. Despite sending multiple e-mail messages and leaving multiple messages on voicemail, they received no response over a 3-month period.
With the help of the MRI technologists, the module was then presented in January 2014 to nonradiologist managers in the radiology department. These individuals expressed interest in implementing the module and further presented it to the hospital’s risk management director in a meeting at which the radiologists were not present. Then, shortly thereafter, the radiologists received an e-mail from the director of hospital risk management, saying that they wanted to implement the program within the next few days in preparation for a Joint Commission visit the following week.
This represented a dramatic change in the institution’s posture, from not even acknowledging the quality improvement team’s efforts to establish contact to saying that the educational module needed to be deployed within the space of a week. What happened? As it turned out, there had been a safety incident in the MRI suite, in which a metallic gas canister had been brought into the MRI suite and had damaged the scanner, requiring it to be shut down for repairs. Fortunately, no patient had been present at the time of the incident. This incident had evidently “lit a fire” beneath hospital administration, and an attitude of indifference had been supplanted by one of urgency.
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References
1. Griffith B., et. al.: Improving imaging utilization through practice quality improvement (maintenance of certification part IV): a review of requirements and approach to implementation. Am J Roentgenol 2014; 202: pp. 797-802.
2. Winklehner A., et. al.: Iterative reconstructions versus filtered back-projection for urinary stone detection in low-dose CT. Acad Radiol 2013; 20: pp. 1429-1435.
3. Tamm E.P., et. al.: Quality initiatives: planning, setting up, and carrying out radiology process improvement projects. RadioGraphics 2012; 32: pp. 1529-1542.
4. Kruskal J.B., et. al.: Quality initiatives, quality improvement in radiology: basic principles and tools required to achieve success. RadioGraphics 2011; 31: pp. 1499-1509.
5. National Patient Safety Goals. The Joint Commision. Available at: http://www.jointcommission.org/standards_information/npsgs.aspx . Accessed July 21, 2014
6. Centers for Medicare and Medicaid. Quality initiatives: general information. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGen-Info/index.html?redirect=/qualityinitiativesgeninfo . Accessed July 21, 2014
7. Hawkins C.M., Nagy P.: Quality improvement projects for residents. JACR 2013; 10: pp. 301-302.
8. Nagy P., et. al.: Tips for incorporating quality improvement projects into a residency program curriculum. JACR 2011; 8: pp. 84-85.