Guidelines for PQI Projects

Projects in the five topic areas highlighted below could be designed by individual radiologists, radiology practice groups or departments, institutions, healthcare systems, or by professional radiology societies. Every radiologist participating may receive PQI credit for the project. Some projects may also offer CME credit through the normal CME approval process.

Because the key competencies to be addressed through PQI projects include systems-based practice, practice-based learning and improvement, and interpersonal/communication skills, the ABR strongly encourages incorporating others involved in providing care to radiology patients into the project team.

Projects selected to meet the practice quality improvement (Part IV) requirement of the ABR's Maintenance of Certification (MOC) program should:

• Be relevant to your practice
• Be achievable in your practice setting
• Produce results that are suited to repeat measurement during your MOC cycle
• Be reasonably expected to bring about quality improvement

PQI Projects broadly conform to the following template. The appropriate steps within a PQI Project are:

1. Select a topic area in which you would like to see your practice improve, and within it, decide on a challenge that is relevant to your practice.
2. Decide what specifically you will measure to assess current performance and future improvement. Create a data collection form to record the measurements, if one does not already exist.
3. Make a baseline measurement in an appropriate number of cases drawn in an unbiased manner.
4. Analyze results.
5. Identify the potential root causes of error or suboptimal performance.
6. Develop a written improvement plan.
7. Implement the plan.
8. Remeasure.
9. Decision point: determine whether you have met your performance goal. If so, select another project to start while maintaining the gains made in the initial project. If not, continue with the initial project.

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Project Guidelines by Topic Area

Patient Safety

See example of a patient safety intiative

Individual practitioners, medical professional societies, and healthcare institutions are addressing national patient safety priorities. PQI projects in patient safety enable ABR diplomates to take part in this important movement.

PQI project examples in patient safety may be drawn from the 2007 National Patient Safety Goals, Hospital Version Manual Chapter Including Implementation Expectations . These are developed through broad-based consensus, updated, and published annually by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The following are example 2007 goals and implementation expectations, each of which could form the basis of a PQI project:

• Goal 1: Improve the accuracy of patient identification
• Goal 2: Improve the effectiveness of communication among caregivers
• Goal 3: Improve the safety of using medications
• Goal 7: Reduce the risk of healthcare-associated infections. Under this topic, Implementation Expectation 7A (Comply with Current Center for Disease Control and Prevention Hand Hygiene Guidelines) is an important potential project for any diplomate working in a department where multiple personnel (physicians, nurses, technologists, aides) handle patients. See the CDC Hand Hygiene Guidelines .
• Goal 9: Reduce the risk of patient harm resulting from falls
• Goal: Fulfill the expectations set forth in JCAHO's Universal Protocol

In addition to JCAHO's National Patient Safety Goals, patient safety PQI projects may be developed in accordance with the National Quality Forum's 30 Safe Practices for Better Healthcare , the reports of the National Council on Radiation Protection and Measurements , and other national iniatives.

Other examples of Patient Safety PQI project topics that are particularly relevant to radiology include:

• Safe use of iodinated contrast material
• Radiation safety
• MR safety

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Practice Guidelines

PQI projects in practice guidelines will make use of the current practice guidelines published by the American College of Radiology. The diplomate or group planning the project is required to use the Communications Guideline and select one other guideline relevant to its practice.

The most important aspect of the communications guideline is the communication of urgent, critical or unexpected findings. The points to be evaluated by answering yes or no to each are:

1. Is there a list of the findings that the group agrees are urgent to communicate with the referring physician (e.g., pneumothorax, free intraperitoneal air, malpositioned life support devices, etc.)?
2. Is such a list communicated to the members of the group?
3. Is there a process to determine documentation of communication of urgent, critical findings?

For each answer of "no" to the above, a solution(s) should be incorporated into the written improvement plan.

For the second, elective guideline, the diplomate or group must select at least one aspect of that guideline (e.g., technique for performing examination) and audit one percent of annual cases. The criterion for acceptable performance is the guideline being followed, or valid documentation of reason for variance, in 100 percent of cases.

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Accuracy of Interpretation (Double Reading)

Accuracy of imaging interpretation is fundamental to the practice of diagnostic radiology. Ideal PQI projects in this category have the following characteristics:

• Easily implemented/integrated into practice routines
• Generate results suitable for entry into local or national registries for comparison with other radiologists
• Provide objective or semiquantitative metrics such as error rate and assessment of error significance

Three such projects could be based on the following:

• Double readings of imaging examinations
• Radiology-pathology correlation, or correlation with surgical findings
• Participation in RADPEER™

RADPEER™ is a product of the American College of Radiology. Diplomates desiring to use RADPEER™ for their participation in Part IV (practice quality improvement) of MOC should consult the American College of Radiology to enroll. Participation in RADPEER™ may not by itself fulfill the entire PQI requirement. Consult the steps in the PQI project process and the PQI guidelines for specific requirements.

Projects based on double readings or radiology-pathology correlation could be designed by individual diplomates, groups, or professional radiology societies.

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Referring Physician Surveys

The quality of one's practice can be improved by assessing its strengths and weaknesses and developing a plan to improve the areas of greatest opportunity. In most cases, the benefits of diagnostic imaging are not realized until the referring physician acts upon the results of the study. Thus, the radiologist's communication with that physician and the feedback on the quality of care the radiologist delivers is valuable.

A sample referring physician survey is posted below. This survey instrument, or others developed by a professional radiology society or your own healthcare system, may be used.

For those selecting this project, the survey must be administered at least times. A minimum of 20 responses at each administration is recommended, to ensure that an adequate number of data points can be plotted to detect improvement. After tabulating the results, an improvement action plan for improving the weakest area(s) must be developed. The second survey should be administered after the action plan has been in place for at least one year. This process of tabulating survey results and developing an action plan for improvement must be done again and followed with a third survey at least one year after the improvement plan has been implemented.

The survey results and improvement plans are to be kept by the participant(s). The survey materials, either paper or electronic, must be retained by the participants throughout the 10-year cycle.

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REFERRING PHYSICIAN SURVEY

Communication with referring physicians is an essential part of patient care. We would like to know how well the radiologist communicates with you. Your answers are confidential, so please be as honest as you can.

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Reporting Timeliness and Critical Value Reporting

See example of a report timeliness initiative

The objectives of a PQI project in the topic area "Report Timeliness" are:

• Measure and document the timely communication of results of imaging examinations.
• Measure and document direct communication of critical values.

In most cases, report timeliness will require data collection at the practice or departmental level. Data collection at the individual level may also be permissible.

Such projects are expected to impact patient safety and improve outcomes; to reduce errors, morbidity, and complications; to improve patient satisfaction; to increase compliance with standards; and to improve practice efficiency and communications. For example, one of the JCAHO 2007 National Patient Safety Goals is to improve the effectiveness of communication among caregivers. Meeting this goal requires that when orders are given verbally or by telephone, or when critical test results are reported by telephone, the person giving the order or report should have the person receiving the information verify the information by "reading back" the complete order or test result.

For those selecting report timeliness as a project, there should be an existing departmental or individual process for measuring and reporting time from examination completion to approval of final report, or a plan for implementing such a process. For those selecting critical value reporting as a project, there should be an existing departmental or individual process for measuring and reporting time from the identification of a critical value to the communication of results to a caregiver, or a plan for implementing such a process.

Those having neither an existing process for making such measurements, nor the ability to generate such a process, should select another project.

The following represent the minimum data to be collected for a report timeliness project:

• Measure of time from examination completion to posting of results in the medical record
• Number of cases in the audit
• Mean and/or median time from exam completion to availability of report to caregivers

The following represent the minimum data to be collected for a critical value reporting project:

• Measure of time from identification of critical or unexpected finding to notification of caregiver
• Number of cases in the audit
• Mean and/or median time from exam completion to availability of report to caregivers
• Compliance with departmental /institutional policy regarding notification of critical values

The project should include the following comparison to benchmarks:

For report timeliness:

• Departmental mean
• Individual performance/prior audits

Critical value reporting:

• Requirements of departmental critical value reporting policy