1. Primer in quality improvement
in radiology department
Dr/Ahmed Bahnassy
Consultant Radiologist

2. • Why hospitals should
fly ?
In 1914, Dr. Codman said:
You hospital superintendents
are too easy. You work hard
and faithfully reducing your
expenses here and there—a
half-cent per pound on potatoes
or floor polish. And you let the
members of the [medical]
staff throw away money by
producing waste products in the
form of ill-judged operations
and careless diagnoses.

3. IOM pivotal reports
• The first report, To Err is Human,
estimated that nearly 44,000 Americans
die each year as a result of medical errors.
• The second IOM report, Crossing the
Quality Chasm, asked for a fundamental
change based on 6 key dimensions :

4. Think STEEEP
Safety—avoid injury to patients from the care that is intended
to help them
Timeliness—reduce waits and harmful delays
Effectiveness—provide services based on scientific knowledge
to all who could benefit and refrain from providing services
to those not likely to benefit (avoiding overuse and
underuse, respectively)
Efficiency—avoid waste
Equitability—provide care that does not vary in quality because
of personal characteristics such as gender, ethnicity,
geographical location, and socioeconomic status
Patient centeredness—provide care that is respectful of and
responsive to individual patient preferences, needs, and values

5. signposts in the road of quality
NHS experience

6. Radiology department and quality
The initial step is the gathering of relevant information, followed
by the collection and analysis of quality and performance data; analysis
and ranking of causes that likely contributed to a process failure,
error, or adverse event; and prioritization and local implementation
of solutions, with careful monitoring of newly implemented processes
and wider dissemination of the tools when a process proves to be
successful

8. Analysis of current state(brain
storming )
SWOT analyses allow a department or organization
to identify major internal and external
stressors as well as opportunities for improvement.
Internal factors to consider include the strengths and
weaknesses of a product or service.
External factors include possible new opportunities and any
threats, limitations,or competition that may exist.

9. Fishbone diagram analysis
(ishikawa)

10. actual problem
long waiting list of ultrasound

11. Road to Solutions
In generating solutions to an identified problem,
consideration must be given not only to minimizing
the effect or impact that introducing such
solutions has on a department and its personnel,
but also to defining, achieving, and maintaining
a so-called preferred
(ideal) state.
A brainstorming session may be required to define the
preferred
state. In defining this state, it is important to seek input from all
customers. Once the preferred state has been defined, a strategy
must be mapped out for optimal achievement of the desired goals.

12. P-D-S-A
• The Plan-Do-Study-Act (PDSA) cycle is
integral to rapid-cycle change
methodology with emphasis on the “S” or
study part of the cycle. Once data is
collected, study is the analysis and
interpretation phase, and when it is
completed, an organization can proceed to
“A” or acting on the data.

13. P-D-S-A
In planning to implement change, one should
develop a time line, assign ownership, monitor
and measure the consequences and impact, and
consider contingencies in case not everything
goes as expected.

14. If the solution is not working, it is important
to consider the following questions:
(a) Was the plan for implementation properly
executed?
(b) Was the selected solution the correct one?
(c) Was the initial problem attributed to the wrong
cause? In such a setting, one should reanalyze the
initial problem

15. In addition, it is important to consider
whether the educational plan was
adequate and whether all staff were
adequately informed, trained, and
prepared for the change. Each of these
domains offers possible reasons why an
implemented “improvement” is not having
the intended consequences.

17. The QI Plan is a detailed, and overarching
organizational work plan for the health
care organization's clinical and service
quality improvement activities
A QI Project is born out of the QI Plan.

18. How to write a quality improvement
plan
The process for developing and implementing a quality
improvement plan incorporates the following:
1.An issue is identified through a variety of sources (e.g.,
member complaints, providers, over or under utilization,
clinical quality or safety, or administrative quality
indicators).
2.The issues with the greatest impact on the enrolled
population are identified based on demographics,
utilization and cost of care. Quality indicators are then
selected (i.e., it is determined what will be measured and
how it will be measured). Through this step, it is
determined what data is appropriate for measurement.
3.Data is collected and reviewed for performance and/or
outcomes.
4.Targets for improvement are set.

19. 5.A specific work plan is developed that will
lead to improvement in performance
and/or outcomes.
6.The plan is approved or modified as
necessary and implemented.
7.After an appropriate time period, new data
may be gathered to assess the success of
the plan for improvement or data may be
gathered at regular intervals on an
ongoing basis for continuous assessment
of performance.

20. 8.Through analysis of the data, barriers to improvement are
identified.
9.Based on the analysis, a decision is made regarding the
next step:
a.Continue the process as is with the same
indicators/data monitoring
b.Continue the process with modifications (i.e.,
implement additional interventions to remove identified
barriers)
c.Add new monitors/quality indicators
d.Stop monitoring.
10.New thresholds are developed or current targets are
maintained.
11.A new work plan is developed.

22. Sources..ACR
http://www.acr.org/Quality-Safety/Quality-Measurement/Quality-in-Practice/PQI-Projects

23. sources..ABR
http://www.theabr.org/moc-dr-pqiguides

24. sources..personal
http://radiologyquality.com/(S(hyzd4055rgy5ujzimi2bwobg))/default.aspx

25. Example 1
Standardized Reporting of Lumbar Spine
MRI Findings
Purpose and Rationale
This project aims to increase utilization of the standard lexicon in
MRI reports of the lumbar spine.
There is enormous variability in the terms used in reporting lumbar
spine MR findings. Various phrases and words used are confusing
to clinicians reading the reports. There is no standardization in the
various terms used to describe the same process, (e.g. herniated
disc versus disc extrusion).
The ASNR has come up with a standard lexicon to be used for
pathologic findings on lumbar spine MRI reports. That lexicon has
been incorporated into the comprehensive radiology lexicon,
RadLex. Utilization of this lexicon by all radiologists reading MRI
scans of the lumbar spine would standardize the reporting and make
it easier for clinicians to understand the implications of the findings.

26. Resources :
Consensus Nomenclature and
classification of Lumbar Disc Pathology –
recommendations of the combined
taskforce of the North American Spine
Society, American Society of Spine
Radiology, and American Society of
Neuroradiology
www.asnr.org/spine_nomenclature.
http://www.rsna.org/Informatics/radlex.cfm

27. Measure:
Numerator Number of MRI reports of the lumbar spine
utilizing the appropriate lexicon /Denominator total # of
MRI reports of the lumbar spine
Collecting baseline data
Review the lexicon and make a determination about
which of the terms you wish to make the focus of your
project. It may be all of the lexicon terms, or it may be a
subset of particular importance to your practice (e.g.,
disc herniation descriptions including the terms of
extrusion, protrusion, sequestration).

28. Example 2
Appropriate Management of Indeterminate Pulmonary
Nodules Found on CT
Primary Authors: Jeffrey P. Kanne, M.D.
Ella A. Kazerooni, M.D. M.S.
Purpose and Rationale
This project focuses on adherence to appropriate recommendations for follow-up of
small, indeterminate pulmonary nodules detected on thoracic CT.
Incidental pulmonary nodules are found on 30-50% of thoracic CT studies.
Radiologists’ recommendations for follow-up may be inconsistent. Individual practices
or institutions may or may not have an existing policy for follow-up of incidentally
detected indeterminate pulmonary nodules.
The Fleischner Society has released guidelines for management of small pulmonary
nodules detected on CT scans.1 Practices may have a policy that is based on these
guidelines or may have estab lished their own. The goal of this project is to monitor
and improve adherence to the practice policy.
Project Resources
Guidelines for management of small pulmonary nodules detected on CT scans: a
statement from the Fleischner Society. MacMahon H, Austin JH, Gamsu G, Herold
CJ, Jett JR, Naidich DP, Patz EF Jr, Swensen SJ; Fleischner Society. Radiology
2005 Nov;237(2):395-400.

29. Data Analysis
The goal is to achieve high compliance
with the policy. There may always be
cases for which some deviation from the
policy is medically appropriate, so 100%
compliance may not be reasonable or
desirable. It is reasonable, however, to set
a goal of 0 cases containing no follow-up
recommendation.

30. anayzing causes of low performance
1. Lack of radiologist knowledge/awareness of
current Fleischner Society guidelines or your
institution policy.
2. Lack of a standard reporting template.
3. Lack of familiarity with or use of reporting
templates. Here, work with IT staff or colleagues
to integrate the templates into the practice
workflow and promote their use.
4. Lack of a transcriptionist template for nodule
follow-up. Here, work with the transcription staff
or company to adopt a pulmonary nodule followup template.

31. Other examples of quality projects
•
•
•
•
Standardizing thyroid ultrasound report.
Pulmonary embolism report template.
Turn around time decrease from A&E.
Decrease of exposure of pediatric patient
in fluoroscopy ,CT .
• Accuracy of ultrasound brain in neonates.
• PIRADS
• LIRADS
The list is endless..