DEPARTMENTAL CQI IMPLEMENTATION:REALITIES

Richard L. Baron, M.D.

Chair, Dep’t of Radiology

University of Chicago

CQI Implementation:Background

• Department Goal: incorporate CQI process into routine sectional operations

• Sectional bonus compensation pool:– 2/3 objective; 1/3 subjective– 3 measurable areas for improvement

• Clinical service; education; academic

• Meet mutually pre-agreed upon criteria

CQI Planning Requirements

• Clinical focus (not administrative)• Incorporated into routine (as frequently as

possible) • Must incorporate all physician members of

section, including residents & fellows• Should engage external people interfacing

with operational procedures• Must not be a single, end point but

continuous evaluation and analysis

PROCESS

• Choosing CQI project

• Getting started

• Recording data

• Analysis of data

• Instituting Change

The Problem:• Many MDCT PE studies are done on an

emergency basis after hours• Large variations in exam quality occur• Lack of consistency in results, due to many

practical issues of training and implementation of scan protocols.

• Beta test site for not yet released CT equipment

Pulmonary Embolism CTA: CQI Project

Chest Imaging Section, U of C

Analysis of quality• Indentify all PE CT scans over weekly periods• Review reports for non-diagnostic/suboptimal

scans• Review for opacification (HU>200), motion, noise.• Classify and quantitate causes of poor quality• Intervene with improvements• Remeasure

Chest Imaging Section, U of C

Pulmonary Embolism CTA: CQI Project

Interventions:

• Tracker location: Change to from PA to descending aorta• Tracker image: Improve quality with higher mA• I.V. location and size: Specify above wrist at least 20g• Arm position: Raised with hands on scanner• Contrast bolus: Increase rate from 4 to 5cc/sec• Record new breath-hold instructions: Avoid deep breath• Eliminate obsolete or redundant protocols from scanners• In-service training session for all technologists

Chest Imaging Section, U of C

Pulmonary Embolism CTA: CQI Project

Pulmonary Embolism QA Project

Pulmonary Embolism CTA QA Project

September : 25% Non-diagnostic January: 5% Non-diagnostic

Chest Imaging Section, U of C

Issues• Choosing CQI project

• Getting started

• Recording data

• Analysis of data

• Instituting Change– Remeasure, Reanalyze

– Handle Depression

MSK CQI Project

• PLAN: Improve radiographic quality/patient care• METHOD: Two days/mo all plain films evaluated by

attendings/fellow– Type of Exam; Location; Quality of exam– Cases rated as poor discussed at MD – Tech

quarterly meetings• RESULTS:

– Certain clinics had better quality than others– Certain exam types had repeated lower quality– No change seen in any of above during process and

quality was actually measured lower at end of project• ACTION:

– Cases rated as poor discussed in quarterly tech meetings

Peds Radiology CQI Project• PLAN: Improve clinical history for portable radiographs

• METHOD: Review one week of Requisitions/Records– 2 radiologists (attending and resident)– 3 pediatricians (intensivist and 2 residents)

• RESULTS:– 139 requests in 32 patients– 53 adequate; 86 inadequate

• ACTION:– Two educational lectures @ morning rounds– Pediatric intensivists personally contacted– Pediatric residents rotating through radiology educated

•RESULTS @ 5 Months:– 138 requests 30 patients– 49 adeq; 89 inadequate

CULTURE STRATEGY

CULTURE EATS STRATEGY FOR LUNCH SEVEN DAYS A WEEK

Issues

• Choosing CQI project– Look around operations. What are problems– Individual approach to problems rather than sectional– Tackling something too big– Tackling something too small without recurring

analysis problems or not meaningful enough

• Getting started• Recording data• Analysis of data• Instituting Change

Issues

• Choosing CQI project• Getting started

– Daily focus on clinical work, academic work– Sectional approach – personalities– Lack of experienced approach

• Doesn’t recognize not getting started properly

– Data collection overwhelming (need to simplify)

• Recording data• Analysis of data• Instituting Change

Issues

• Choosing CQI project• Getting started• Recording data• Analysis of data• Instituting Change

– MD willingness to integrate meaningfully with nonradiologist management to effect change

Issues

• Choosing CQI project• Getting started• Recording data

– Systematic– Proper data– Time Consuming

• Analysis of data• Instituting Change

– Remeasure, Reanalyze

Must become part of routine (almost daily) procedures

General Issues

• Physicians not trained in management– Few management minded MDs get training– Academicians attend specialty meetings - lack of presence

• Physician workload interferes– Priorities of immediacy

• Education lacking– Importance of process to department

• Department functionality • Image of Department in Hospital• Finances of Department

– Efficacy of CQI to improve patient outcomes and physician work effort

• Physicians are individual process oriented – the realities require group oriented processes

• Physicians and personnel from other departments may be difficult to engage (for same reasons as above)

• Choosing CQI projects – Carefully to ensure early success– Start within department before tackling out of

department• Getting started

– Provide simple, but substantial assistance• Department administrative support• Other physician CQI leaders• Won’t wait for sections to ask for help

• Recording data• Analysis of data

• Instituting Change– Each section works closer with Department CQI

Committee, with monthly reporting and integration with all aspects of Department

DEPARTMENTAL CQI IMPLEMENTATION:

FUTURE AT UCH