1

USING TEAM AUDITS TO IMPROVE

IMAGE QUALITY:

Our Institution’s Experience

Lincoln L. Berland, MD

Deborah D. Flint, PE, BIE, MBA

Beth S. Winningham, BSRT, MBA

UAB Health System

900-bed Facility and Level 1 Trauma Center

Outpatient Center providing examinations and treatment

rooms for 660 physicians

219-bed facility acquired by UAB Health System in 2006

2

81 resident, fellow and faculty radiologists working in various

imaging subspecialties

Imaging Areas include:

Abdominal Imaging

Breast Imaging

Chest Imaging

Cardiopulmonary

Emergency Radiology

General Radiology

Interventional Radiology

Molecular Imaging and Therapeutics

Musculoskeletal Imaging

Neuroradiology

Pediatric Imaging

Physics & Engineering

VAMC

UAB Radiology

Background

• Radiologists believed that image quality was

sub-optimal too often

• Avoidable errors were being made

• Sub-optimal image quality could negatively

affect patient care

• Overall patient experience could be negatively

affected

3

Background

• In response, Image Quality Audit Teams were

formed

• Teams Consist of:

• Radiologists

• Technologists

• Radiology Educator

• Facilitator

Background

• This new image quality project was sponsored by:

• Radiology Vice Chair of Quality Improvement and Patient

Safety

• Radiology Vice Chair for Operations

• Administrative Director of Radiology, UAB Hospital

4

Exam Quality Audit Team Timeline

2009: CT Exam Quality Audit Team formed

(UAB Hospital and UED only)

2011: TKC and UAB Highlands CT added to CT Audit Team

2011: Diagnostic Radiograph Audit Team formed

(UAB Hospital and UED only)

2013: MRI Exam Quality Audit Team formed

(UAB Hospital, UED, TKC, and UAB Highlands)

2015: TKC Diagnostic, Highlands Diagnostic and Highlands

Orthopedic will be added to the Diagnostic Radiograph

Audit Team

• Each month team members review a set of exams randomly selected

by the team facilitator.

• Team members use a predetermined list of criteria based on the

factors that are most critical to optimal image quality. Each item is

scored with “yes” or “no.”

• Criteria include but are not limited to:

• Appropriate area scanned

• Appropriate field of view and centering

• Appropriate technical factors

• Are avoidable artifacts present

• Is the area of interest over scanned

• Appropriate contrast dose and documentation

• Appropriate contrast enhancement

• Are markers present and correct (no electronic markers used)

• Is the exam or protocol correct for the indication given on the order

Audit Process Overview

5

• Completed audits are returned to the facilitator to be summarized.

• Summarized audits are reviewed at the monthly team meetings.

• Feedback from the meetings is given back to radiology staff

through staff meetings, email, notice boards and one to one

meetings.

• The number of exams in each audit are based on a 95%

confidence interval

• The same basic protocol is used for all of the audit teams,

however, some variation in image selection and review is allowed

due to the differences in the imaging modalities being reviewed

Audit Process Overview-continued

• Each month the team reviews images selected from a

designated section.

• Auditing by section allows for more exams of each type to be

reviewed

• Physicians are able to attend the meetings related to their

specialty/section and provide feedback for improvement

• Sections for CT include:

• Neuro

• Body

• Chest

• Musculoskeletal

• Vascular Interventional

• Top opportunities for improvement are identified

• Yearly summaries are given for each section and for CT

overall

CT Exam Quality Audit

6

Example of Audit Summary: CT

97.1%

98.4%

96.3%

95.0%

95.5%

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

Oct-13 Mar-14 Aug-14

Audit scores represent the percentage of the audit without errors

FY14 CT Exam Audit Scores--Neuro

(includes UABH, UED, UAB Highlands, TKC and Acton Road)

Audit scores for each section are reported to the

team after the audits are reviewed in the monthly

meeting. The audit summary report for CT shows

the percentage of the audit without errors.

Pareto of Audit Summary Opportunities for Improvement: CT Neuro

27%

55%

82%

91%

100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%

120%

0

1

2

3

4

1. Entire area

scanned?

2.

FOV/centering

6.

Overscanned?

4. kVp 7. Doc

contrast dose

approp?

3. mAs 5. Rem obj

causing

artifacts?

8. Contrast

enhancement

approp?

9. ROI placed

approp?

10. Threshold

approp?

Opportunities for Improvement-Neuro FY 14

YTD Cumulative %

Opportunities for improvement

are identified and tracked

7

• Each month, techs review a selection of images from

Chest, Musculoskeletal and GI imaging (excluding fluoro).

• The top opportunities for improvement are identified.

• Current top three opportunities for improvement being

tracked are:

• Markers missing or electronic markers used

• Poor positioning

• Anatomy excluded

• Overall monthly audit results are given for each of the three

sections

• Audit results for the top opportunities for improvement are

tracked

• Yearly summaries are given for each section and for the top

opportunities for improvement

Diagnostic Radiography

Example of Audit Summary:

Diagnostic Radiography

0.00

0.05

0.10

0.15

0.20

0.25

Diagnostic Radiograph Audit Results Error Rate by Exam Type(Audit Scores represent the percentage of the audit with errors)

MSK CHEST GI (Abdomen)

The audit summary report for

Diagnostic Radiography shows the

percentage of the audit with errors

8

Pareto of Audit SummaryOpportunities for Improvement: Diagnostic Radiography

44%

78%

89%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%

120%

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

August 14 Diagnostic Radiograph Audit

MSK Chest GI (Abdomen) Cumulative %

Opportunities for improvement

are identified and tracked

Example of Audit Summary:

Diagnostic Radiography

0.0%

2.5%

5.0%

7.5%

10.0%

Pe

rce

nt

of

Au

dit

ed

Exa

ms

wit

h N

o M

ark

er

err

or

typ

e

Diagnostic Radiograph Audit

Type of Error: No Markers

MSK CHEST GI

The opportunities for improvement that are

most often seen are tracked for each exam

type. Note: Electronic markers are not

permitted and are considered “No Markers.”

9

• Each month the team reviews images from a particular

section.

• Sections for the MRI audit includes:

• Neuro

• Body

• Breast

• Musculoskeletal

• Top opportunities for improvement are identified

• Current top opportunities for improvement include:

• Patient motion

• Artifacts present

• Yearly summaries are given for each section and for MRI

overall

MRI

Example of Audit Summary: MRI

92.9% 93.8%96.2%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Dec-13 Apr-14 Aug-14

(Audit scores represent the percentage of the audit without errors)

MRI Exam Quality Audit Scores -Body FY 14

Audit scores for each section are reported to

the team after the audits are reviewed in the

monthly meeting. The audit summary report for

MRI shows the percentage of the audit without

errors.

10

Pareto of Audit Summary Opportunities for Improvement: Body MRI

25%

50%

72%

86%92% 94% 97% 100% 100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%

120%

0

1

2

3

4

5

6

7

8

9

10

MRI Exam Quality Audit: Body Opportunities for Improvement

Sep-14 Cumulative %

Opportunities for improvement are

identified and tracked.

Results: CT

6.3% decrease in errors from the baseline to Present

This report represents the percentage

of the audit without errors.

90.3%

94.4%

92.8%

94.8%

96.3%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

**FY 10 FY 11 *FY12 FY 13 FY 14

**Baseline

CT Exam Audit Scores--All Sections

(includes UABH, UED, UAB Highlands, TKC. Acton Road)

*TKC and UAB Highlands added to the audit

11

Results: Diagnostic Radiography

Decrease in errors from baseline

MSK: 9.0%

Chest: 12.9%

GI (Abdomen): 4.8%

87%

83%

91%

96%

85% 85%

95%

98%

85%85%

89%

90%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Jan-12 Jan-13 Jan-14 YTD 14

Diagnostic Radiograph Audit Scores

MSK CHEST GI (Abdomen)

This report represents the percentage

of the audit without errors.

Results: MRI

0.2% decrease in errors from the baseline

94.5% 95.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

FY 13 FY 14

MRI Exam Quality Audit Scores- All Sections

This report represents the percentage

of the audit without errors.

12

• All areas have seen a decrease in preventable errors

• Opportunities for improvement are more easily identified

and tracked

• Improvement plans are determined jointly by the

technologists performing the exams and the radiologists

reading them

• Communication between the technologists and

radiologists is more open both in and outside of the

teams

Conclusions

• Staff members are more engaged in quality improvement

because they are active participants in the process

• Team members are publicly recognized for excellent work

identified during the audits

• Staff with outstanding recognitions are identified as

potential mentors for new staff members

• Best practices in exam performance and quality management are

taught to new staff from the beginning of employment

Conclusions-continued

13

UAB School of Medicine Department of Radiology

http://www.uab.edu/medicine/radiology/

Sources