Quality in Emergency RadiologyHow we do it

Dinesh VarmaAssociate Professor

Acting Director of RadiologyHead of Emergency and Trauma

RadiologyThe Alfred & Monash University.

Melbourne1

Quality

• Practice Management System • Equipment • Personnel• Regisitration and Licencing• CPD• Professional Supervision• Appropriateness of Request and Patient

Preparation

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Safety• Safety of the Practice Environment • Infection control• Patient management• Radiation Safety

– ALARA Principle – Compliance with Radiation Safety

Legislation – Radiation Safety Officer – Waste Management – Use of Contrast Media

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Purpose• Commitment to Best Practice through an evidence-based

culture,• Focus on patient outcomes and equity of access to high quality

care• An attitude of compassion and empathy. • Acting with Integrity • Ethical approach: doing what is right, not what is expedient; • Forward thinking and collaborative attitude and patient-centric

focus. • Accountability • Strong leadership that is accountable to patients

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Quality Manager

•The practice personnel records identify: the quality manager and his/her associated job description; OR •that the role of quality manager is fulfilled within the practice across more than one position, and the practice can identify which personnel members fulfill this role and how this is co-ordinated.

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Quality Manual

The quality manual includes a quality policy defining the quality objectives. The quality policy is issued under the authority of senior management, Ensures continual improvement of the effectiveness of the management system and to the quality of all services provided.

•It includes policies relating to the management system. •It outlines the structure of the practice’s documentation hierarchy. •It makes reference to supporting documentation. •It defines the role and responsibilities of management personnel, including the Quality Manager.

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Documentation

Document on policies, guidelines and procedures A master list of controlled documents shall be maintained which identifies the current version and distribution of documents.

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Documentation

Established documentation systemAll documents are uniquely identified to include the date of issue or revision number, page numbering and the issuing authority. Define how changes to documents are to be made and controlled including documents maintained in computerised systems. Periodically reviewed and revised when necessaryOnly current versions of documents are available.

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Documentation

Master copies of old and/or superseded document versions are retained or archived for legal and knowledge preservation purposes and are appropriately identified.

When its examinations involve remote reporting via teleradiology, the practice has documentation clearly defining the agreed responsibilities of both the examining and reporting sites. This includes issues of liability, patient safety, transmission arrangements, report turnaround times and confidentiality.

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Records

Procedures shall be established for the integrity, identification, collection, storage, protection and disposal of records.

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Corrective and Preventive Action

Have a process for identifying and investigating non-conforming work and departures from authorised policies and procedures, and for implementing corrective action/s accordingly. It has a process for identifying and implementing preventive action to eliminate the causes of potential non-conformities, incidents and adverse clinical events.

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Continuous Quality Improvement

Establish a program of continuous quality improvement for the key areas of operations.

This program of activity will include corrective and preventive action and be supported by internal audits, and assessments conducted by external bodies where applicable.

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Audit of documentation of pregnancy status July 2013- June 2014

Pregnancy status recorded, 473, 52%

Pregnancy status not recorded, 435, 48%

Angiography and Fluoroscopy cases (2013-2014) Females aged

15-50 y•Total 908 exams

• No unplanned foetal exposures

• Difficulties with compliance

• Manual data entry and non-mandatory field

• Definition of child-bearing capacity

• Question might have been asked, but documentation needed improvement

• Pregnancy status has become a mandatory field as of 1 July 2014

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Pregnancy Status Check updated and Included on Procedure Worksheet

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2. Quality ProgramPatient ID Incidents Per Annum

Monthly- Consistently more in first half of year Incidents PA

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Feedback and Complaints Feedback is actively sought from patients and referrers to ensure appropriate service provisions, patient and referrer satisfaction and continuous quality improvement.

Have a policy covering the procedure for handling complaints Records are maintained of all feedback, complaints, investigations and corrective actions taken.

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Patient Delay AuditMain Radiology CT/US/Angio/Fluoro

• Total - 73 patients experienced a delay across a period of 9 days

• Multitude of different reasons for delay

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What this equates to in terms of patients

• CT - 13 hours = 34 pts• US - 8 hours = 16 pts• Angio - 7 hours = 5 pts• Fluoro – 6.5 hours = 5 pts

Next steps : • Feedback to NM group • Look at solutions to issues

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Management Review

Senior management shall regularly review the practice management system to ensure continuing suitability and effectiveness in support of patient care and to introduce any necessary changes for improvements.

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Facilities for Imaging Procedures

Allow the safe and correct performance of diagnostic and/or interventional radiology services.

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Diagnostic Equipment

• Monitors• Workstations• Digital data image management• Exchange of digital image data and reports

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Equipment Inventory

Maintain a current equipment inventory, which is supplemented by an equipment register.

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Equipment

Ensure that all equipment (including software) is appropriate to its use and that it is appropriately maintained so that imaging results are consistently of diagnostic quality.

The practice complies with legislation concerning the procurement, sale or disposal of any equipment which generates ionising radiation.

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Personnel

• Recruitment of Personnel • Orientation • Training• Qualifications, Registration and Licensing

– Radiologist– Radiograpgers– Nurse– Physicist– Admin staff– Service personnel

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CPD/CME/Credentialing

– Radiologist– Radiograpgers– Nurse– Physicist– Admin staff– Service personnel

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Performance of the Imaging Examination

• Review of Appropriateness of Request and Patient Preparation

• Utilisation of Medical Imaging Techniques • Administration of Contrast

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Interpretation and Reporting

A single named radiologist is to be responsible for the supervision, interpretation and reporting of the entire study.

Where a trainee radiologist has reported under supervision, this should be indicated in the report.

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Communication of Imaging Findings and Reports

Ensure that reports are made available in a clinically appropriate, timely manner and shall carry out regular reviews at least once every year on the time between the performance of the study and the issuing of the report.

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Infection Control

All applicable regulatory health-related infection control guidelines shall be followed.

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Hand Hygiene- One moment Compliance

Average compliance = 12/13 - 60% 13/14 – 64% General x-ray remain the best!!

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Radiation Safety

• ALARA Principle• Compliance with Radiation Safety Legislation• Radiation Safety Officer • Waste management

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Reportable Radiation Incidents

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Patient Management

• Patient Identification and Records• Correct Patient, Site and Procedure • Discharge Procedure • Patient Consent • Privacy Policy

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Patient Identification and Verification

The aim of this Standard is to ensure that the health workforce correctly identifies all patients whenever care is provided and correctly matches patients to their intended treatment.”

– Examples of patient identifiers> patient name (family and given names)> date of birth> gender> address> medical record number and/or Individual Healthcare Identifier.

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Open Disclosure

Open disclosure is the open discussion of incidents that result in harm to a patient while receiving health care with the patient, their family, carers and other support persons.

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Open Disclosure

Implement an open disclosure programwhich is consistent with the National Open Disclosure Framework

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IV Contrast ExtravasationRetrospective Study May 2010 - March 2015

Contrast Injections n = 57,148 CT = 39,629, MRI = 17,519Number of extravasations: CT = 124, MRI = 13

CT incidence = 0.31%, reported range in literature 0.1-1.2%(1-4)

MRI incidence = 0.07%, reported incidence in literature of 0.05%(3)

IP - fully documented compliance with protocol 82%OP - fully documented compliance with protocol 75%1. Wang CL,et al. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69,657 intravenous injections. Radiology. 2007;243(1):80-7.

2. Wienbeck S, et al. Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT. AJR Am J Roentgenol. 2010;195(4):825-9.3. Cochran ST,et al. Trends in adverse events after IV administration of contrast media. AJR Am J Roentgenol. 2001;176(6):1385-8.4. Sinan T, et al. Contrast media extravasation: manual versus power injector. Med Princ Pract. 2005;14(2):107-10.

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Conclusion

High-quality patient care is our most important product and it requires a deliberate and organized approach.

Important to embed quality and safety in everyday care that embraces continuous improvement around key outcome measures related to quality, safety, process improvement, outcome assessment, and patient and staff satisfaction.

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Thank you

D.Varma@alfred.org.au

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