Fundamentals of Quality and Safety in Diagnostic Radiology

doi:10.1016/j.jacr.2014.08.028

Journal of the American College of Radiology

Volume 11, Issue 12, Part A, December 2014, Pages 1115-1120

https://doi.org/10.1016/j.jacr.2014.08.028 Get rights and content

The most fundamental aspects of quality and safety in radiology are reviewed, including a brief history of the quality and safety movement as applied to radiology, the overarching considerations of organizational culture, team building, choosing appropriate goals and metrics, and the radiologist’s quality “tool kit.”

Introduction

The quality and safety movement in American medicine arguably may have had its beginning at an October, 1996 meeting of more than 300 safety experts from around the world held in Rancho Mirage, California. This conference, which became known as the “First Annenberg Conference,” was convened by the AMA, the American Hospital Association, the US Department of Veterans Affairs, and several other national organizations, set into motion a cascade of events, including patient safety investigative research studies, which ultimately led to the Institute of Medicine’s publishing its 1999 landmark monograph, To Err Is Human [1], which propelled the topic of health care quality and patient safety to the forefront of national awareness and is commonly cited as having initiated medicine’s quality and safety movement. The publication of To Err Is Human led to a widespread realization that the then current state of affairs in American medical care was unacceptable and that drastic, immediate action was urgently needed to improve the safety of patients, especially hospitalized patients.

The quality and safety movement in American medicine quickly spread to involve radiology departments throughout the country, and the leading national radiology societies rushed to develop quality and safety educational programs and support to assist their member radiologists and others to pursue their own quality journeys. These included substantial investments by, and reorganization of priorities within, the major American radiology societies, including the ACR (which adopted the motto Quality Is Our Image™), the RSNA, the ARRS, and the ABR, among others. Currently, each of these organizations and societies provides considerable educational and other resources to guide radiologists and organizations in designing and carrying out meaningful quality improvement projects at their own centers, including in-person continuing medical education programs and conferences (such as the ACR conference on quality and safety held in February of each year), web-based tutorials, and print media. An organized program of online study materials known as the Open School is available from the Institute for Healthcare Improvement (http://www.ihi.org/education/ihiopenschool/). Links to web resources for further study are appended at the end of this article. Underscoring the importance of radiologists’ mastery of this relatively new area of competence, the ABR now requires a basic understanding of practice quality improvement as part of its Maintenance of Certification process, and ABR diplomates must complete approved practice quality improvement project every 3 years to satisfy the requirements of Maintenance of Certification.

Section snippets

The Primary Role of Organizational Culture

The most fundamental component in health care quality and safety is the establishment of a culture of safety within the organization. The culture of safety is a construct that overlaps the concepts of blameless culture and Just Culture, a term originally introduced by David Marx [2]. It is generally held that no enduring progress can be made in quality improvement within a health care system or organization without first establishing a culture of safety within that system or organization. The

Building a Team

The practice of quality improvement is, by necessity, a team effort, requiring sustained input from many people throughout the organization and across a broad spectrum of skill sets. It is extremely difficult, if not impossible, for a single individual to carry out a successful quality improvement initiative on his or her own. Most quality projects in radiology will, at a minimum, require a team of 3 or 4 persons, including a clinician or radiologist, a representative technologist, a manager,

Goals for Quality and Safety

In 2001, with the publication of Crossing the Quality Chasm, the Institute of Medicine [5] delineated what has become known as the “6 aims” of quality and safety. Within this broad framework, a very broad range of programs, policies, and initiatives can be viewed as “quality improvement,” including those that are primarily management tools—such as analyzing practice efficiency with the goal of improving access and reducing waste and waiting times—and those that are more humanistic, such as

The Quality and Safety Toolbox

The key to quality improvement is accurate measurement and remeasurement of appropriately chosen metrics. Without this, there is no way to determine the effectiveness of a quality intervention, and the entire exercise is of dubious value. Typically, measurable metrics are compared with standard or commonly accepted consensus expectations (also known as “benchmarks”), to determine whether an acceptable level of quality or performance is present or whether an improvement intervention should be

Key Performance Indicators, Graphical Analysis Tools, and the Quality Dashboard

Metrics of particular importance to an organization are known as key performance indicators (KPIs). The choice of what metrics are chosen as KPIs depends on the department’s and institution’s priorities and overall quality strategy; they generally are centered on patient safety and quality of care but can also reflect customer service issues, provider performance, and even financial management issues. KPIs are often displayed in some readily updated, colorful electronic visual format, known as

The Plan-Do-Study-Act Cycle

The most widely applicable methodology in quality and safety is the plan-do-study-act (PDSA) cycle, which was advocated by W. Edwards Deming (1900–1993) beginning in 1950 and is commonly credited to him, although it was actually created by Shewhart and others in the 1930s 8, 9, 10. Also sometimes called the plan-do-check-act cycle or the Deming-Shewhart wheel, the PDSA cycle was central to quality improvement programs in Japanese automobile manufacturing. It is a deceptively simple and yet

Sentinel Events, “Near-Miss” Events, and Root-Cause Analysis

Not all efforts in quality and safety are proactive; frequently adverse occurrences or patient safety events, those in which errors or mishaps lead to patient harm, and “near-miss” events, those in which patient harm is narrowly averted, can also serve as detection “triggers,” warning of underlying flawed systems or processes that require immediate retrospective analysis and remedial attention to prevent future harm to patients. Even those incidents that are deemed to be primarily attributable

Failure Modes and Effects Analysis

Although RCA is retrospective, failure modes and effects analysis (FMEA) is a prospective method for error prevention, which was derived in the 1950s as a means to anticipate failures of military systems, was used heavily by NASA in the 1960s during the space program, and was adapted for health care by the American Society for Healthcare Risk Management, which first proposed health care FMEA [11]. FMEA is a team-based, systematic method is used proactively to evaluate a process on the basis of

Lean and Six Sigma

Also derived from manufacturing, lean and Six Sigma are both analytic tools relying on statistical methods, either to remove “waste” (Lean) from processes or to reduce defects and errors to acceptably low levels (Six Sigma). Both involve skilled teams, use relatively complex methodologies, and require extensive training to perform. Applying lean or Six Sigma to a problem requires considerable expertise, is extremely labor intensive, and requires commitment of significant resources. These

Summary

Quality improvement and patient safety within radiology use the same rationale and draw on a fundamental tool kit of methods that are commonly used in other facets of medicine as well as other industries, such as manufacturing and aviation. Radiologists can obtain training in these methods from the ACR and from other organizations (see the Appendix).

Take-Home Points

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Fostering a “culture of safety” within an organization is the first priority in any quality and safety effort; this includes learning to see problems through a “systems lens” and removing blame and recrimination for human error. The Just Culture concept is a very powerful construct in this task, balancing accountability with a blameless approach.
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The explicit and unwavering support of top leadership is essential for the success of a quality improvement program
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A multidisciplinary team must be

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Original articleFundamentals of Quality and Safety in Diagnostic Radiology