DOI: 10.1148/rg.281075199
RadioGraphics 2008;28:3-5
© RSNA, 2008
Editorial
Quality Initiatives in Radiology: Historical Perspectives for an Emerging Field1
Jonathan B. Kruskal, MD, PhD
1 From the Department of Radiology, Beth Israel Deaconess Medical Center, West Campus, Rm 302B, 1 Deaconess Rd, Boston, MA 02215. Received and accepted September 28, 2007. The author has no financial relationships to disclose.
Address correspondence to the author (e-mail: jkruskal{at}bidmc.harvard.edu).
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Introduction
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Since the Industrial Revolution, the manufacturing industry has long recognized the value and benefits of applying the basic processes of quality assurance to improve productivity. For radiologists, these quality initiatives have typically been relegated to technical quality control, with less attention focused on the processes associated with improvement in clinical quality and performance. As our profession responds to burgeoning clinical demands and increasing regulation, coupled with rapidly advancing and complex technologies, the need to apply the basic principles and tools of quality assurance to our practices to improve patient safety and to remain competitive becomes tantamount. Recognizing these needs, and as part of the Radiological Society of North America’s (RSNA’s) broad-based strategy for educating radiologists about the processes associated with quality assurance, RadioGraphics introduces a new section dedicated to quality initiatives with this issue. As the first article published in this new section, Dr Robert Hattery’s President’s Address on strengthening professionalism from the 2006 RSNA Annual Meeting offers timely, keen insights into the nature and importance of professionalism, especially in today’s volatile arena for providing health care (1). Dr Hattery issues us radiologists some fundamental challenges, and the pursuit and development of quality initiatives neatly dovetail with his call to action.
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Historical Perspectives
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Just as the processes of performance improvement frequently rely on incremental changes, so too does the development of quality management. The first phase of quality improvement emerged during the Industrial Revolution, when mass production resulted in teams rather than individuals working together on specific stages of production. In the late 1800s, industries that relied on mass production, such as automobile manufacturing, recognized that the quality of their products varied due to lack of standardized designs. This recognition allowed changes to be introduced that resulted in improved product quality.
The second phase in the evolution of quality improvement occurred through the application of scientific method and statistical control to manufacturing processes. These efforts were stimulated largely by the production requirements of the two World Wars. The resulting quality management systems were established through the pioneering work of W. Edwards Deming (2).
The third phase of quality management is the present, where quality initiatives have expanded beyond manufacturing to include almost all services (including medical care), which are applying the processes and lessons learned from industry to their fields. What is the current state of quality programs in radiology departments? In a study by Deitch et al (3), the majority (86%) of hospital radiology departments reported having a program to monitor and evaluate physician performance. Of these, 51% collected incorrect diagnoses by specific radiologist, whereas 28% gathered some quality-specific data through computer information systems. Respondents representing 58% of hospital radiology departments thought that quality assurance and continuous quality improvement (CQI) efforts contributed to improvement in patient care, but only 19% of radiology practices answered that CQI had been of cost benefit to their organizations.
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What Are Quality Initiatives?
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It is not enough to do your best; you must know what to do, and then do your best.
W. Edwards Deming (2)
To fully understand how application of quality initiatives can benefit our patients and our practices, it is important to be familiar with the confusing and conflicting array of terms applied to this field. Several excellent reviews have addressed this topic (4,5). As radiologists, we are used to the concept of quality control, which involves regular surveillance and testing of medical equipment and evaluation of image quality to ensure conformity with regulations (6). Quality assurance represents a more comprehensive quality management program, characterized by the systematic collection, analysis, and management of collected data. From a more global perspective, quality management is a method for ensuring that all activities necessary to design, develop, and implement a product or service are effective and efficient with respect to the system and its performance. Quality management enables organizations to identify, measure, control, and improve the various core processes that will ultimately lead to improved performance.
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Why Are Quality Initiatives Important?
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It is not necessary to change. Survival is not mandatory.
W. Edwards Deming (2)
There is no doubt that improvements in patient care and patient outcomes relate directly to improved quality of delivered care. This relationship is particularly clear in the broad field of radiology, in which technical and clinical performance can easily be monitored and measured. Meeting the growing demand for accountability in radiology requires that the discipline (a) adopt innovative approaches for assessing its technologies and (b) acquire new types of data, including documentation of the cost savings accrued by selective use of radiologic technologies and of the efficiency and cost-effectiveness of triage schemes that lead to more effective decision making (7).
In the very near future, some portion of physician reimbursement will be based on the quality and efficiency of service, a practice commonly referred to as pay for performance. Indeed, the Centers for Medicare and Medicaid Services anticipate fully phasing in a pay for performance program in 2008. Performance benchmarks are the discrete parameters of structure, process, or outcome metrics whose attainment defines good quality care. Private payers are already rewarding primary care physicians for practices that adhere to quality standards, are efficient, involve information technology, and result in high patient satisfaction (8).
One of the challenges of getting physicians to participate in what may be considered menial, bureaucratic, and even tiresome processes of quality assurance is the lack of readily visible evidence that the efforts translate into actual performance improvement and improved patient care. We view this need for proof as a challenge to engage radiologists in the processes associated with CQI, and through the pages of RadioGraphics, we aim not only to educate radiologists about the methodologies that can result in improved performance but to help such processes be easily and enthusiastically incorporated into our daily practices.
We should all embrace the opportunities for practice improvement that the processes of quality management offer us. This philosophy has been recognized by the many regulatory organizations that regulate our profession. As examples, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) stipulates that all hospitals and offices where clinical services are provided must collect and analyze data to monitor performance (9). The Accreditation Council for Graduate Medical Education (ACGME) now requires that "sponsoring institutions must ensure that formal quality-assurance programs are conducted and that there is a review of complications and deaths. To the degree possible and in conformance with state law, residents should participate in appropriate components of the institution’s performance improvement program" (10). Furthermore, as a component of the ACGME Outcome Project, the common program requirements expect all training programs to integrate all general competencies into their curricula. As part of practice-based learning and improvement competency, residents must be able to "systematically analyze their practice using quality improvement methods, and implement changes with the goal of practice improvement" (10). Many state medical boards now require demonstration of a peer-review process for reaccreditation of physicians. The American Board of Radiology (ABR), as one of its requirements for Maintenance of Certification (MOC) (Part IV–Evaluation of Practice Performance) (11), now requires that a practice quality improvement (PQI) project be completed by each radiologist seeking recertification (12). The ABR requires each physician "to demonstrate commitment to practice quality improvement and competence in clinical practice by selecting a project or projects that potentially can improve the quality of the diplomate’s practice and enhance quality of care." It is anticipated that most PQI projects will include a majority of or all six general competencies of medicine as defined by the ACGME (10) for training and practice: medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice.
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The Role of RSNA
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"The RSNA aspires to be the premier professional association in radiology improving patient care through radiological science and education" (13). In parallel with this RSNA vision statement, the new RadioGraphics quality initiatives section aims to be the premier educational and practical reference tool in radiology for improving patient care and safety by educating radiologists (including those in training) in the methodologies and practical applications of continuous quality improvement. In keeping with the RSNA mission statement of "promoting excellence through education and by fostering research" (13), the new RadioGraphics quality initiatives section will be the premier tool for teaching the techniques of CQI as they relate to radiologists’ clinical and technical performance. Moreover, as its educational mission, this section will support and facilitate satisfactory completion of the newly required radiology resident outcomes project (of the ACGME) and the MOC PQI requirements (of the ABR).
In keeping with the goals and objectives of the RSNA, the highest priority of Goal 1 is to "facilitate continuing professional development and the means for maintenance of certification" (13). By publishing articles that illustrate the methodologies for identifying, commencing, and completing PQI projects, RadioGraphics will support all radiologists and allow them to successfully meet and complete the requirements of Part IV of the MOC. The RSNA Board also believes the Society should "exploit technological innovations in publications and education" (13). In keeping with this goal, we will work closely with the RSNA CQI Initiative Committee to link the educational roles of RadioGraphics with the CQI link on the RSNA Web site. As an example, an article illustrating how radiologic errors or adverse events can be investigated and managed will refer the reader to the CQI Initiative home page, where tools for facilitating actual management of errors and adverse events are illustrated.
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Quality Initiatives Section
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Starting with this issue of RadioGraphics and Dr Hattery’s challenge to strengthen professionalism (1), the quality initiatives section will include articles covering a spectrum of quality, safety, and performance improvement topics. The sources for these articles will include education exhibits displayed at RSNA annual meetings, topics covered in the RSNA 2007 Quality Improvement Symposium, suggestions from members of the RSNA CQI Initiative Committee, and scientific papers presented at the RSNA annual meetings. Each issue of RadioGraphics will contain a review article covering broad quality-related subjects, such as suggestions for implementing a quality management program in a radiology department, practical tips for dealing with errors and adverse events, and strategies for completing the PQI project now needed to meet MOC requirements. In addition to these articles, we will also introduce focused topics related to the broad overviews, as well as the best PQI projects, resident outcomes projects identified at national forums, and grand round case discussions on quality and safety. I welcome and encourage suggestions for topics from readers.
In summary, and in keeping with the mission of the RSNA, we hope to educate our members about the processes of quality management in radiology practice. The goals are not only to support our members by facilitating successful completion of regulatory requirements but ultimately to improve patient safety and the quality of care that we provide.
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References
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- Hattery RR. President’s address from the Opening Session of RSNA 2006: strengthening professionalism. RadioGraphics 2008;28:7–11.[Free Full Text]
- Deming WE. Elementary principles of the statistical control of quality. Tokyo, Japan: Nippon Kagaku Gijutsu Renmei, 1950.
- Deitch CH, Chan WC, Sunshine JH, Zinninger MD, Cascade PN, Cochran ST. Quality assessment and improvement: what radiologists do and think. AJR Am J Roentgenol 1994;163:1245–1254.[Abstract/Free Full Text]
- Erturk SM, Ondategui-Parra S, Ros PR. Quality management in radiology: historical aspects and basic definitions. J Am Coll Radiol 2005;2:985–991.[CrossRef][Medline]
- Applegate KE. Continuous quality improvement for radiologists. Acad Radiol 2004;11:155–161.[CrossRef][Medline]
- Hynes DM. Quality management. Can Assoc Radiol J 1994;45:353–354.[Medline]
- Hendee WR, Brown EF, Stanley RJ, Thrall JH, Zylak CJ. Colliding forces in radiology: technologic imperative, resource limitations, and accountability demands. RadioGraphics 1994;14: 647–653.[Abstract]
- Moser JW, Wilcox PA, Bjork SS, et al. Pay for performance in radiology: ACR white paper. J Am Coll Radiol 2006;3:650–664.[CrossRef][Medline]
- The Joint Commission web site. Available at: http://www.jointcommission.org. Accessed June 22, 2007.
- The Accreditation Council for Graduate Medical Education web site. Available at: http://www.acgme.org. Accessed June 22, 2007.
- Madewell JE, Hattery RR, Thomas SR, et al. American Board of Radiology: maintenance of certification. RadioGraphics 2005;25:285–296.[Free Full Text]
- Strife JL, Kun LE, Becker GJ, Dunnick NR, Bosma J, Hattery RR. American Board of Radiology perspective on maintenance of certification: part IV—practice quality improvement for diagnostic radiology. RadioGraphics 2007;27:769–774.[Free Full Text]
- Lentle BC. RSNA board of directors develops a 3-year strategic plan. RadioGraphics 2002;22:457–459.[Free Full Text]
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Introduction
Historical Perspectives
