Quality improvement requires a team effort
CHICAGO, Nov. 28—In three separate “Quality Improvement” lectures at the 93rd annual meeting of the Radiological Society of North America (RSNA), radiologists discussed how to properly improve the quality of workflow and quality of work environment within hospitals through the fostering of a team approach to quality control issues. 

The RSNA 2007 organizers of the one-day quality multi-session course said that “with consumers, regulators and payers demanding proof of quality in healthcare, radiologists cannot ignore the threats to their reimbursement and job security, which is why they extended the session to an entire day. RSNA also had to make more seating available in the planning process because of the popularity of the courses.

James P. Borgstede, MD, FACR, of the University of Illinois College of Medicine, focused on his lecture on “Getting the Expertise In-House,” and said that the premise behind his proposals for quality is “what is best for the patient is best for the physician and changing practice requires a healthcare team effort.”

In order to build quality improvement in-house, Borgsteade said that the planners need to establish an organizational hierarchy: The team must be led by a driver, who is respected member of the medical community; followed by a strategic leader and a structural leader, followed by willing participants; and finally, questioners should be incorporated into the process.

He said that to train the team for project success, the entire healthcare team needs to be involved; physicians need to be involved in the project; and all team members must have specific topics.

Borgstede did acknowledge some of the “realities” that confront these types of projects, such as most physicians assume that they already practice with quality and physicians are independent. As a result, he said there needs to be some positive rewards for participants, and the avoidance of negative repercussions is not enough of a motivator.

In terms of motivation, he said the external motivation can sometimes be forced or rooted in a desire for financial benefits, but the internal motivation is optimal patient care; optimal for the future of our specialty, and personal recognition.

Borgstede stressed that to ensure program success “physicians must be treated as partners.” He added that “I would promote that physicians get paid for their participation in such a program.” The rules established by a program must apply to everyone in the hospital, and doctors need to be a part of that design, he said.

Paul Nagy, PhD, is an associate professor of radiology and the director of quality and informatics research at the University of Maryland Medical Center (UMMC) in Baltimore, began his lecture by analyzing “what happened to image quality control?”

He suggested that the accelerated pace and performance pressure have left quality control marginalized. “Increased productivity and demands, very little interaction between individuals, and the vendors don’t help because their CR systems and PACS are all about throughput workflow,” Nagy said. IT systems have been created to make everyone more productive, but they also be used to increase communication between the radiologist and technologist as opposed to decreasing it.

The ingredient for change is that the radiology department adds a quality control (QC) tool (log button) to the PACS, “in order to add comments or select the root cause of a problem,” said Nagy. With this tool in place, when new types of issues, called data quality issues, they can be tracked and solved. “So you can convert PACS as a knowledge base for: in-service training, performance appraisal, etc.,” Nagy said.

As a result of the new tool utilized on the UMMC PACS, 40 percent of issues are now resolved in one hour, as opposed to a day or week later. “We need to leverage real-time information for quality as well,” he added. Also, 75 percent of issues are assigned a root cause, so those consistent problems can begin to get filtered out. Currently, at UMMC, 292,000 procedures in more than one year are completed, and 2,472 QC issues submitted.

Under a data driven metamorphosis model, Nagy said first, get the radiologists to submit issues, which takes one month, but that is “where quality just begins.” Second, get the supervisors to resolve issues—phase of training supervisors what the issues were and how to respond, which takes one month. Third, get the supervisors to resolve issues quickly, which takes another month. Fourth, get the supervisors to assign a root cause and technologist if warranted, which three months. Finally, get the supervisors to use issue resolution for customer relations management, which takes six months. Ultimately, Nagy said “you can teach our tech supervisors to use the QC as a marketing point.”

In his conclusion, Nagy said that there are most PACS vendors can support URL-based QC tool.

In the third presentation, Ramin Khorasani, MD, FRCPC, vice chairman in the department of radiology and information management division director at Brigham and Women’s Hospital (BWH) in Boston suggested that change management required a nine-step process that he devised to establish if an institution should begin a program, and if they can sustain it.

According to Khorsani, to lead change, the team must address: scope, definition of success, metrics; cost/financials and to process those issues, the team must first identify the current state and future state design through a collaborative effort with clear definitions of success.

Based on a case study at BWH, the first step is to ask, “why?”

“As a team, you must ask themselves what are the things that you want to do, and will it be supported by your department and administrated,” according to Khorsani. The second step is to collectively ask Why Now? – “is there a sense of urgency about this quality improvement program,” He told his audience to ask themselves. The third step is to create a vision – “can you tell the story in less than two minutes, or actually under 30 seconds. If you can’t explain your goals in around 30 seconds so anyone can understand them, you might not be successful,” Khorsani said. The fourth step is to form a powerful guiding coalition. IT leadership and a modality expert will help to create a team with a shared vision. The fifth step is to communicate the vision to anywhere, anyhow, anybody. “If you can convince your grandmother about the excitement of the project, then you can convince hospital administration,” he jested. The sixth step is to empower others to act on the vision and improve it. “You are not the only person with great ideas,” Khorsani reminded his audience members. The seventh step is planning for and creating short term wins. “I really believe this should be a part of your planning process. You have to find and develop goals that are palpable” and can foster pride in the program, he said. The eighth step is consolidating improvements and still producing more change. The final and ninth step is instituting new approaches. Khorsani said “by creating an organizational structure (job descriptions, scope, definition of success, resources, return-on-investment) that can maintain its initial intended goals” the program is much more assured to be successful.

“For change management, you must address people more than anything else,” Khorsani said.