It’s easy to let quality assurance (QA) slip into a lip-service category, but that is something that a nighttime stat-reading teleradiology service can’t afford to do—particularly if it is an industry leader like NightHawk Radiology Services. Dionne Watts, quality-assurance supervisor, says “QA for teleradiology is important because the client facility doesn’t know our radiologists. They like to see how good we are. They don’t personally see us on a day-to-day basis, so there is a trust factor that takes a lot longer to build. QA is a part of that.”
Watts, an Australian who now works at NightHawk headquarters in Coeur d’Alene, Idaho, says that NightHawk put its QA program together eclectically, using Joint Commission requirements, ACR guidelines, and HIPAA regulations to frame its QA structure. NightHawk went further, though. The company researched QA at other big health care institutions and then added some ingenuity of its own to devise a program that met its special needs as a teleradiology provider. The result is a QA program that could be a model for other health care providers—and in fact, it often is. Watts calls it a “robust, reliable, and educational program.”
NightHawk’s QA program isn’t simple. It can be quite complicated, but it’s built on a simple framework: image interpretation errors or omissions are reported, reviewed, and studied for prevention next time.
One lesson that NightHawk learned was not to mix image-quality or patient-positioning issues with interpretation issues, Watts says. In the beginning, QA did handle image-quality issues—poor images, poor transmission, or artifacts—but that proved too distracting to the performance of QA on the interpretation side. Now, all image-quality and transmission problems are handled by NightHawk’s customer-service and IT departments, working with the client hospital’s corresponding teams or with the technologist sending the images. Issues of turnaround time on reports are also handled by customer service, Watts explains.
NightHawk’s QA is reserved for interpretation issues. “We deal primarily with report quality. The product we supply—that’s QA’s domain. Anything to get to that point, like image transmission, falls to customer service,” Watts says. QA being the complex domain that it is, inevitably, there are overlaps where QA, customer service, and IT may confer on an interpretation issue. Watts uses an example of NightHawk radiologists missing an increased number of appendicitis cases. It turned out that the radiologists were having trouble visualizing the appendix due to a glitch in the workstation. “We had a QA conference and determined that the workstation needed an upgrade. That was a useful outcome from a collaborative conference,” Watts recalls.
To understand the NightHawk implementation of QA, it helps to know more about NightHawk itself. The company only makes use of US board-certified radiologists to provide readings for US health care institutions. The NightHawk radiologists, who are reading from Sydney, Australia, and Zurich, Switzerland, are interpreting during their daytime hours, so no one is reading while tired.
When a client hospital sends a case to NightHawk for interpretation, it uses a requisition that includes the patient data, the number and type of images to be read, and pertinent patient history, Watts says. She says the last item is especially important, noting, “We’re not there and we can’t see the patient. It’s imperative to make the clinical history accurate for us.”
NightHawk provides preliminary and final interpretations for its US hospital clients, most often stat readings for nighttime emergency-department patients. The preliminary reports that NightHawk provides must be overread by the client hospital’s own radiologists and a final report must be issued. This is the key step on which NightHawk’s QA program hinges. Without the client hospital’s overreadings, there would be no feedback on the NightHawk preliminary reports sufficient to instigate the QA process.
When NightHawk began providing its service in the 1990s, it was controversial because foreign jurisdictions were suddenly getting involved in US health care. There was also the complaint that radiological interpretations were being commoditized. Despite those concerns, the company has prospered and grown, and its stock is now publicly traded. It has also branched into daytime reading, producing final readings for