The Quest for Quality in Radiology

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With Quality Counts as its theme for 2009, the RSNA’s 95th Scientific Assembly and Annual Meeting in Chicago, Illinois, obviously emphasized multiple aspects of quality assurance, control, and improvement. On December 1, several multispeaker sessions had an even stronger focus on the practical steps that radiology providers can (and should) take to promote high quality in their operations and in their staff performance. Three of the presenters were particularly generous in sharing their experience and insight.

imageJonathan B. Kruskal, MD, PhD
imageJames R. Duncan, MD, PhD
imageLucy W. Glenn, MD

Jonathan B. Kruskal, MD, PhD, is chair of the department of radiology and director of quality assurance at Beth Israel Deaconess Medical Center, Boston, Massachusetts, and is a professor of radiology at Harvard Medical School. He presented “Anatomy and Pathophysiology of Errors in Radiology Practice,” stressing that the quality-improvement field is beset by myth in some areas. For example, it is often believed that errors are random occurrences, but they are actually attributable to factors that can be detected and corrected. Likewise, he says, the notion that properly trained professionals rarely commit errors is false.

James R. Duncan, MD, PhD, associate professor of radiology in the division of interventional radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, noted the importance of analyzing and then preventing these professional errors in “Assessing Physician Performance.” This process is vital not only to improving patient care but to enhancing public perception of the value of imaging services. He says that members of the public are “spending an incredible amount of money on health care, and their impression is that they’re not getting their money’s worth.”

The quest to improve quality and reverse that impression should begin, Kruskal notes, with the division of errors of all common types in radiology into two primary categories: process errors and professional errors. Technical flaws, incorrect protocols, organizational and cultural failings, poor workflow patterns, substandard work environments, and mistake-prone procedural habits all fall into the category of process errors. Professional errors encompass everything that a radiologist (or a technologist, nurse, or other staff member) might do incorrectly, either habitually or by making an isolated mistake.

Process Errors

Lucy W. Glenn, MD, chief of radiology at Virginia Mason Medical Center, Seattle, Washington, presented “Strategies for Minimizing Errors in Diagnostic Imaging.” Her institution has addressed process errors through the use of a system of patient-safety alerts.

Each reported alert is given a color assignment based on how serious the event is. A yellow alert can be managed within the department, for example, but a vice president becomes involved in investigating orange alerts, and the processes involved might need to be stopped during that evaluation. If an alert is considered capable of harming the patient, it is designated red and is investigated within 24 hours by multiple departments.

Kruskal says, “When something goes wrong, it’s easy to identify who made the error, but there are often plenty of other associated factors that contributed to that error.” These are the process-related elements that call for changing the situation, not the people involved, he adds. As an example, he cites the need to eliminate reading-room problems such as intrusive teaching rounds, telephone interruptions, and excessive ambient light before complaining that some radiologists are too easily distracted.

Duncan also supports beginning any quality-improvement program with a thorough understanding of process errors. While there are several competing and complementary proprietary systems in wide use for finding problems and correcting them, he says, “It all boils down to the scientific method. Study the past to gain knowledge, and use that knowledge to influence the future.”

Glenn recommends three strategies: First, for any error that threatens patient safety, do what a factory would call stopping the line; in other words, end the processes involved until the cause of the problem can be found. Second, see that errors are corrected both immediately and, if possible, where they began. Third, ensure that safety considerations are part of every step within each process.

It is critically important, she continues,