Engaging Physicians in Hospital Radiology Quality Initiatives

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The question of how to engage physicians in hospital quality initiatives “is one that many organizations are grappling with,” according to Albert Bothe, MD, chief quality officer for Geisinger Health System, Danville, Pennsylvania. He believes that any commitment to quality must start at the top, with leaders demonstrating their commitment to improving quality to staff at all levels. “Quality needs to be a highly visible leadership interest,” he says. “It can’t just be leadership putting out memos. Leaders need to demonstrate engagement by making quality a part of their meeting agendas or doing quality rounds within the organization.”
imageAlbert Bothe, MD
John Cardella, MD, chair of the radiology department at Geisinger Health System, concurs. “Some organizations are successful at engaging radiologists in these initiatives, and some are not,” he says. “The approach I’ve taken is that if I express an interest in quality and try to lead by example in terms of making quality a priority in the department, then others will follow. It’s very difficult to tell people quality’s important if you don’t participate yourself. You have to model it. You have to live it.”
imageJohn Cardella, MD
Bothe and Cardella should know: At Geisinger Health System, quality is an institutional priority. Each department commits to annual improvement initiatives across four goals named by the organization: quality, innovation, market growth and securing the legacy. “The CEO of Geisinger Health System has made quality the first, in numerical order, of the four strategic aims,” Bothe notes. “From there, the priorities cascade down through the organization to the department chairs and the vice presidents, who translate the information to the individual work units where it’s relevant.” Department chairs meet with organization leaders annually to determine what the department’s goals will be for the year and what resources are required to meet those goals. “A number of us hold dialogues with radiology leaders about what quality initiatives they intend to pursue in the coming year,” Bothe says. “Clinical and administrative leaders ensure that those initiatives fit with the organization’s overarching quality goals, while radiology leaders bring their own local knowledge about how the initiatives will express themselves.” This year, Geisinger Health System’s radiology department is examining operations using a front-to-back approach that analyzes each aspect of the imaging process, from the moment an image is ordered to the time that the final report is delivered to the referring physician. “We have small teams looking at subsets of the practice. How can we get our dictations done more quickly, how can we improve the quality of our images, and how can we improve our scheduling?” Cardella asks. “Everyone is given to understand that his or her job has a quality aspect to it, and each employee contributes to the success of the program by thinking of ways to do that job better.” Another current imaging-category quality initiative involves anonymous peer review of performance on a random basis, in a program that extends to both radiologists and technologists. For radiologists, the quality of the radiological interpretation is critiqued by a peer; for technologists, quality is measured by review of the diagnostic sufficiency of the image itself. In both cases, results are shared with the staff member in question and are reviewed anonymously by the Radiology Quality Committee; in cases of serious mistakes, the individual is asked to review the case or image with a peer radiologist or technologist. “On rare occasions, there is disagreement between the reviewer and the person who originally did the work,” Cardella says. “In that situation, we convene a small group of peers to address the difference of opinion and mentor the practitioner so people can learn from mistakes. Quality improves when you share, understand root causes, and correct mistakes in teams of health care providers.” Geisinger Health System’s radiologists have a very real incentive to participate in these organizational initiatives: 20% of their salary is dependent on compliance with the quality, innovation, market-growth, and securing the legacy programs, with the quality category positioned as the largest contributor to the overall percentage. Bothe explains that every physician is measured using objective criteria in each of the four categories. Those measures are assigned scores and, Bothe says, “The incentive portion of the compensation is calculated based on them. Goals are visibly demonstrated by leaders, but they’re also translated into the workings of the organization through performance evaluation.” Cardella cautions others against taking a punitive approach to quality improvement at the departmental level. “When we began the peer-review process, we said, ‘We’re going to start a process that makes us all better by examining the way the department does things,’” he notes. “That’s a better statement than, ‘We’re going to zero in on who’s making the mistakes and make them better.’ We try to close the loop—to make it an improvement tool so our radiologists and staff can get better.” From the administrative tier, meanwhile, Bothe reiterates that “unilateral dictating of goals is fraught with failure.” He also notes that quality metrics must be quantifiable as opposed to qualitative, and that closing the loop is equally important on a departmental level. He notes that it is important to use indicators that can be measured and to give timely feedback. He says, “You don’t want to wait until the 11th month of the year and thus leave individuals or departments no opportunity to correct their performance and improve it. Make the feedback as near to the action as feasible.” Cardella predicts that in the future, particularly with the advent of health care reform, quality will be increasingly linked to reimbursement. With that in mind, he urges health care organizations to embrace quality-improvement activities. “My projection is that in the future, payors are going to ask for actual demonstration that your quality is good,” he says. “That means that large, complex physician organizations, in particular, are going to have to get behind quality assurance and process improvement in a big way.” Cat Vasko is editor of Medical Imaging Review and ImagingBiz.com.