Radiology’s New Focus on Quality
Radiologists, like all physicians, have always been concerned about the quality of their work, but in recent years, the specialty’s focus on quality has been renewed. Paul Larson, MD, chair of the Commission on Quality and Safety of the ACR®, says, “Historically, we looked almost exclusively at whether we got the right answers in our reports. What’s changed is the recognition that there are a lot more factors that define overall quality.” The increasing emphasis on quality has an impact on both business and clinical operations, Larson observes. On the business side, radiologists are affected by the Physician Quality Reporting Initiative (PQRI) and other pay-for-performance measures; on the clinical side, more attention is being paid to factors such as critical-results communication and report structure. “Quality has become increasingly visible and increasingly measured,” Larson says. “The ability to measure and the ability to improve form a cycle that feeds on itself.” Larson notes that this will be the most lucrative year for radiologists electing to participate in the PQRI program, who stand to receive a year-end bonus of up to 2%. “Even at that, there’s the question of how much effort you have to put in to get that bonus,” Larson says. He cites the recently published PQRI experiences of Duszak and Saunders,¹ who found that PQRI yields actual bonuses that are much smaller than expected, even when aggressively pursued. Larson adds, however, that a renewed focus on quality can yield benefits for a radiology practice if efficiency can be improved. “If you can do the same work with fewer full-time radiologists, that’s a much bigger gain than 2%,” he says. “Rather than chasing this small bonus through measures that aren’t even that strong, we can do other things within our practices that truly improve our quality and efficiency, and that will put us way ahead.” Hospital contracts might also increasingly depend on a practice’s scores on quality metrics, as evidenced by the recent addition of imaging-related measures to the DHHS Hospital Compare online tool. “A recent article² about Hospital Compare in the Chicago Tribune names specific hospitals looking bad on some of the imaging measures,” Larson notes. “It’s all but saying they’re providing bad care, and members of the public may be driven to seek their care elsewhere. A radiology group could lose its contract to another group with metrics that look better.” From a clinical standpoint, Larson says, radiology groups will need to become more focused on their reports—both how they’re structured and how they’re delivered. “We have to communicate better,” he says, “and that means not just the structure of our reports, but their timeliness. There are increasing expectations to document delivery of critical results.” He observes that turnaround time, in particular, has become more important in the past decade because “if we go back 10 years, part of why we didn’t worry about it as much was it was harder to track, and there was nothing to do about it—of the overall process, only small parts were under our control,” he says. With the advent of PACS and voice recognition, a larger percentage of turnaround time is potentially under radiologists’ control, and turnaround time can be effectively tracked and benchmarked. Radiology reports themselves also merit increased attention, Larson says. “Quality isn’t just the conclusion of the report,” he observes. “It’s also the structure. It’s separating out what different people want from the report, and making it so people can find what they want very quickly.” He adds that both the Joint Commission and hospitals are increasing their expectations that monitoring will be applied to individual physicians. “Well-structured reports feed into providing that sort of documentation,” he says. “Hospitals are using the dashboard approach for focused reviews of clinical performance, and some groups are looking at one specific clinical quality measure for each division of their imaging departments.” Those groups include Mayo Clinic (Rochester, Minnesota). Larson concludes that while improving quality in radiology is increasingly vital from both business and clinical perspectives, the two sides are also inextricably intertwined: Improving clinical quality can yield benefits from a business perspective, while improving business-focused measures can yield better patient care. “The clinical and business sides overlap to a certain degree,” he says. “Even issues like the appropriate use of imaging, which is a general quality measure, have a business impact; if you’re doing exams that are appropriate, you’re probably getting paid for them, whereas for inappropriate exams, you may get zero. In the future, groups will be able to compete better for contracts by demonstrating their quality measures—some of which may be publicly available. That’s huge.”