DEPARTMENTAL CQI IMPLEMENTATION: REALITIES

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DEPARTMENTAL CQI IMPLEMENTATION REALITIES

• Richard L. Baron, M.D.
• Chair, Dept of Radiology
• University of Chicago

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CQI ImplementationBackground

• Department Goal incorporate CQI process into
  routine sectional operations
• Sectional bonus compensation pool
• 2/3 objective 1/3 subjective
• 3 measurable areas for improvement
• Clinical service education academic
• Meet mutually pre-agreed upon criteria

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CQI Planning Requirements

• Clinical focus (not administrative)
• Incorporated into routine (as frequently as
  possible)
• Must incorporate all physician members of
  section, including residents fellows
• Should engage external people interfacing with
  operational procedures
• Must not be a single, end point but continuous
  evaluation and analysis

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PROCESS

• Choosing CQI project
• Getting started
• Recording data
• Analysis of data
• Instituting Change

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Pulmonary Embolism CTA CQI Project

• The Problem
• Many MDCT PE studies are done on an emergency
  basis after hours
• Large variations in exam quality occur
• Lack of consistency in results, due to many
  practical issues of training and implementation
  of scan protocols.
• Beta test site for not yet released CT equipment

Chest Imaging Section, U of C
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Pulmonary Embolism CTA CQI Project

• Analysis of quality
• Indentify all PE CT scans over weekly periods
• Review reports for non-diagnostic/suboptimal
  scans
• Review for opacification (HUgt200), motion, noise.
• Classify and quantitate causes of poor quality
• Intervene with improvements
• Remeasure

Chest Imaging Section, U of C
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Pulmonary Embolism CTA CQI Project

• Interventions
• Tracker location Change to from PA to descending
  aorta
• Tracker image Improve quality with higher mA
• I.V. location and size Specify above wrist at
  least 20g
• Arm position Raised with hands on scanner
• Contrast bolus Increase rate from 4 to 5cc/sec
• Record new breath-hold instructions Avoid deep
  breath
• Eliminate obsolete or redundant protocols from
  scanners
• In-service training session for all technologists

Chest Imaging Section, U of C
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Pulmonary Embolism CTA QA Project
Pulmonary Embolism QA Project
January 5 Non-diagnostic
September 25 Non-diagnostic
Chest Imaging Section, U of C
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Issues

• Choosing CQI project
• Getting started
• Recording data
• Analysis of data
• Instituting Change
• Remeasure, Reanalyze

• Handle Depression

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MSK CQI Project

• PLAN Improve radiographic quality/patient care
• METHOD Two days/mo all plain films evaluated by
  attendings/fellow
• Type of Exam Location Quality of exam
• Cases rated as poor discussed at MD Tech
  quarterly meetings
• RESULTS
• Certain clinics had better quality than others
• Certain exam types had repeated lower quality
• No change seen in any of above during process and
  quality was actually measured lower at end of
  project
• ACTION
• Cases rated as poor discussed in quarterly tech
  meetings

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Peds Radiology CQI Project

• PLAN Improve clinical history for portable
  radiographs
• METHOD Review one week of Requisitions/Records
• 2 radiologists (attending and resident)
• 3 pediatricians (intensivist and 2 residents)
• RESULTS
• 139 requests in 32 patients
• 53 adequate 86 inadequate
• ACTION
• Two educational lectures _at_ morning rounds
• Pediatric intensivists personally contacted
• Pediatric residents rotating through radiology
  educated

• RESULTS _at_ 5 Months
• 138 requests 30 patients
• 49 adeq 89 inadequate

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• CULTURE STRATEGY

CULTURE EATS STRATEGY FOR LUNCH SEVEN DAYS
A WEEK
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Issues

• Choosing CQI project
• Look around operations. What are problems
• Individual approach to problems rather than
  sectional
• Tackling something too big
• Tackling something too small without recurring
  analysis problems or not meaningful enough
• Getting started
• Recording data
• Analysis of data
• Instituting Change

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Issues

• Choosing CQI project
• Getting started
• Daily focus on clinical work, academic work
• Sectional approach personalities
• Lack of experienced approach
• Doesnt recognize not getting started properly
• Data collection overwhelming (need to simplify)
• Recording data
• Analysis of data
• Instituting Change

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Issues

• Choosing CQI project
• Getting started
• Recording data
• Analysis of data
• Instituting Change
• MD willingness to integrate meaningfully with
  nonradiologist management to effect change

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Issues

• Choosing CQI project
• Getting started
• Recording data
• Systematic
• Proper data
• Time Consuming
• Analysis of data
• Instituting Change
• Remeasure, Reanalyze

Must become part of routine (almost daily)
procedures
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General Issues

• Physicians not trained in management
• Few management minded MDs get training
• Academicians attend specialty meetings - lack of
  presence
• Physician workload interferes
• Priorities of immediacy
• Education lacking
• Importance of process to department
• Department functionality
• Image of Department in Hospital
• Finances of Department
• Efficacy of CQI to improve patient outcomes and
  physician work effort
• Physicians are individual process oriented the
  realities require group oriented processes
• Physicians and personnel from other departments
  may be difficult to engage (for same reasons as
  above)

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DEPARTMENTAL CQI IMPLEMENTATION FUTURE AT UCH

• Choosing CQI projects
• Carefully to ensure early success
• Start within department before tackling out of
  department
• Getting started
• Provide simple, but substantial assistance
• Department administrative support
• Other physician CQI leaders
• Wont wait for sections to ask for help
• Recording data
• Analysis of data
• Instituting Change
• Each section works closer with Department CQI
  Committee, with monthly reporting and integration
  with all aspects of Department