DEPARTMENTAL CQI IMPLEMENTATION: REALITIES Richard L. Baron, M.D. Chair, Dep’t of Radiology University of Chicago

CQI Implementation: Background 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

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

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

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

Analysis of quality Indentify all PE CT scans over weekly periods Review reports for non-diagnostic/suboptimal scans Review for opacification (HU>200), motion, noise. Classify and quantitate causes of poor quality Intervene with improvements Remeasure Chest Imaging Section, U of C 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 Pulmonary Embolism CTA: CQI Project

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

Issues Choosing CQI project Getting started Recording data Analysis of data Instituting Change –Remeasure, Reanalyze – Handle Depression

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

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 morning rounds –Pediatric intensivists personally contacted –Pediatric residents rotating through radiology educated 5 Months: – 138 requests 30 patients – 49 adeq; 89 inadequate

CULTURE STRATEGY CULTURE EATS STRATEGY FOR LUNCH SEVEN DAYS A WEEK

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

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

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

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

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)

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 Won’t 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 DEPARTMENTAL CQI IMPLEMENTATION: FUTURE AT UCH