1. QA and CQI: How? Merri L. Bremer MEd, RN, RDCS, FASE

2. Disclosures Relevant Relationship Member, ICAEL Board of Directors Off Label Usage None

3. Learning Objectives Define QA Discuss ideas for development and implementation of Echo Lab QA

4. QA: What is it? Many names (QA, QI, CQI) Method of continuously examining processes and making them more effective Focus is on the process, not the individual

5. QA: What is it not? PunitiveDemeaningDemoralizingDivisiveBusyworkOR…..

6. When you watch me, they want me to do it differently…

7. Benefits Develops and maintains quality in your practice Ensures uniform, consistent standards for interpretation and reporting Excellent continuing education tool

8. Standards and Guidelines ICAEL Standards ASE Guidelines and Standards SDMS Position Statements ASE Sonographer Minimum Standards

9. ICAEL QA Components Written policy AUC Instrument maintenance Procedure volumes CME Peer review Correlation Report Timeliness Conferences Record keeping

10. Writing a QA Policy Identify required elements (ICAEL Standards) Figure out how YOUR TEAM can accomplish them and write them down Sample policies on ICAEL website Try them….revise and try again if necessary Communicate! Frequently!

11. Appropriate Use Criteria (AUC) Mandatory requirement for accreditation effective January 1, 2012 Appropriate use must be measured in a minimum of 30 consecutive TTE, 30 consecutive TEE and 30 consecutive Stress patients annually ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography Percentage of appropriate, inappropriate and uncertain indications for testing must be measured

13. Appropriate Use Criteria A program for education and reporting must be developed and include: –Baseline rates of adherence –Patterns of adherence –Goals for improvement –Measurement of improvement –Confidential reports on patterns of adherence Ordering physician Ordering practice Interpreting practice

14. Instrument Maintenance Recording of method and frequency of maintenance Establishment of and adherence to a policy regarding routine safety inspections and testing of all laboratory electrical equipment Establishment of and adherence to an instrument cleaning schedule

15. Instrument Maintenance Use institutional resources if you have them If you don’t have them, create a policy using the manufacturer’s guidelines and follow it Ask your equipment reps for help!

16. Maintenance Log

17. Procedure Volumes Annual individual and laboratory stats Records of individual procedure volumes should include volumes from all laboratories where staff perform/interpret echocardiograms Methods of tracking –Schedule –Procedure list –Billing

18. Sonographer Procedure Volume Log

19. MD Procedure Volume Log

20. CME Documentation of echocardiography- related continuing education for all medical and technical personnel must be maintained Keep in central location; update annually Materials –CD, journal, Internet, videotape materials –Departmental, local, regional and national conferences and courses

21. CME 15 echo-related CME credits required for all staff (3 year period) Category 1 AMA credit Other approved non-category 1 credit (ASE, SDMS or ARRT) that have content specific to echocardiography

22. CME Log

23. Peer Review Feedback is essential for improvement! Intermittent peer review of both performance and interpretation of studies should be performed Optional QA measure, but very useful Both physicians and sonographers should be involved

24. Peer Review Differences in interpretation styles and performance should be reconciled Individual vs group reviews Confidentiality Document it!

26. MD Peer Review

27. Variability EF, wall motion analysis and degree of regurgitation/stenosis must be assessed on a minimum of two cases per modality per quarter to be reviewed in quarterly conferences Represent as many physicians as possible Policy to address discrepancies

28. Variability Worksheet

29. Variability Summary

30. Correlation EF, wall motion analysis and degree of regurgitation/stenosis will be correlated on a minimum of two per modality per quarter with other imaging modalities in quarterly conferences Represent as many physicians as possible Policy to address discrepancies

31. http://www.icael.org/icael/pdfs/Correlation_Form.pdf

32. Report Review Minimum of 10 random reports per quarter Time from performance of study to report sign-off – –Inpatient: 24 hours – –Outpatient: end of next business day Report completeness (Standards) Represent as many physicians as possible Policy to address discrepancies

34. QA Conferences Quarterly conferences must be held to review the results of variability, correlation and report timelines, to address discrepancies and to discuss difficult cases Attendance by the medical and technical directors or their designees is required at all meetings

35. QA Conferences All medical and technical staff are required to attend at least two of the four meetings Minutes of the meetings and attendance must be recorded

36. Record Keeping If you don’t document it, it didn’t happen Keep data in a central location and back it up Annual summary of information required

37. Requirements for Success Leadership Commitment Commitment of Resources Individual Commitment BUY-IN

38. Accreditation/QA Resources http://asecho.org/ http://www.icael.org/icael/index.htm http://www.sdms.org/ http://www.asq.org/learn-about- quality/index.html http://www.asq.org/learn-about- quality/index.html

39. Merri’s Rules for QA Keep it SIMPLE and practical Involve lots of people and ideas Steal shamelessly from others Adapt what you’ve stolen Be methodical Document Share what you’ve found