History and Current Status of Quality Improvement in Radiology

To Err is Human

When the Institute of Medicine (IOM, now the Academy of Medicine) first released its report, To Err Is Human , in 1999, headlines were made throughout the world. The notion that our healthcare delivery system was not only not achieving the positive exceptionalism that one might expect from the most expensive system in the world, but also guilty of contributing to the demise of nearly 100,000 people each year, was more than unsettling. The report was widely credited for blowing the whistle on an immense problem with our healthcare system. Many knew of these errors few had an idea of the scope, but all wanted to reduce them. Improvement would never come about if the collective knowledge of medical errors was sequestered to the confines of morbidity and mortality talks, hospital board rooms, and isolated court cases. The report better defined the magnitude of the issue and ultimately helped to bring about a change in attitude; this was a monumental problem, and a difficult one, that required candid discussion, accurate quantification, effective collaboration, and measureable solutions.

After the whistle was blown, 2 years later the IOM released a second report, Crossing the Quality Chasm . With this, the IOM threw down the gauntlet, challenging the leadership of US healthcare delivery to make good on its promises. The report issued six aims for improvement:

• 1.

  Healthcare must be safe.

• 2.

  Healthcare must be effective.

• 3.

  Healthcare must be patient centered.

• 4.

  Healthcare must be timely.

• 5.

  Healthcare must be efficient.

• 6.

  Healthcare must be equitable.

Realizing the magnitude of the systemic dysfunction and the enormity of the task that healthcare faced, the IOM rightfully made no attempt to specify a plan for improvement. Rather, they set forth 10 rules for redesign, looking to establish a framework within which individuals and entities would be free to innovate their own solutions. Although all 10 of these rules are important, we feel there are a few that should be stressed as paramount principles considered when undertaking quality improvement initiatives:

• It must be patient centered.

• Free exchange of patient information and knowledge (including errors) is a necessity.

• Safety should focus on systems rather than individuals.

• Transparency must exist for patients (and clinicians).

• Waste should be continually decreased.

Together, the IOM reports successfully kick-started a culture of patient safety. It is a culture that has begun to permeate the halls of all healthcare institutions, public and private, as the field seeks to achieve these aims. Quality improvement initiatives have been undertaken and published with increasing frequency. To Err Is Human has served as the de facto benchmark against which progress can be measured. How is the healthcare sector doing? Results are mixed to say the least. There are published accounts of meaningful progress but often at a brutally slow pace. Some suggest that problems are worsening. Others, such as the Consumers Union Safe Patient Project 10-year review of the industry response to the IOM reports are not shy in giving the healthcare response a failing grade.

How can this be? Although some problems appear to be worsening, it is logical to conclude that some of this can be attributed to better recognition, measurement, and reporting of the issues at hand, something that should be taken as a positive and worthy step on the road to better healthcare. The number of and use of incident report systems have grown, in large part secondary to the Joint Commission requiring their use by hospitals. Despite this, (1) accurate and well-defined measurement, (2) standardization of data, and (3) proper implementation of this data-driven improvement continue to be an issue for a multitude of reasons. These include underreporting, lack of accepted standards, fragmentation of systems, and the inherent variability among different patient populations and care settings. There is increasing need to identify data that actually affect patient outcomes, and, of course, balance quality data with the cost and time required to collect it. In the continued efforts for improvement, healthcare has begun to embrace the practice of high-reliability organizations (HROs), learning from multiple other industries. The application of this concept to healthcare has been summarized based on three main tenets: (1) strong and committed leadership at all levels, (2) an institution-wide culture of safety, and (3) a methodical identification of root problems allowing for robust process improvement.

Better quantification of errors and their prevention in the delivery of care are only part of the problem. Some patients are directly or indirectly harmed before any attempt at treatment is even made. The need for improvements in patient diagnosis, of particular interest to the field of radiology, was recently examined in a 2015 IOM publication, Improving Diagnosis in Health Care . It is currently estimated that on a yearly basis, 5% of adults seeking outpatient care are improperly diagnosed. This harms the patient and adds cost to the system in the form of wasted resources. Much like To Err Is Human , perhaps this will serve as another much-needed benchmark for improvement.

Radiology’s Preemptive Work in Quality Improvement

To Err Is Human was a major wakeup call to medicine. It was a necessary call to attention to the fact that physicians and other care providers, no matter how skilled or competent, do not operate in a bubble. Despite their best intentions, care providers were still at risk of causing substantial harm, even if it was mainly secondary to systemic problems. Healthcare workers needed to be aware of the care settings, systems, and governing policies that were a part of their daily clinical duties and how each of these impacts the quality of care they were delivering. As such, many of the principles written about in To Err Is Human and Crossing the Quality Chasm could and would parallel the extradiagnostic aspects of radiology that are important today. That being said, the field of radiology was not oblivious to the issues at hand in 1999.

Just prior to the publication of To Err Is Human , through the leadership of Philip Alderson, noninterpretive skills for radiologists—in particular residents—was getting attention. He rightfully questioned the growing gap between a radiologist’s adequate interpretation skills and a lack of understanding of one’s place within the general healthcare delivery system. This was recognized in 1997 by the Association of Program Directors in Radiology (APDR), which later collaborated with the American College of Radiology (ACR) to produce a curriculum of noninterpretive skills that was further publicized by the American Journal of Radiology (AJR).

Much of this series focused on aspects of radiology care delivery that correlated with the IOM’s call for a more effective and patient-centered approach to healthcare. In particular, there was an in-depth look at the ACR’s efforts to create practice standards, accreditation of subspecialty programs, and the appropriateness criteria for imaging that had already been instituted. These published standards provided radiologists and other care providers with practice guidelines that, if followed, would increase the quality of care provided by radiologists. Accreditation programs, the first being the program in radiation oncology in 1966, ensured that techniques or practices underwent an evidence-based formal review process to ensure that specific quality standards were met. The widely recognized success of the mammography accreditation program, established in 1985 in response to disparities in mammography quality, led to measurable improvements in the quality of mammography throughout the United States and was eventually adopted by the US Food and Drug Administration (FDA). The ACR Appropriateness Criteria, introduced in 1993 and continually refined, defined evidence-based best use standards for selection of imaging exams or therapeutic processes for specific clinical conditions. This not only allowed radiologists and medical clinicians to deliver the most appropriate and effective care to each patient, but also preempted yet-to-be implemented future developments in healthcare that would require valid justification for and evidence supporting tests ordered prior to payment.

Around the same time that the IOM was releasing these pivotal reports, the American Board of Radiology (ABR) also recognized the importance of noninterpretive skills in the education and competence of our workforce. Today, the Diagnostic Radiology Boards include examination in noninterpretive skills, as does the Maintenance of Certification (MOC) Program. Recently, the number of ways to fulfill this requirement has greatly expanded, giving radiologists more flexibility and allowing for more creativity in fulfilling the required competencies in practice quality improvements. The ABR has maintained a syllabus, the Noninterpretive Skills Domain Specification and Resource Guide, which is available online and continually updated. The syllabus directly addresses the IOM aims for quality care and embraces the 10 guidelines for healthcare redesign. It provides valuable information for today’s radiologist and serves as a framework within which to examine efforts made by the field over the past 2 decades in addressing the IOM aims. The syllabus is divided into six sections, each of which receives a brief overview in the following pages and helps introduce some of the concepts that will be evaluated in this text. Despite the value and wealth of information provided by the syllabus, it is by no means a comprehensive work; it is the intention of this book to fill in the gaps and further develop these important aspects of radiology.

Part I: General Quality Improvement

The complexity of healthcare demands a continuous effort of all involved parties to achieve meaningful quality improvement . The unremitting nature of improvement can be contrasted with the more traditional, and much more static notion of quality assurance, in which the goal is merely compliance with predefined standards. There are multiple approaches to quality improvement. One of the most recognized is the Plan-Do-Study-Act (PDSA) cycle, which by its very name implies continuous improvement efforts. It embraces the isolation of and quantification of a specific problem, targeted interventions, and measurable outcomes. “Lean” process improvement focuses on elimination of waste and an institution-wide culture of mutual trust and continual improvement. Failure mode and effect analysis can be used to proactively assess complex processes for possible errors. Innumerable other methodologies exist and can be used to complement one another. Specific quality improvement tools that can be applied to any of these methods include establishing key performance indicators, value stream maps, cause-and-effect diagrams, time series plots, Pareto charts, prioritization matrices, and simulation walk-throughs.

Regardless of the methods and tools used, there are key components in all successful quality improvement projects. A specific opportunity for improvement should be identified. A qualified and inclusive team should be assembled. A clear aim statement should define specific goals of the project. Appropriate measures and benchmarks should be selected. Objective data sources should be identified and appropriately collected, including baseline values. Thorough process analysis should be performed to obtain a complete understanding of specific problems that are obstacles to improvement. A project plan should be constructed, implemented, and continuously evaluated. Initially, when doing quality improvement projects, things may appear to get worse before they get better. This situation is probably due to the Hawthorne effect, which is the initial part of the Abujudeh curve and results from an increase in awareness and observations ( Fig. 1.1 ). When appropriate, the project should be closed, at which time there is documentation of what was learned, proposals for other areas in which this change could be applicable, and ideas for future exploration.