Real World Application of Imaging Record Reconciliation Process and - PowerPoint PPT Presentation

Real World Application of Imaging Record Reconciliation Process and Quality Improvement R.L. “Skip” Kennedy, MSc, CIIP Technical Director of Imaging Informatics, The Permanente Medical Group, Northern California Julie Rae Verney, MPA, CIIP PACS/Informatics North Valley Service Area The Permanente Medical Group, Northern California June 30 th , 2016

Imaging Quality Information System (QIS) If you can't measure it, you can't improve it. - Peter Drucker

Imaging Quality Information System (QIS) RIS PACS Module? Module? Independent?

Overview 1. Quality Information System (QIS) 2. Planning the Project 3. Developing the Application 4. Implementing the Application 5. Ongoing Quality Assessment and Improvement leveraging the Application

Imaging Quality Information System (QIS) • Defining Quality metrics, functions and goals: – Imaging Quality (KPIs, Key Performance Indices) – “Demographic Quality” (patient/study context) – “Image Quality” (positioning, technique, protocol, etc.) – Quality Issue Tracking and Remediation of acquired Exams – QIS as “communication” tool not only “tracking” – Quality Performance Assessment of acquired Exams – Quality Improvement of acquired Exams

Imaging Quality Information System (QIS) Potential Areas for quality measurement/metrics • Technologist errors (Technologist self reported) – In scope • Acquired image quality – (Radiologist input/feedback) – In scope • Modality measurement accuracy (DICOM SR) – In scope • Exam requests – (Appropriateness, decision support) – Out of scope (Separate application, work in progress) • Dose reporting – (RDSR) – Out of scope (separate application) • Protocol Management – (DICOM MPPS) – Out of scope (work in progress) • Radiologist Peer Review – Out of scope (separate application)

Imaging Quality Information System (QIS) The Problem:  7% of exams represent some Technologist error in one measured Radiology department  Minnigh, T. R., & Gallet, J. (2009). Maintaining Quality Control Using a Radiological Digital X-ray Dashboard. Journal of Digital Imaging , 22(1) 84-88.  Radiology, as Diagnostic Imaging, is involved in over 10% of all medical visits  Harvey L. Neiman Health Policy Institute™.

Imaging Quality Information System (QIS) The Problem – continued:  Performance Improvement needs areas included • Improperly identified patient/exam requested • Improper technique • Incomplete exams • Missing or wrong anatomy/laterality • Wrong protocol • Improper measurements • Missing series or views • Mismarked exams • Modality settings incorrect

Imaging Quality Information System (QIS) The Consequence: • Missed, Incomplete, or wrong diagnosis which could have significant medical consequences leading to medical legal ramifications. • Exams repeated unnecessarily, increasing Dose to patient, delaying patient care and/or departmental throughput. • Increased reading time which delays patient care and increases Radiologist workload, decreasing diagnosis turn around time. • Risk to institutional reputation • Human Resources required to correct PACS, EHR, RIS, Dictation, etc. etc.

Imaging Quality Information System (QIS) What was being done about it historically: • Exam worksheets  Slow, cumbersome, individual events  Radiologists will not fill them out • Tech QA review programs (survey of available systems)  Expensive, long implementations  Little to no technologist feedback  Not real time • Very few for the most part • “Live with the problem”

Imaging Quality Information System (QIS) • Assessing QIS in your own Organization – Do you need one? – Do you want one? – Are you ready for the reality of the findings? – Are you ready to take on the challenge of Quality Improvement based on your findings? • Determine your organization’s preparedness • Begin Developing your action plan

QIS – Project Action Plan (ours) 1. Gather data 2. Evaluate/Analyze data 3. Initiate introductory meetings: Leadership/Peers/Chiefs/Radiologists/Staff 4. Establish QIS criteria 5. Sign off on QIS design and plan (stakeholders) 6. Publish design and workflow plan (user community) 7. Develop developer Scope of Work (SOW) 8. Develop API design to PACS 9. Implement API integration to PACS 10. Develop HL7 interface design from RIS 11. Implement HL7 interface from RIS 12. Identify QIS Administrators 13. Charter QIS Committee 14. Implementation/Launch 15. 30 day assessment 16. Review Data - Develop/Implement Ongoing Monthly Reporting Process 17. 60 and 90 day design assessment and review 18. 120 day final assessment 19. Publish final QIS Policies and Procedures 20. Implement Improvement Plans

QIS, well, 20 modest steps, not 95… Martin Luther Posts his 95 Theses on door of Castle Church in Wittenburg, 1517 Illustration: Pinterest

QIS - Gather Data (1)  Gather your historical data  “What’s Broken, and how can we Fix it?”  Measure and prioritize your risk factors • What do you want to present as high risk? • What do you want to present as most frequent?

QIS – Evaluate/Analyze data (2)  Assess and define your imaging quality challenges and improvement opportunities • What/Who are your challenges? Techs: Image quality? Demographics? • Rads: Image quality? Demographics? • Providers: Requests/Protocol? Demographics? •

QIS – Introductory Meetings (3)  Solicit input from a wide range of potential users/stakeholders  Physicians/Radiologists  Radiology Management  Technologists  HR/Employee Representation  Key step! If you don’t gather input from all parties, it will compromise “buy-in” at implementation and beyond. Make the tool THEIR tool!  Note: we specifically excluded “productivity” as a metric—this tool was designed to address quality, not productivity. This was a key aspect of discussions with Technologist representation.

QIS – Introductory Meetings (3) Imaging Directors and Managers Chiefs and Radiologists, Providers Imaging Technical Staff – all modalities Imaging Support Staff • Informatics • PACS • File Room •  Everyone will have something to contribute!  Help them OWN and understand the Quality Tool!  If they OWN it and understand it, they will use it!  Set this program up for positive team improvement!!

QIS – Establishing your QIS criteria (4)  Once you have identified your focus, you can organize your criteria into logical categories for monitoring and tracking. Example: KP Imaging defined our QIS Process as QAT = Quality Assurance Tool We further categorized our Quality Issues between two user groups, the Technologists and the Radiologists.

QIS – QIS Development Elements, Ours (4)  Develop a web based app integrated into the PACS System to provide communication and tracking on the quality of Radiology Exams.  Integrate with RIS through HL7-Orders and Results interfaces from RIS  Rapid access by Technologists and Radiologists through a series of configurable pull down lists.

QIS – Establishing your QIS criteria (4)  Provides 24 x 7 immediate access to resources equipped to remediate Imaging issues in a timely manner. (Tech-to-PACS communication)  Real time and interactive.  Analytics tracker and real time reports/dashboards for all activities.  Integrates to PACS via API.  Integrates to RIS via HL7 (Orders and Results)

QIS – Establishing your QIS criteria (4) QAT = QUALITY ASSURANCE TOOL (suite) “Janus” model: RQAT = RADIOLOGIST Quality Assurance Tool Radiologist use the QIS within the Radiologist PACS portal to report on exams that are not of diagnostic quality due to a number of issues. TQAT = TECHNOLOGIST Quality Assurance Tool Technologists use the QIS within the Imaging PACS Portal to self report, and communicate to PACS issues for exams that they have submitted for diagnostic interpretation.

QIS – Radiologists Tracking Criteria (4) Input provided by  Imaging Chiefs  Imaging Directors  Radiologists Identified the following focus areas as the RQAT focus criteria:

QIS Radiologist Tracking Criteria (4) Radiologist Quality Assurance Tool (RQAT) criteria: R.1 Captured study with incorrect patient MRN R.2 Captured study with incorrect order information R.3 Incorrect Protocol/Parameters Wrong R.4 Incomplete/Missing patient questionnaire R.5 Suboptimal positioning R.6 AOI not marked/annotated R.7 Removable artifacts present R.8 Motion artifacts R.9 Image Over/Under Penetrated R.10 Image Mismarked or Marker Missing R.11 Bundled Studies Not Combined R.12 Wrong Patient R.13 Wrong/missing Anatomy R.14 Collimator Error R.15 Incomplete Documentation R.16 Pertinent Information covered by labels R.17 Appropriateness of order R.18 Prior exams not present R,19 Exam generally poor R.20 Exam Excellent, above and beyond

QIS – Technologist Tracking Criteria (4) Input provided by  Imaging Managers  Imaging Technologists  PACS Administrators  Imaging File Room staff Identified the following focus areas as the TQAT focus criteria: