Introduction to the Special Issuee Quality Improvement in Radiology Paul Nagy, PhDa, Ruth C. Carlos, MD, MSb Quality is not an act, it is a habit.
—Aristotle
Quality improvement methodology comes from an extensive history of organizational experimentation and is the culmination of literally hundreds of management programs tried in the business world over the past 50 years [1]. Quality improvement techniques are, at their core, reliable methods to drive change and improve efficiency. The goal of the quality management field is to create real-world processes and structures to introduce positive change into a work environment in a repeatable way that is nondisruptive and at a minimal cost. Critical elements in any quality program include leadership willing to experiment and take risks. These experiments should be viewed and conducted as science, specifically implementation science. Enhancing a quality improvement program is the ability to identify best practices in other arenas and adapt to a specific use or environment. With the increasing shift to value-based reimbursement from volume-based reimbursement [2], radiology needs to demonstrate improved patient safety and outcomes at the same or reduced cost of care, a critical facet of population health management. Although we have implicitly operated in this role, collectively, we have not explicitly demonstrated our value through systematic practice-based or institutional projects focused on quality care delivery through well-recognized standard methods of quality improvement. Part of the reluctance to do so may lie in the relative lack of experience in quality management techniques or the reluctance to move beyond the limits of one’s perceived area of control, a component of the circle of influence model. The circle of influence model, described by Stephen Covey [3], has 3 nested circles (Fig. 1). The circle in the center is the area directly under our control, the larger circle around that is our area of influence, and the largest circle is the area of concern, where we have little to no influence, though potentially high clinical and economic stakes in decisions made within this largest outer circle. Imaging practices must expand their areas of practice influence to be successful in a value-based reimbursement environment. a
Department of Radiology, Johns Hopkins University, Baltimore, Maryland.
b
Department of Radiology and the Program for Imaging Comparative Effectiveness and Health Services Research, University of Michigan, Ann Arbor, Michigan. Corresponding author and reprints: Paul Nagy, PhD, Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected]. ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.08.030
In this special issue of JACR, we have focused on providing practical guidance on implementing quality improvement projects in radiology. Bruno and Nagy [4] introduce the fundamentals of quality and safety in diagnostic imaging, including a review of the most common analytic methods for quality improvement. Hawkins [5] describes the preplanning process before formally planning and launching a quality improvement project, including assessing a practice’s readiness to change. Several project ideas across the spectrum of expertise, from beginner to advanced, are provided as workbook examples for these analytic methods that can be implemented in one’s practice. These projects are organized around the circle of influence model. Knechtges and Decker [6] broadly describe the kaizen method and apply it to improve radiologist workflow management, a quality improvement project located in one’s area of control, the reading room. Lee and Larson [7] introduce the Institute for Healthcare Improvement’s Model for Improvement, a 3-cycle quality improvement method, illustrated with a project centered in the radiology practice to decrease the “miss” rate of retained surgical foreign bodies on operative room radiography. Itri et al [8] present the Six Sigma methodology used to develop a CT center of excellence, also within their radiology practice. Lee et al [9] summarize value-stream mapping as a method to describe complex processes capturing both the material needs and the process needs for improvement. Lee et al [9] illustrate value-stream mapping with an example centered in one’s area of influence, whereby a multidisciplinary team, created with participants from both within and outside the radiology department, comes together to improve the delivery of a specific imaging service. Moving away from one’s area of control to one’s area of influence, Bruno [10] delineates the steps required for radiologists to lead multidisciplinary quality improvement teams that change care processes outside the direct control of the radiologist using lessons learned from an institutional project optimizing pulmonary embolism CT utilization. Durand [11] describes strategies and potential levers available to radiologists seeking to influence referring physicians’ ordering patterns through a radiologist consultation service. The strategies described by Durand will help expand one’s area of influence, even beyond one’s area of direct control. The ACR recently launched the Imaging 3.0 initiative to “provide concrete steps to allow all radiologists to take a leadership role in shaping America’s future health care system” [12]. This is in recognition of the economic pressures driving radiology from volume-based success to value-driven success [2]. At the core of the 1113
1114 Journal of the American College of Radiology/Vol. 11 No. 12PA December 2014
Area of Control
Area of Control
Fig 1. Expanding radiology’s area of influence.
Imaging 3.0 initiative is the “belief that significant imaging care occurs prior to and following exam interpretation” [13], as well as beyond the confines of the radiology department. This workbook is designed to demystify the practice quality improvement process and provide sample projects that can be replicated or adapted for one’s local practice, while giving individuals the skills and strategies to expand their institutional areas of influence and leadership. These skills and strategies will permit radiology to thrive, even as the pace of change accelerates around us. REFERENCES 1. Davenport TH, Prusak L, Wilson HJ. What’s the big idea? Creating and capitalizing on the best management thinking. Cambridge, Massachusetts: Harvard Business School Press; 2003. 2. Duszak R Jr. Value: imaging’s new wave imperative. J Am Coll Radiol 2013;10:484-5. 3. Covey S. The 7 habits of highly effective people. New York: Free Press; 2004.
4. Bruno MA, Nagy P. Fundamentals of quality and safety in diagnostic radiology. J Am Coll Radiol 2014;11:1115-20. 5. Hawkins CM. Assessing local resources and culture before instituting quality improvement projects. J Am Coll Radiol 2014;11:1121-5. 6. Knechtges P, Decker MC. Application of kaizen methodology to foster departmental engagement in quality improvement. J Am Coll Radiol 2014;11:1126-30. 7. Lee CS, Larson DB. Beginner’s guide to practice quality improvement using the Model for Improvement. J Am Coll Radiol 2014;11:1131-6. 8. Itri JN, Bakow E, Woods J. Creating an outpatient center of excellence in CT. J Am Coll Radiol 2014;11:1137-43. 9. Lee E, Grooms R, Mamidala S, Nagy P. Six easy steps on how to create a Lean Sigma value stream map for a multidisciplinary clinical operation. J Am Coll Radiol 2014;11:1144-9. 10. Bruno MA. Advanced Practice Quality Improvement: beyond the radiology department. J Am Coll Radiol 2014;11:1150-4. 11. Durand DJ, Kohli MD. Advanced Practice Quality Improvement project: how to influence physician ordering behavior. J Am Coll Radiol 2014;11:1155-9. 12. American College of Radiology. Imaging 3.0. Available at: http://www.acr. org/Advocacy/Economics-Health-Policy/Imaging-3. Accessed June 2014. 13. Ellenbogen P. Imaging 3.0: what is it? J Am Coll Radiol 2013;10:229.
—Aristotle
Quality improvement methodology comes from an extensive history of organizational experimentation and is the culmination of literally hundreds of management programs tried in the business world over the past 50 years [1]. Quality improvement techniques are, at their core, reliable methods to drive change and improve efficiency. The goal of the quality management field is to create real-world processes and structures to introduce positive change into a work environment in a repeatable way that is nondisruptive and at a minimal cost. Critical elements in any quality program include leadership willing to experiment and take risks. These experiments should be viewed and conducted as science, specifically implementation science. Enhancing a quality improvement program is the ability to identify best practices in other arenas and adapt to a specific use or environment. With the increasing shift to value-based reimbursement from volume-based reimbursement [2], radiology needs to demonstrate improved patient safety and outcomes at the same or reduced cost of care, a critical facet of population health management. Although we have implicitly operated in this role, collectively, we have not explicitly demonstrated our value through systematic practice-based or institutional projects focused on quality care delivery through well-recognized standard methods of quality improvement. Part of the reluctance to do so may lie in the relative lack of experience in quality management techniques or the reluctance to move beyond the limits of one’s perceived area of control, a component of the circle of influence model. The circle of influence model, described by Stephen Covey [3], has 3 nested circles (Fig. 1). The circle in the center is the area directly under our control, the larger circle around that is our area of influence, and the largest circle is the area of concern, where we have little to no influence, though potentially high clinical and economic stakes in decisions made within this largest outer circle. Imaging practices must expand their areas of practice influence to be successful in a value-based reimbursement environment. a
Department of Radiology, Johns Hopkins University, Baltimore, Maryland.
b
Department of Radiology and the Program for Imaging Comparative Effectiveness and Health Services Research, University of Michigan, Ann Arbor, Michigan. Corresponding author and reprints: Paul Nagy, PhD, Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected]. ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.08.030
In this special issue of JACR, we have focused on providing practical guidance on implementing quality improvement projects in radiology. Bruno and Nagy [4] introduce the fundamentals of quality and safety in diagnostic imaging, including a review of the most common analytic methods for quality improvement. Hawkins [5] describes the preplanning process before formally planning and launching a quality improvement project, including assessing a practice’s readiness to change. Several project ideas across the spectrum of expertise, from beginner to advanced, are provided as workbook examples for these analytic methods that can be implemented in one’s practice. These projects are organized around the circle of influence model. Knechtges and Decker [6] broadly describe the kaizen method and apply it to improve radiologist workflow management, a quality improvement project located in one’s area of control, the reading room. Lee and Larson [7] introduce the Institute for Healthcare Improvement’s Model for Improvement, a 3-cycle quality improvement method, illustrated with a project centered in the radiology practice to decrease the “miss” rate of retained surgical foreign bodies on operative room radiography. Itri et al [8] present the Six Sigma methodology used to develop a CT center of excellence, also within their radiology practice. Lee et al [9] summarize value-stream mapping as a method to describe complex processes capturing both the material needs and the process needs for improvement. Lee et al [9] illustrate value-stream mapping with an example centered in one’s area of influence, whereby a multidisciplinary team, created with participants from both within and outside the radiology department, comes together to improve the delivery of a specific imaging service. Moving away from one’s area of control to one’s area of influence, Bruno [10] delineates the steps required for radiologists to lead multidisciplinary quality improvement teams that change care processes outside the direct control of the radiologist using lessons learned from an institutional project optimizing pulmonary embolism CT utilization. Durand [11] describes strategies and potential levers available to radiologists seeking to influence referring physicians’ ordering patterns through a radiologist consultation service. The strategies described by Durand will help expand one’s area of influence, even beyond one’s area of direct control. The ACR recently launched the Imaging 3.0 initiative to “provide concrete steps to allow all radiologists to take a leadership role in shaping America’s future health care system” [12]. This is in recognition of the economic pressures driving radiology from volume-based success to value-driven success [2]. At the core of the 1113
1114 Journal of the American College of Radiology/Vol. 11 No. 12PA December 2014
Area of Control
Area of Control
Fig 1. Expanding radiology’s area of influence.
Imaging 3.0 initiative is the “belief that significant imaging care occurs prior to and following exam interpretation” [13], as well as beyond the confines of the radiology department. This workbook is designed to demystify the practice quality improvement process and provide sample projects that can be replicated or adapted for one’s local practice, while giving individuals the skills and strategies to expand their institutional areas of influence and leadership. These skills and strategies will permit radiology to thrive, even as the pace of change accelerates around us. REFERENCES 1. Davenport TH, Prusak L, Wilson HJ. What’s the big idea? Creating and capitalizing on the best management thinking. Cambridge, Massachusetts: Harvard Business School Press; 2003. 2. Duszak R Jr. Value: imaging’s new wave imperative. J Am Coll Radiol 2013;10:484-5. 3. Covey S. The 7 habits of highly effective people. New York: Free Press; 2004.
4. Bruno MA, Nagy P. Fundamentals of quality and safety in diagnostic radiology. J Am Coll Radiol 2014;11:1115-20. 5. Hawkins CM. Assessing local resources and culture before instituting quality improvement projects. J Am Coll Radiol 2014;11:1121-5. 6. Knechtges P, Decker MC. Application of kaizen methodology to foster departmental engagement in quality improvement. J Am Coll Radiol 2014;11:1126-30. 7. Lee CS, Larson DB. Beginner’s guide to practice quality improvement using the Model for Improvement. J Am Coll Radiol 2014;11:1131-6. 8. Itri JN, Bakow E, Woods J. Creating an outpatient center of excellence in CT. J Am Coll Radiol 2014;11:1137-43. 9. Lee E, Grooms R, Mamidala S, Nagy P. Six easy steps on how to create a Lean Sigma value stream map for a multidisciplinary clinical operation. J Am Coll Radiol 2014;11:1144-9. 10. Bruno MA. Advanced Practice Quality Improvement: beyond the radiology department. J Am Coll Radiol 2014;11:1150-4. 11. Durand DJ, Kohli MD. Advanced Practice Quality Improvement project: how to influence physician ordering behavior. J Am Coll Radiol 2014;11:1155-9. 12. American College of Radiology. Imaging 3.0. Available at: http://www.acr. org/Advocacy/Economics-Health-Policy/Imaging-3. Accessed June 2014. 13. Ellenbogen P. Imaging 3.0: what is it? J Am Coll Radiol 2013;10:229.
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