Quality Management

purpose of a quality management program

control or minimize variables that degrade the quality of products and services offered

to maximize efficiency

to continually improve outcomes

• safety

• efficiency

• effectiveness

parts of a quality management program

quality assurance

quality control

continual quality improvement (CQI) goal

produce quality images in a safe environment, create quality images with min amount of radiation

quality assurance (QA)

focuses on processes and quality of services offered

• pt care

• wait times

• image interpretation

• timeliness of reports

quality control (QC)

focuses on equipment and technical quality

• equipment performing within established parameters

• radiation exposure

  • minimize repeats

  • pt safety

  • ALARA

factors to minimize variables

expected quality

• influenced by outside factors

perceived quality

• very subjective

• brings pts back to the hospital

actual quality

• statistical data measures outcomes

key process variables

manpower

• personnel involved in process

machines

• equipment used

materials

• supplies used

environment

• both physical and psychological aspect of people involved in processes

policies

• established procedures and/or policies

who are the customers

patients

ordering physicians

other hospital departments

clinics

other businesses

insurance companies

hospitals must change to become more efficient in order to survive

advances in technology

government regulations

accreditations

mergers and buyouts

reimbursement

changes in technology

computers

digitized images

HIS/RIS/PACS

CT

MRI

PET

government regulations to note

mammography quality standards act (MQSA)

• enforced by the center for devices and radiologic health which is part of the FDS

title 21 of the code of federal regulations

Care Bill

• consumer assurance of radiologic excellence

regulatory bodies

department of health and human services

national center for devices and radiological health

food and drug administration

occupational safety and health administration

environmental protection agency

American college of radiologists

when did the US federal government initiate quality management regulations compared to imaging departments

US in 1968

imaging departments in the 1930s

health insurance portability and accountability act (HIPAA) of 1996

established the national standards for

• security of electronic records

• standardized formats for electronic record keeping

• identifiers and codes for institutions, personnel, diagnoses, and treatments

• confidentiality and privacy rules

desired outcomes in diagnostic imaging

cost savings and customer satisfaction

• lower repeat rates

• minimize equipment downtime

• improved operational efficiencies

  • high quality images

  • low pt dose

  • improved turnaround time

  • accurate reports

  • lower pt wait times

Florence Nightingale

pioneer of nursing

created clean environment

reduced infection rate

established pt services

W Edwards Deming

developed the plan/do/check/act method

best known for his 14 point system for understanding variation and appreciation

• focus on improving the process, not changing the people

the joint commision (TJC)

a hospital accrediting body that establishes quality standards

• assesses institutions based on these standards

  • hospitals are surveyed every 3 years

• provides certification

  • links reimbursment to recertifications

  • hospital status is posted online

2024 National Patient safety goals established by TJC

identify pts correctly

improve staff communication

use medications sagely

use alarms safely

prevent infection

identify pt safety risks

improve health care equity

prevent errors in surgery

DNV

hospital acreditation

global foundation that provides hospital accreditation, management system sertification, specialized program certification, and training

what dose DNV stand for

Det Noske Veritas

“the Norwegian Truth”

process

ordered series of steps that help achieve desired outcome or a sequence of tasks associated with a particular outcome

system

group of related processes

parts of a system

supplier

• vendor

input

• knowledge needed for order

output

• activity/action that achieves desired outcome

customer

• orderind doctor, patient, etc.

who determines what constitutes as qulaity

the customer

• high quality images

• accurate reports

• high quality pt care

• high level of customer satisfaction

Press Ganey survey

measures customer satisfaction

• hospitals receive a raw score and a score comparing them to other facilities

goal is to

• improve pt experience

• improve quality and delivery of healthcare

process improvement teams

made of groups of individuals most familiar with the process and best able to identify problems

• 6-12 people who share responsibilities

• should be highly trained in the are

types of process improvement teams

quality improvement teams

quality circles

work teams

problem solving teams

tools used by process improvement teams

brainstorming

• used to collect ideas

focus groups

• smaller groups tackle specific issues identified in the brainstorming sessions

multi-voting

• used afer brainstorming session

consensus

• used after a brainstorming session

• final decision is accepted by all

types of problem-solving processes

the 5 whys

• explores cause and effect

thought process map

• helps identify all information and progress

TJC 10 step process

TJC cycle for improving performance

TJC 10-step process

1. assign responsibility

2. delineate the scope of care and service

3. identify important aspects of care and service

4. identify indicators or performance measures

5. establish a means to trigger evaluation

6. collecrt and organize data

7. inititate evaluation

8. take actions to improve care and service

9. asses effectiveness of actions and maintain improvements

10. communicate results to affeted individuals and groups

TJC cycle for improving performance:

design

• plan

measure

• do

asses

• check

improve

• act

should be an ongoing process to obtain continual improvement

TJC cycle for improving performance: design (plan)

develop the process

• mission

• vision

• needs

• expectations

• current knowledge

• resources available

TJC cycle for improving performance: measue (do)

collect valid and reliable data to demonstrate effectiveness and efficiency of care and performance improvement

TJC cycle for improving performance: assess (check)

compare data to reference point or standard

benchmarking

• compare against results of other established groups/outcomes

TJC cycle for improving performance: improve (act)

take action to improve process

• refine

• redesign

FADE

process improvement program

Focus

Analyze

Develop

Execute

FADE: focus

choose problem and describe it

FADE: analyze

learn about problem by collecring and analyzing data

FADE: develop

develop a solution and plan

FADE: execute

implement the plan

adjust as needed

SWOT analysis

analyzes the internal and external environments

strength

weakness

opportunities

threats

six sigma

seeks to measure errors in a process so that they can be statistically removed

adopted by GE and now used in healthcare

LEAN

seesks to eliminate wasteful steps in a process

• identifies every step in a process

• determines and eleminates wasteful steps

FOCUS

Find process improvemtn opportunity

Organize a team that knows the process

Clarify current knowledge of the process

Uncover root causes for process ariation

Start improvement cycle

FMEA

failure mode and effects anaylsis

procedure for analysis of potential failure within a system

1. detemine severity of all possible failure modles

2. determine how often the failuyre occurs

3. rank the possible failure by how easily mistakes or errors can be detected through inspection and testing

4. calculate risk priority nnumber (RPN) by multiplying number values from 1-3. used as a threshold value to reduce failures

information ananlysis tools

flowchart

cause effect diagram

histogram

pareto chart

scater plot

trend chart

control chart

population

entire group of items being measured

sample

number of items from a population that are actually measured

data set

the information acquired by evaluating the sample

frequency

the number of occurrences of an event or variable

dependent variables

change in response to independent variables

independent variables

are deliberatly manipulated to cause a change on dependent variables

mean

average from all observations

median

numeric middle of values

mode

one value that occurs most frequently in a data set

reliability

reproducibility of results

range

difference between highest and lowest values in a data set

standard deviation

range of variation surrounding the mean

histogram

bar graph used for data display

x-axis is the category

y-axis is the frequency

pareto chart

variation of a histogram

x-axis is the factor

y-axis is the requency

scatter plot

determines if a relationship exists between two variables

trend chart

evaluates data over a period of time

pictoral representation

control chart

modification of a trend chart

designates upper and lower control limits

demonstrates performance over time

risk management goal

quality pt care in a safe environment

• identify areas of potential risk

• establish policies and procedures to reduce risk

• educate staff

• periodic inspections

• documentation

sentinel event

an unexpected occurrence causing a death or a serious physical or psychological injury or the risk thereof

• require immediate investigation and response

• infrequent and undesirable

EX: death post CT/IV contrast, infant abduction, wrong site surgery, etc.

root cause analysis

determines the cause of a sentinel event and initates appropriate corrective action

quality management programs and tools for diagnostic imaging

equipment QC

administrative responsibilities

risk management

radiation safety - ALARA

radiation safety program

required by federal law in the US

NRC enforces the regulations

total quality management (TQM)

goal is continual quality improvement

be aware of both department and hospital wide QI initiatives

the responsibility of TQM belongs to

everyone

Aurora CQI Initiatives

care management impact scores

• impacts employee performance evaluations

culture of safety

• measures progress on delivering top decile outcomes in alignment with Advocate Aurora’s Elevate Clinical Preeminence and Safety Pledge

safety hudles

your responsibility for quality improvement

report errors

fix the problem

follow through

colunteer to participate on CQI team or project