Quality Management Notes

Chapter 1: Introduction to Quality Management

Image Quality Factors and Effects

• Image quality is affected by:
  • Human factors.
  • Equipment factors.
• Effects of poor image quality:
  • Repeat exposure.
  • Increased dose.
  • Increase in department costs.
  • Compromised images.
  • Decreased interpretation accuracy.
  • Decreased customer satisfaction.
  • Loss of business and revenue.
  • Poor patient outcomes.

Three Levels of Quality

• Expected Quality: What the customer expects, influenced by outside factors.
• Perceived Quality: The customer’s subjective perception, which stimulates return business and influences patient actions more than actual quality.
• Actual Quality: Measured outcomes with statistical data, considering all factors, and allowing comparison with competitors.

Recent Changes in Health Care (Since the 1980s)

• Advances in technology, equipment, and procedures.
• Legislation and Government Regulations:
  • MQSA (Mammography Quality Standards Act).
  • Medicare Improvements for Patients Act.
  • OSHA (Occupational Safety and Health Administration).
  • FDA (Food and Drug Administration).
  • EPA (Environmental Protection Agency).
  • Increased responsibility for medical imaging departments to follow procedures and documentation guidelines.
• Accreditation Procedures: TGC (The Joint Commission).
• Economic Conditions:
  • 30% of hospitals have closed since 1980.
  • Mergers and acquisitions by “for-profit” organizations to reduce costs.
• Methods of Reimbursement.

Reimbursement Methods

• Previously “fee for service.”
• Shift to HMO/PPO with lower payment rates.
• Insurers employ Radiology Benefits Managers (RBM) to assess the appropriateness of imaging.
• Affordable Care Act capped reimbursements.
• Bundled payments for conditions like broken hips requiring multiple exams.

Cost of Quality Management

• Quality management is required and essential for the operation and survival of imaging departments.
  • Decreases repeat rates.
  • Decreases equipment downtime.
  • Improves efficiency.
  • Improves customer perception.

History of Quality Management

• Florence Nightingale (1860s): Analyzed mortality rates.
• Ernest Coleman (1910): Tracked patients to determine treatment effectiveness.
• Frederick Winslow Taylor (1900s): Advocated dividing tasks to decrease complexity and errors.
• W. Edwards Deming & Joseph Juran (1950s): Focused on quality control with management input.
• The Joint Commission (1992): Developed an Accreditation Manual for Hospitals based on Deming and Juran's concepts.

Governmental Action

• Radiation Control for Health and Safety Act of 1968
  • Law to reduce radiation exposure from electronics.
  • Implemented by the Bureau of Radiologic Health (BRH).
  • In 1978, BRH recommended QA for Radiology Departments.
  • Adopted by most state public health agencies.
• Consumer-Patient Radiation Health and Safety Act of 1981
  • Addressed unnecessary repeats and screenings.
  • Accreditation of educational programs and certification of radiographers.
• Consistency, Accuracy, Responsibility and Excellence in Medical Imaging and Radiation Therapy (CARE)
  • Proposed to require licensing but never passed.
• Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
  • Requires non-hospital advanced imaging facilities to be accredited.
• OSHA Standard Precautions (1980s)
  • Implemented by 1992.
  • Addressed infection control due to the AIDS outbreak.
  • Requires standard precautions and exposure control plans, free Hep B immunizations, and PPE.
• Safe Medical Devices Act of 1990
  • Mandates reporting of medical equipment causing death or injury.
• Mammography Quality Standards Act of 1992
  • Mandates all facilities performing mammography have QA programs and FDA approval.
• Health Insurance Portability and Accountability Act of 1996 (HIPAA)
  • Provides safeguards to protect patient information and encourages electronic transmission of information.
  • Failure to comply can result in up to $250,000$ fine and 10 years in prison.
• American Recovery and Reinvestment Act of 2009
  • Health Information Technology for Economic and Clinical Health Act (HITECH).
  • Amended HIPAA and provided categories of violations.
• Deficit Reduction Act of 2005
  • Designed to cap costs at outpatient imaging centers.
  • Required quality standards.
• Patient Protection and Affordable Care Act of 2010 (Obama Care)
  • Bundled payments for “episode of care”.
  • $2.3\%$ tax on imaging equipment.

HITECH Penalties

The HITECH Act outlines penalties for violations based on the level of culpability:

• Tier 1: Entity did not know about the violation (and wouldn't have known with reasonable diligence).
  • Penalty Range: $100$ to $50,000$ per violation.
  • Maximum Penalty: $1,500,000$.
• Tier 2: Violation due to reasonable cause, not willful neglect.
  • Penalty Range: $1,000$ to $50,000$.
  • Maximum Penalty: $1,500,000$.
• Tier 3: Violation due to willful neglect, corrected within 30 days.
  • Penalty Range: $10,000$ to $50,000$.
  • Maximum Penalty: $1,500,000$.
• Tier 4: Violation due to willful neglect, not corrected within 30 days.
  • Minimum Penalty: $50,000$ per violation.
  • Maximum Penalty: $1,500,000$.

The Joint Commission (TJC)

• Voluntary Accreditation.
• May be required for Medicare and Medicaid reimbursement.
• Often not obtained at rural hospitals due to “Critical Access” status, which still allows Medicare and Medicaid reimbursement.
• Requires QA testing and documentation on all equipment and devices.
• Performance Standards Documentation.

Det Norske Veritas (DNV) Healthcare

• Mission to safeguard life, property, and the environment.
• Given permission to accredit hospitals in 2008.
• Standards similar to TJC:
  • Customer Focus
  • Leadership
  • Involvement of people
  • Process approach
  • System approach to management
  • Continual improvement
  • Factual approach to decision making
  • Mutually beneficial supplier relationships

Quality Assurance

• All-encompassing management program.
• Philosophy is to achieve and maintain a certain level of quality through data collection and evaluation.
• Focuses on:
  • Patient scheduling
  • Management techniques
  • Policies
  • Technical effectiveness
  • Efficiency
  • In-service education
  • Image interpretation and timeliness

Quality Assessment

• Measures the level of quality at a specific point in time without efforts to change or improve it.
• Provides data for quality assurance or quality management programs.

Quality Control

• Part of a Quality Assurance/Quality Management program.
• Deals with the monitoring and maintenance of equipment.

Three Levels of Quality Control

• Level I – Noninvasive and Simple
  • Performed by any technologist.
  • Examples: Wire mesh test, spinning top timer test.
• Level II – Noninvasive and Complex
  • Performed by technologists trained in QC.
  • Uses special tools and meters for noninvasive evaluation of radiation output.
• Level III – Invasive and Complex
  • Involves some disassembly of equipment.
  • Completed by engineers or physicists.

Types of Quality Control Tests

• Acceptance Testing
  • Establishes baseline performance.
• Routine Performance Testing
  • Performed on equipment at specific intervals.
  • Diagnoses changes before they are noted on images.
• Error Correction Testing
  • Completed to diagnose malfunctioning equipment.

Continuous Quality Improvement (CQI)

• Focuses on improving quality and not just maintaining it.
• Incorporated by TJC in 1991 and adopted into quality management.
• Differentiates quality assurance from quality management.
• Focuses on process improvement rather than individual performance.
• Seeks input from everyone involved.
• Expected to meet or exceed expectations.
• Focuses on the organization as a whole, promoting unity of purpose.
• Employees are considered assets, not expenses.

Process Improvement

• Process: An organized series of steps that help achieve a desired outcome.
  • Problems and variability typically stem from process issues, not employee issues.
  • Workers closest to the process often know what is wrong.
• System: A group of related processes.

Premises of Process Improvement

• 85/15 Rule
• 80/20 Rule
• Worker involvement
• Structured problem-solving
• Data-driven changes
• Customer satisfaction

Key Quality Characteristics

• Qualities most important to the customer.
• Must be constantly monitored.
• Examples: Availability of procedures, accuracy and timeliness of reports, minimal waiting time.

Key Process Variables

• May affect the final output:
  • Manpower
  • Machines
  • Materials
  • Environment
  • Policies

Analysis of Problems: Group Dynamic Tools

• Brainstorming: Large, unconfined collection of ideas.
• Focus Groups: Small group focused on solving one problem.
  • Requires a skilled facilitator and data.
• Consensus: Group members agree on the most important issue to be addressed from the brainstorming session.
• Multivoting: Dismisses non-essential ideas from brainstorming.
• Quality Improvement Teams: Group that implements solutions discovered by a focus group.
• Quality Circles: Meet regularly to identify potential problems and develop solutions.
• Work Teams (6-12 employees): Work together to solve a complete problem, not just a portion.
  • Must be highly trained in the problem they are working on.
• Problem-Solving Teams: Work on specific tasks and meet to solve particular problems and root causes.
  • Identify, analyze, and solve.

Root Cause Analysis Problem-Solving Tools

• 5 Whys:
  • Identify the problem and ask