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 30th, 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 Module? PACS 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
• ne 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
• ver 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

• n 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

• f 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:

QIS – Technologist Tracking Criteria (4)

Technologist Quality Assurance Tool (TQAT) criteria:

T.1 Imaging the wrong patient T.2 Imaging (CT) a fetus without an order T.3 Imaging the wrong anatomy T.4 Repeating study, re-exposing patient T.5 Capturing study with incorrect patient MRN T.6 Capturing study with incorrect order information T.7 Processing/closing study within RIS with incorrect demographic information T.8 Capturing Suboptimal, duplicate, blank image T.9 Mismarking images, laterality, body part, AOI T.10 Poor Patient positioning T.11 System related issue

QIS Tracking Criteria (4)

With the criteria identified, the issues were placed in a ranking

• rder with Risk values associated with each issue, to be used

when developing P&Ps, SLA, and triaging support or when assessing Quality Assurance Improvement. Its not only how many QA issues there are, but it can depend upon the severity of the issues as well. This schema makes working with the different levels of issues easy to categorize.

4 - MAJOR SEVERITY 3 - MODERATE SEVERITY 2 - MINOR SEVERITY 1 – MAINTENANCE/MISC

• Imaged wrong patient
• Imaged fetus without order
• Imaged wrong anatomy
• Study repeated without order
• Combined Studies/image for

different patient

• Scanned wrong paperwork from

different patient

• Combined study/image for same

patient

• Updated incorrectly, wrong

procedure protocol or cancelled accession number

• Missing or unusable patient

demographics, MRN or ACC#

• Scanned wrong paperwork, same

patient

• Image Quality suboptimal
• Image over/under penetrated
• Image mismarked
• Poor patient positioning
• Combined study/image for

same patient

• System-related Issue

(Equipment, etc)

• Patient Name Change/DOB
• Provider cancelled or changed
• rder
• Fileroom issue

QIS Project Design Sign Off (5)

Provide copies of your Project Documentation to your Imaging Leadership to request approval and sign off on the Project and Action Plan. Once leadership has approved of the project and signed off on the design, the real work can begin! This also provides a “cut off” to the project scope – avoiding scope creep as best as is possible.

QIS Publish the approved design (6)

Be sure to let all interested stake holders know the plan has been approved and the work will begin. This is a GREAT time to share the inclusions or limitations of the Project as approved by Imaging

• Leadership. This will serve you well as

additional requests are made during the development cycle.

QIS Scope of Work (7)

It is highly recommended you take the time to produce a Project Scope of Work. Be as detailed as you can and provide mock ups of forms and reports! In the long run, this can keep your project well defined, on target, in budget and on time! Review your scope with your development team and get acceptance and sign off!

QIS Design and Develop the QIS API and RIS integrations (8,9,10,11)

Utilizing your Scope of Work, developing the code can begin. It is beneficial to have a team of managers and users selected to assist as “testers” during this long phase of the project. Keep this work as organized as possible, with well kept records, especially progress, acceptance, and deadlines. It is recommended that the Project Manager NOT be involved in the development of the app, but is a team member primarily responsible for managing and documenting the project.

QIS Establish QIS Administrators (12)

Determine who the Administrators will be for the final product. Begin maintaining ongoing communications and progress reports with this group. Solicit feedback and recommendations as needed.

QIS Charter the QIS (Quality) Committee (13)

Determine who the QIS Committee Members will be and solicit potential stakeholders for the committee membership. Once the membership has been assembled, document your Charter credentials and process through your Enterprise Administration.

QIS Launch (14)

• After tool has been developed and accepted:
• Be sure to socialize the upcoming launch to all

user groups.

• Provide users with training and manuals in a

timely manner.

• Provide practice sessions, if possible.
• Provide a team of support personnel at sites as

users begin using the tool live.

• Provide feedback to users and administrators.

QIS 30 days design assessment, user review (15, 16)

• Provide the project stakeholders with a 30 day

review on the progress of the implementation and the users acceptance and use of the QIS.

• Be prepared to provide initial statistics,

demonstrating the % of overall users and the initial Quality Assurance “score” compared to the performance benchmark.

• Provide a report to the Quality Assurance

Committee.

QIS 60 and 90 day design assessment, user review (17)

• Provide the project stakeholders with a 60 and 90

day review on the project progress and the users acceptance and use of the QIS – demonstrating the increase or decrease in usage.

• Be prepared to provide comparative statistics, 30

days vs 60 days vs 90 days.

• Trends should begin to be recognizable.
• Schedule your kickoff Quality Assurance

Committee Meeting to review the first 60 days of data, looking for trends to visualize.

QIS 120 day review (18)

• At 120 days, it should be obvious if program

changes need to be made, and if so, how to develop/deploy them.

• Discuss program alterations with the

implementation team for acceptance.

• Provide a four month review to the Quality

Assurance Committee.

• Begin making recommendations for P&Ps

QIS Policies and Procedures (19)

Implement your strategy for Developing Imaging Quality Assurance Policies and Procedures, leveraging the new QA tools. P&Ps, and later management actions based on

• them. Actions must be married to, and

supported by, analysis for there to be an end benefit.

QIS Quality Performance Improvement Plans (20)

With four months of data as reference, work with Imaging Leadership to develop and implement your new Quality Improvement Plan(s), based on finalized P&Ps and analytics. Again, actions must be married to, and supported by, analysis for there to be an end benefit.

Example of a working QIS System

PACS Error has occurred: Technologist realizes the study they performed was submitted to the PACS System using the wrong MRN. Tech navigates to that study in their PACS System and accesses the QIS by calling up the system by right clicking on the study and selecting the QIS

• ption from the drop down list.

Example of a working QIS System

Technologist accessing the QIS (TQAT 2.0) portal from the PACS System.

Example of a working QIS System Technologist is first challenged to provide their Enterprise Credentials before logging into the QIS. Technologist is then provided with a QIS submission window which will be pre-populated with exam demographics as were presented by the HL7 message from the RIS.

Example of a working QIS System

Blank QIS “QA” submission eForm. The tech chooses the QA type and submits.

Example of a working QIS System

Completed submission eForm for a study that has been submitted using a MRN from a different patient. Depending upon the QA type submitted, each has is own pop- up message for the technologist, assisting them with the process and prompting for helpful information and next steps.

Example of a working QIS System

When the QA is submitted, a pre-formatted email notification goes out to leadership and PACS team, alerting them to the QA issue that needs to be resolved. This is extremely valuable for high RISK issues. Instantaneous notification facilitates immediate remediation.

Example of a working QIS System

The Remediation Worklist is provided as a “QA Tracker” within the Administrative Module of the

• QIS. The QA Team – in this case, the PACS Administrators, monitor this worklist for incoming

issues that require remediation. NOTE: This issue “worklist” can be formatted to monitor one or many sites, providing the ability for a Federated support model. The worklist is monitored 10 hours per day during normal work days. The technologist can submit a QA 24 x 7, if a QA needs stat attention, the PACS team can be contacted by calling the on call number provided 24 x 7.

Example of a working QIS System

During the remediation process, update notes will be added by the remediation team to document the process and the issue. By selecting the “notify” icon, update and completion communications will be sent via email to the submitter.

Example of a working QIS System

At any time, the management and PACS Team can visualize ALL of the QAs submitted for a given period of time, or for individual facilities, or combined facilities.

Example of a working QIS System

If the remediation team becomes concerned about a particular technologist’s performance, they can easily use the QA Tracker to isolate the history of any technologist in the system. This provides immediate data to act upon. NOTE – notice the different QA types are color coded according to their RISK factors.

Example of a working QIS System

Searching by the QA Type.

Example of a working QIS System : MANAGERS DASHBOARD

Shows Dashboard elements for the individual facilities within the Selected Service Area

Displays Dashboard elements: Can be filtered by date range, by location, displaying: Volume # of errors QIS Score

Example of a working QIS System : MANAGERS FACILITIES REPORT

Elements can be filtered by month, by Service Area, by Facility, or by Modality

Displays QIS Elements: Most frequent QA types Modality Success Scores

QIS – Quality Improvement Process

“In addition to focusing on quality, in the near future we will need to measure it and demonstrate the results”

Jon Robins, M.D. Chairman-Healthcare Imaging Solutions

Collecting the data is the first step. Taking action is the key step. Process Improvement is the final step.

QIS – Quality Improvement Process

“PSM” model of behavior

Pride (preferred behavioral driver) Shame (less preferred driver, but powerful) Money (reward/punishment, least desired driver)

Thank you for listening!

If you would like copies of this presentation or additional information regarding the Development of this KP QIS Program – you are encouraged to contact: Julie Rae Verney, MPA/HA, CIIP Kaiser Permanente, Sacramento, California Julie.Verney@kp.org (916) 973-6520

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