RQ Radiology Quality Procedural Pause

PROJECT OVERVIEW

BACKGROUND: Timing, documentation and tracking of critical result reporting is a national patient safety goal as designated by the Joint Commission. A critical result in radiology refers to any condition that could be potentially life threatening to the patient and/or merit immediate medical intervention. Each institution determines which radiologic findings are critical. Examples of critical results include:

• Pneumothorax, if unsuspected

• Tension Pneumothorax

• Significant Intracranial Hemorrhage

• Leaking Abdominal Aortic Aneurysm

• Acute Aortic Dissection

• Acute Deep Vein Thrombosis

• Acute Testicular/Ovarian Torsion

• Acute Spinal Cord Compression

• New Perforated Viscus

• Ectopic Pregnancy

• Massive Hemoperitoneum on CT or Ultrasound

• Acute Pulmonary Embolism

• Unstable Spine Fracture

• Significant Misplacement of Tubes or Catheters

Critical results must be communicated to a licensed healthcare provider, who is able to act on the result, within an institutionally designated time frame (usually not to exceed 60 minutes). Documentation of the critical result report includes the name of the provider, and the date and time the provider was notified.

IMPORTANCE: Critical result reporting is designated as a National Patient Safety Goal by the Joint Commission. This illustrates the importance it has in providing safe, timely and effective patient care, which is directly relevant to clinical practice. Consistent critical result reporting standardizes safe practice performance.

METRIC/BENCHMARK: The Joint Commission requires 100% compliance. Unpublished benchmark data from a large multicenter academic institution has compliance rates ranging from 39% to 100%.

GOAL: 100% compliant critical result reporting

PROJECT STEPS - login and document each competed step

Step 1 (Select project and metric): After selecting the critical results reporting project, the diplomat will review:

American Board of Radiology requirements for the PQI process http://www.theabr.org/moc/moc_dr/moc_dr_comp4.html
Joint Commission guidelines regarding the critical result reporting
Their local institutional policy regarding reporting and documentation of critical results
Example policies from other institutions, if no local institutional guidelines exist, http://radiologyquality.com/share.aspx

Step 2 (Collect baseline data): Each institution will determine their optimum data source. Ideally, an automated keyword search of the electronic medical record will be utilized to identify radiology reports containing critical results. The reports will be reviewed to assess for accurate documentation of critical result reporting. Report review can be performed by a member of the allied health staff. The numerator is the number of appropriately documented critical results. The denominator is the total number of reports containing critical results. The minimum recommended measurement time frame is one month, although this can be altered based on institutional/group needs. During the designated time frame, the following table should be used to decide the minimum number of occurrences that should be evaluated for compliance. This sample size of cases may be randomly selected from the total number of cases in the group or institution.

Number of Cases	Sample Size
< 30	100% cases
30 – 100	30
101 – 500	50
> 500	70

Results will be entered into the Radiology Quality database (http://radiologyquality.com) where the results will be stored and the diplomat may compare his or her results to others across the nation.

Step 3 (Analyze the data): The collected baseline data will be reviewed. If 100% compliance is achieved and it is felt that there is no opportunity for improvement, then the diplomate will discontinue this project and choose another. If there is opportunity for improvement, i.e. compliance rates being less than 100% or need to ensure continued 100% compliance, then the diplomate will continue this project and undergo a root cause analysis. There are many different methods for identifying performance problems. The diplomat is referred to resources on the Radiology Quality web site “Timeline” pages and general information available free on the internet such as Wikipedia (http://en.wikipedia.org/wiki/Root_cause_analysis). For this project, it is specifically recommended that the diplomate consider using the “5 Whys” (http://en.wikipedia.org/wiki/5_Whys) technique of root cause analysis.

Step 4 (Create improvement plan):The diplomate will make an improvement plan based on the findings of their baseline data acquisition and data analysis. Three suggested improvement plans are as follows. The first recommended improvement plan is to review and refine the existing critical result reporting policy within each institution. Communication of this policy to radiologists performing procedures must be shared via personal or written communication. The next improvement plan option is the development of guidelines defining what constitutes appropriate documentation of the critical result reporting. Changes in institutional documentation should be reviewed by the institution's Joint Commission specialist, if one exists. These guidelines should then be implemented. The final recommended improvement plan option involves the direct education of individuals who are failing to comply with the critical result reporting. One-on-one discussion with individuals is performed to identify and remove obstructions to their compliance. One of the above suggested improvement plans or a plan developed by the diplomat is documented on the Radiology Quality web site and implemented.

Step 5 (Collect data, compare to initial data, and summarize results): After institution of the improvement plan, the compliance data will then be again collected using the same method the baseline data. This data will be analyzed and summarized. The data will be compared with both the internal baseline data and with other institutions/individuals submitting to the centralized Radiology Quality database.

Step 6 (Control & Close Project): It is of utmost importance to maintain the advances the diplomat has achieved. A final report of the project, including the data from the different collection points along with the improvement plan undertaken at each step, should be generated using the Radiology Quality web site. Achieved goals from this project are to be maintained by assigning the continued intermittent collection of data with scheduled review of this data by designated individual(s). After appropriate hand off of this responsibility is performed, a new project is started.