Radiologists in Quality Management

The Key to Effective and Comprehensive Quality Management in Medical Imaging

A basic assessment of the diagnostic quality of medical images is a natural, integral part of the interpretation process.  In its Practice Guideline for Communication, the American College of Radiologists recommends that diagnostic radiology reports “identify factors that may limit the sensitivity and specificity of the examination.”  This communication is important because it may affect the referring physician’s treatment decisions.  Since it has become a standard of patient care, most radiologists have become accustomed to conveying their concerns with image quality to the referring physician in the diagnostic report.  Capturing and leveraging this valuable assessment is truly indispensable to comprehensive and effective quality management.

Value of Radiologist Feedback 

The value of the radiologist quality assessment as a resource for quality management is derived from these attributes: 

1. Authority:  The radiologist is the most qualified individual in the medical imaging workflow to determine the diagnostic value of the exam. 
2. Range of Expertise:  Radiologists are able to determine quality of exams from all imaging modalities. 
3. Coverage:  All exams undergo radiologist quality assessment; therefore, once the practice of providing feedback on dissatisfactory exams is established, exams that have no mention of quality detraction may be considered to be satisfactory. 
4. Efficiency:  In the interpreting process, radiologists have already completed a significant portion of quality review work by opening the images in PACS, reviewing patient history, and noticing image quality.  It is simply wasteful from a process design standpoint to not capture the radiologist assessment at the time of interpretation. 
5. Vested Interest:  Radiologists have a natural vested interest in image/exam quality.  In addition to the desire to provide optimal care for patients, radiologists experience additional stress and work strain from reading poor quality images.  Further, no other individual in the process is typically held more accountable for a missed diagnosis that might result from interpreting compromised images. 

Ease & Efficiency of Providing Feedback

Since feedback on only dissatisfactory exams is required, and typically only 1% to 3% of exams are found to be dissatisfactory, radiologists are only looking at providing feedback maybe once or twice in an average workday.  Integration of a simple utility in the PACS interface can allow for radiologists to quickly and easily provide feedback.  The radiologist may provide text explaining the nature and extent of the exam quality detraction.  If this is thought to be too cumbersome for the radiologist, then at least “tagging” the exam as dissatisfactory for later review by the quality manager will provide enormous benefit to the efficacy and efficiency of the quality manager’s review process. 

Helpful Disciplines

The value is maximized if the radiologist truly embraces his/her role in providing quality feedback and applies the following disciplines to this activity:

1. Intentionally disregard of the identity of the performing technologist.  This is an important discipline for two key reasons:

First, when the radiologist does not notice the identity of the individual performing technologist, he/she is able to provide unbiased accounting of the quality of the images without the influence of subtle prejudices that may have accumulated from prior dealings either personal or professional.

Second, management is in a better position to handle instances involving technologist attempts to marginalize radiologist feedback as biased personal criticism.

Once radiologist feedback has become common, and as this discipline of disregarding tech identity is well established, technologists will begin to recognize radiologist feedback on image quality as an integral part of the services rendered by radiologists.

1. Only mention mitigating factors in feedback but do not use them to determine whether feedback is warranted.  For example, suppose the radiologist sees motion artifact on an image but is aware that the patient has Parkinson’s disease.  The radiologist should provide feedback regarding the nature and extent of the image quality detraction (i.e. slight, moderate, or severe motion artifact) and should mention that the patient’s disease is clearly conveyed in the patient history or exam notes.  This will enable the quality manager to properly account for this instance within QMS.  The radiologist should know that the quality manager is able to shift Dissatisfaction Value away from the technologist and into a category for patient-related issues.  This will allow managers to analyze recurrence of patient-related quality detractions.
2. Tag exemplary exams.  Whenever a radiologist provides positive feedback on an exemplary exam, QMS allows the quality manager to assign “Kudos” to an exam record.  This will make it simple for managers to generate a list of exemplary exams useful for review with technologists so that desirable qualities may be replicated and best practices among technologists identified and propagated.  This is especially helpful for exam-types that commonly have quality detractions and are targeted for group improvement initiatives.