QAISys™ - Comprehensive Quality Management in Medical Imaging

Richard B. Dale R.T. (R) (MR) ARRT

“As the call for quality rises, radiology needs to be proactive in helping to build meaningful and appropriate metrics.”^[i]

1.0 Introduction

The QAISys™ (Quality Assessment and Improvement System) process[ii] facilitates comprehensive quality management for medical imaging.  It effectively enables authoritative review of 100% of imaging exams and considers image quality deficiencies of all kinds for all modalities.  The system bridges communication gaps between radiologists, technologists, and managers.  It empowers management to assess and track image quality for each individual technologist and for entire departments by modality, location, or shift.  It enables in-depth analysis of the nature and cause of recurrent quality failures, specifies exam-types that should be targeted for improvement, and then indicates practical, cost-effective solutions for improving image quality. 

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1.01      The Importance of Quality Management in Medical Imaging

An accurate diagnosis is the foundation upon which any appropriate medical treatment is based.  In modern medicine, medical imaging enables accurate diagnoses to be made faster, less invasively, and more cost effectively than ever before.  Because of the vital role that diagnostic imaging has in determining an appropriate course of treatment, consistent quality in these services is imperative.

While technological advances in medical imaging are astounding, there remains a great deal of art in applying the science.   Even the latest advances in technology require a professional to elicit patient cooperation and to manage the examination process.  This professional must have a good understanding of the anatomy being imaged, the physics used to generate the images, and the effects of pathologies on the images.  The technologist must evaluate the diagnostic quality of the images during the examination. When image quality is compromised, the technologist must quickly recognize the inadequacy and determine its source.   He/she must then eliminate the cause, or moderate its effect, and repeat the view or imaging sequence as necessary.  Proficiency in making these corrections is vital - especially within the context of tight examination schedules. 

In its report entitled “To Err is Human; Building a Safer Health System,” the Institute of Medicine (IOM) asserts that medical errors are responsible for thousands of deaths and billions of dollars in lost productivity each year in the U.S.  In response to the IOM report, the American Society of Radiologic Technologists (ASRT) submitted a written testimony to Congress in February of 2000 stating: 

“According to the IOM report, 17 percent of preventable medical errors are errors in diagnosis.  The American Society of Radiologic Technologists believes that a significant number of these diagnostic errors may be attributed to poorly performed medical imaging examinations.”

“The quality of these examinations is operator-dependent.  In other words, the diagnostic quality of any medical image is directly linked to the skill and competence of the person who obtained the image.  Unfortunately, the state of medical imaging technology is not like the modern day point and shoot camera.  To properly perform a medical image requires extensive training and education.”

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1.02      The Difficulty of Quality Management in Medical Imaging

Due to the difficult and vital nature of their work, medical imaging technologists need constructive feedback on the quality of the images they submit for interpretation.  In the past, radiologists have been able to instruct technologists and help them continually learn from their good or bad decisions; however, with the increasing workloads that radiologists are managing and the tighter exam schedules under which technologists are working, there is less time for this kind of interaction.  The growing number of exams being performed in remote locations further diminishes communication between technologists and radiologists.  Many radiologists have never met some of the technologists who submit images to them for interpretation.  They are increasingly dependent upon management to communicate with the technologist when exam quality is compromised.  The highly technical and differentiated nature of medical imaging, the sheer volume of exams, and the dispersion of imaging locations often make effective quality management an overwhelming task.

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1.03      The Key to 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 (ACR) 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. 

The radiologist’s opinion on image quality is an exceptionally valuable resource for quality management.  This opinion is the conclusive standard of quality for two very important reasons: 

1. The radiologist is the most qualified individual in the medical imaging process to determine the diagnostic value of the exam. 
2. Generally, no other individual in the process is held more accountable for a missed diagnosis that might result from interpreting compromised images. 

The radiologist’s assessment of image quality is useful for providing valuable feedback to the technologist and valuable information to management.  When the radiologist is unaware of who performed an exam, the usefulness of the assessment is increased because of its impartiality.  The radiologist’s assessment of image quality is comprehensive in that all exams are interpreted and any kind of quality detraction can be noted.  The QAISys™ process efficiently conveys this comprehensive, impartial, and conclusive assessment of image quality to the performing technologist and his/her supervisor and uses this assessment as the basis for an informative and authoritative statistical rating.   

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1.04      The Means for Comprehensive Quality Management

The latest information systems can support the needed infrastructure to:

• Efficiently collect radiologist feedback 
• Distribute this feedback appropriately
• Convert the feedback to statistical data
• Facilitate in-depth analysis of the data

The QAISys™ process can be implemented in a variety of ways to provide a cost-effective and practical quality control process for medical imaging organizations of all sizes and configurations.

Integration of the QAISys™ process as a component of a RIS/PACS (Radiology Information System/Picture Archiving and Communication System) is the ideal implementation of this Process.  These powerful systems will facilitate automated data entry and an efficient flow of communication.  A RIS/PACS that has a well-designed integration of the QAISys™ process will make comprehensive quality management practical for even the largest and most dispersed medical imaging organizations. 

For a cost-effective and immediately available implementation option that does not require a PACS or RIS, QAISys, Inc. has developed a stand-alone software application called QAISys™ SA.  This software operates on a PC and is designed to collect and organize data, formulate statistical ratings, and generate reports for analysis and conveyance of radiologist feedback.  Though it requires manual data inputs, this software enables practical implementation of the Process in facilities with relatively low exam volumes.  It is also practical for targeted use within larger organizations. 

These modes of implementation are exemplary of an array of various models that will become available.  QAISys, Inc. offers a standard, non-exclusive license agreement to all RIS and RIS/PACS developers who wish to deploy the QAISys™ process in their systems.  We anticipate many innovative system designs.

The QAISys™ process applies time-tested quality management principles to a vital service.  It combines good medical practice with sound business principles.  We believe that patients, providers, and purchasers all have a vested interest in seeing its broad implementation.

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2.0   The QAISys™ Rating Process

The QAISys™ process functions as a direct channel of communication and as an efficient survey or poll.  Exam demographics and radiologist feedback are combined to create a QAISys™ Rating (QR).  A QR is a statistical representation of radiologist satisfaction with image quality over time.  It is a comparison of the frequency and severity of image quality concerns against the total number of related exams.

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2.1    QR Inputs

The QAISys™ process discreetly extracts data sets from two key points in the medical imaging workflow and transfers them to a database where they are used to generate QRs.  The Completed Exams Input Interface (CEII), and the Dissatisfaction Value Input Interface (DVII) will vary in design and function depending upon several key factors:  the configuration of the medical imaging organization, exam volumes, available technology resources, system architecture, and user preferences.  The Implementation Options section (4.0) of this booklet is a discussion of the various options for efficiently collecting the needed data.

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2.11      CEII - Completed Exams Input Interface

Implementing the QAISys™ process involves collecting basic demographics for all exams being rated.  This includes the date and location (specific room) of the exam as well as the exam type and the performing technologist.  Additional demographics such as the specific time of the exam and the age of the patient may be included to improve the analytical capabilities of the system.

Using the demographics collected for each exam in the CEII, we are able to group exams according to shared characteristics.  For example:  All MRI exams performed between January 1^st and March 31^st of 1776 can be filtered down to include only the shoulder MRI exams performed by Thomas Jefferson R.T. at the Lexington Imaging Center,[iii] MRI suite B, between January 1^st and March 31^st of 1776.  Formulating, comparing, tracking, and cross-examining ratings for various groups of exams is the essence of the analytical power provided through the QAISys™ process that enables managers to identify recurrent problems and to discover practical solutions.

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2.12      DVII - Dissatisfaction Value Input Interface

The QAISys™ process provides the radiologist a convenient and effective means to communicate with the appropriate technologist and supervisor when he/she interprets an exam that has some degree of quality compromise.  The information the Process requires from the radiologist to formulate a useful rating is simply the nature of the detraction from image quality and the degree of his/her dissatisfaction with image quality (i.e. “slight”, “moderate”, or “severe”).  For example, the radiologist could make the following notation on a report - “The chest radiograph presented is slightly over-penetrated.”  This kind of notation satisfies compliance with the ACR Communication Guideline and is the only action required of the radiologist for the diagnostic report to become a valuable resource for quality improvement.  The Process forwards this feedback directly to the performing technologist and his/her supervisor and it uses the feedback to formulate a QR.

The DVII converts the radiologist’s expressed dissatisfaction into a Dissatisfaction Value (DV).  This value is assigned to the exam and is based on the severity of the quality compromise.  The DVII also enables radiologists or supervisors to distribute responsibility for DV between three possible sources of image deficiency:

1. The performing technologist
2. The imaging equipment
3. Patient related difficulties. 

Dissatisfaction Value entry is only necessary for imaging exams that are considered dissatisfactory to the radiologist.  Though the radiologist is only providing feedback on dissatisfactory exams, the implied feedback on all other exams is that they are satisfactory and so they are assumed to have a Dissatisfaction Value of zero.

Critical information provided by the radiologist is coupled with the appropriate Completed Exam listing in the database.  Once this is done, the type and severity of the quality detraction are now available as additional querying parameters to empower quality analysis.

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2.2    QR Formulation

Once the QAISys™ Database has received the necessary information from the CEII and from the DVII, QRs can be calculated and tracked for an entire department by modality, location, and/or shift, and for each individual technologist.  QRs are calculated by grouping Completed Exams (CE) by one or more shared characteristics and then comparing the total number of these exams with their Dissatisfaction Factor (DF), which is the sum of the DV assigned to the dissatisfactory exams within the group. 

The components of the QR include:

• The number of Completed Exams (CE) over a specified period of time
• The Dissatisfaction Value (DV) assigned to each unsatisfactory exam describing the degree of dissatisfaction
• The Dissatisfaction Factor (DF), which is the sum of the Dissatisfaction Values generated within the specified group of exams
• The Unsatisfactory Rate (UR), which is the ratio of the Dissatisfaction Factor to Completed Exams expressed as a percentage
• The Satisfactory Rate (SR), which equals the inverse of the Unsatisfactory Rate

The QR formula is expressed as follows:

Building the QR begins with assigning Dissatisfaction Values to each unsatisfactory exam based upon the radiologist’s degree of dissatisfaction.  See Table 1. 

For example, suppose a technologist performs 200 exams in a given month.  Two exams are considered “slightly compromised,” one is considered “moderately compromised,” and one is considered “severely compromised.”  The QR would be 0.7763 calculated as follows:

1. Dissatisfaction Value (DV) is assigned to each dissatisfactory exam in accordance with Table 1:

   0.5 points for each of the “slightly compromised” exams
   1 point for the “moderately compromised” exam
   3 points for the “severely compromised” exam

2. The DV for the dissatisfactory exams is combined to form the Dissatisfaction Factor (DF), which, in the case of our illustration, equals five.  Table 2 illustrates steps one and two.

   
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3. The Dissatisfaction Factor (DF) is then divided by the number of Completed Exams (CE) and expressed as a percentage to equal the Unsatisfactory Rate (UR).

   5/200   = .025 or 2.5%

4. The Satisfactory Rate (SR) is determined by subtracting the Unsatisfactory Rate (UR) from 100%.

   100% - 2.5%   = 97.5%

5. The Satisfactory Rate (SR) taken to the 10^th power equals the QR. 

   97.5%¹⁰    = 0.7763

6. The QR is 0.7763

Factoring the Satisfactory Rate exponentially is important because it makes a clearer distinction between what might otherwise seem to be similar performances.[iv]  If another tech, over the same month, also performed 200 exams but had a Dissatisfaction Factor of 10.  This second tech’s Satisfactory Rate would be 95%, which might seem similar when compared to the first tech’s 97.5%; however, the second tech generated two times the Dissatisfaction Factor over the same number of exams.  In this example, taking the Satisfactory Rate to the tenth power generates a QR of 0.5987, which more appropriately indicates disparity in performance when compared to a QR of 0.7763. 

In practice, the QAISys™ process takes an additional step in determining the QR of a technologist.  The radiologist or the quality manager might assign responsibility for some of the Dissatisfaction Values to equipment-related or patient-related issues.  This enables the system to take factors that are beyond the technologist’s control into account by reducing the technologist’s Dissatisfaction Factor and therefore increasing his/her QAISys™ Rating.  Distributing responsibility for DV in this way also enables tracking of equipment performance as well as the analysis of recurrent patient-related quality detractions.

The QAISys™ process enables users to analyze the information in a number of ways to yield useful insights.  The following section presents a general method of implementing the QAISys™ process, discusses some inherent benefits gained by implementing the Process, and presents a strategic approach to applying the analytical power the Process provides in order to improve the overall quality of medical images.

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3.0   QAISys™ Uses and Effects

Fostering communication and problem solving are two essential functions of management.  These functions define two distinct modes of using the QAISys™ process: 

1. Implementing the QAISys™ Process (3.1) effectively establishes vital communication between radiologists, supervisors, and technologists.  It enables the radiologist to quickly and easily provide succinct feedback for specific instances to the pertinent individuals.  This mode of use is efficient and allows for continuous quality improvement.
2. Applying QAISys™ Data (3.2) as the basis for periodic quality improvement projects facilitates effective problem solving by enabling management to: quickly identify problem areas, discover effective techniques for consistently producing quality images, organize teamwork to more broadly apply these techniques, establish tangible goals, and track progress toward meeting those goals.  The QAISys™ process enables managers to facilitate these projects on a group and/or individual basis. 

These two modes of use are not exclusive.  Implementing the Process is the foundation for applying the data that the system provides.  Users will find that implementing the QAISys™ process will have an immediate, significant, broad, and lasting effect on image quality.  They will also find that periodically applying the data, as the basis of focused quality improvement efforts, will enable managers and technologists to work together to effectively address specific quality issues.

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3.1    Implementing the QAISys™ Process

The most basic level of using the QAISys™ process to improve image quality is to simply implement the Process in an efficient mode.

Implementing the QAISys™ process entails two important communication activities: 

1. Regularly conveying specific radiologist feedback to technologists, supervisors, and managers (appropriate individuals)
2. Regularly providing tracking and trending reports to appropriate individuals

The primary mode of this communication will vary depending upon the technology infrastructure that is used to facilitate the system.  RIS/PACS-integrations of the QAISys™ process will likely distribute key reports and messages via automated email to appropriate individuals who will be able to review them through an electronic Review Interface.  Systems integrating the QAISys™ process that do not provide an electronic Review Interface will convey radiologist feedback to the appropriate individuals via regularly distributed paper copies of reports.  Review Interface designs are discussed in detail in the next section of this booklet - Implementation Options (4.0).

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3.11      Conveying Radiologist Feedback

The QAISys™ process enables the radiologist to provide informative and authoritative feedback in an expedient manner on a regular basis for specific instances to the appropriate personnel.  This can be effectively accomplished by regularly distributing Dissatisfactory Exams Reports to technologists and supervisors.

In these reports, the information that is conveyed regarding each dissatisfactory exam includes:

• The nature of the quality detraction(s)
• The severity of the quality detraction(s)
• The assignment of Dissatisfaction Value (DV) to technologist, equipment, and/or patient-related difficulty
• Links or identifiers that enable the technologist and/or supervisor to obtain dissatisfactory images for review

Dissatisfactory Exams Reports present a listing of this information for all dissatisfactory exams that fall within user-defined parameters.  They can span any period of time and may be generated to include exams performed by an individual technologist or by a group of technologists (modality, location, or shift). 

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Department directors could review a Dissatisfactory Exams Report for the entire department filtered to include only dissatisfactory exams that have “Severe” quality detractions.  This facilitates a structured and efficient mode of follow-up on severely flawed exams.

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3.12      QR Tracking Reports and QR/QR^w Trending Reports

QR tracking and trending enables managers to observe quality trends, set goals, and track progress for each modality, location, shift, and/or technologist. 

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3.121       QR Tracking Reports

QR Tracking Reports list, and graphically display, how QRs track over a specified time period and compare them against calculated group averages, benchmarks, established goals, and tolerance thresholds.  These reports serve as key performance indicators and are especially useful for closely monitoring the progress of specific quality improvement projects.

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3.122       QR/QR^w Trending Reports

QR/QR^w Trending Reports are designed to indicate the quality of the most recently performed exams - irrespective of time.  Effective use of these reports creates a higher level of accountability for each technologist to improve/maintain the quality of each type of exam he/she performs. 

QR Tracking Reports vs. QR/QR^w Trending Reports - The body of exams included in the QR calculation for each point in a QR Tracking Report is generally determined by timeframe parameters (i.e. chest CT scans performed with contrast by C. Braxton R.T. in CT Suite 1 between August 1^st 1776 and August 8^th 1776).  The body of exams included in the QR calculation for Trending Reports is a specific number of the most recent exams (i.e. the 10 most recent chest CT scans performed with contrast by C. Braxton R.T. in CT Suite 1 as of August 8^th, 1776).  Because Trending Reports are based on the most recent body of exams - regardless of when they were performed, QR and QR^w Trending improvement requires a technologist to determine what needs to be done differently in performing the exam-type and then to successfully perform each successive exam.  The mere passing of time does not eradicate the effects of dissatisfactory exams in QR/QR^w Trending Reports.   

QR Trending vs. QR^w Trending - In a Trending Report, the difference between a QR and a QR^w is that the QR^w calculation for each point in the report exaggerates the significance of the most recently performed exams.  This is accomplished through mathematical augmentation.  For example:  the most recent exam performed might be weighted as if it were actually ten exams and so it would add ten to the CE component of the QR^w calculation.  And, correspondingly, a DV assigned to the exam would be multiplied by ten and added to the DF component of the QR^w calculation.  This weighted significance follows a gradient so that the second most recent exam might be weighted by 9, the third weighted by 8 etc.  The 10^th most recent exam and all other exams included as contributors to the QR^w calculation are not weighted.[v]  This serves to create a rating that is highly sensitive to recent successes and failures. 

Consider the following hypothetical situation:

A technologist who performs well for most types of exams has a good overall QR (as indicated in his/her monthly overall QR Tracking Report); however, one particular type of exam performed by the technologist is recurrently dissatisfactory to the radiologists.  The exam may be one that is not frequently performed so it has not significantly impacted the technologist’s QR.  Since the technologist receives a QR/QR^w Trending Report on a regular basis which trends a QR and a QR^w for each type of exam he/she performs, the tech quickly becomes aware of the need to improve performance in this particular type of exam.  In fact, the tech’s QR^w may have fallen below a threshold that is predetermined by the managers of the department.  The QR/QR^w Trending Report for this exam-type might be similar to the following:

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This QR/QR^w Trending graph shows a hypothetical QR and QR^w for a type of exam that needs significant improvement.[vi]  Exam #1 is the most recent exam.  The calculation of each point in the QR^w is based upon the ten most recently performed exams and exaggerates the effects of the most recent exams in a gradient fashion.  The calculation of each point in the QR is not exaggerated and is based upon the most recent 100 exams performed.   

This graph indicates that the standard QR calculated on the most recent 100 exams performed is well below the minimum .7000 QR threshold established by the department.  The QR^w Trending line on the graph also indicates that the most recently performed exams for this exam-type are driving the QR down. 

QR/QR^w Trending Table 1 lists the DV of the ten most recent exams in our hypothetical situation.  It shows that the most recent and sixth most recent exams each had a DV of 3 indicating that they were severely flawed.  The fourth most recent exam had a DV of 1 indicating that it was moderately flawed, and the eighth and ninth most recently performed exams had DVs of 0.5 indicating that they were slightly flawed.

The minimum quality threshold sets long-term and short-term quality improvement/maintenance goals for the technologist.  In the QR/QR^w Trending graph, the 100 Exams QR should be above threshold.  This is a long-term goal that will require consistent quality performance over time.  The QR^w Trend line establishes short-term goals for the technologist by indicating an improvement pathway.  If the technologist is able to perform satisfactory exams so that the QR^w Trend line rises above threshold and remains above threshold, the technologist and his/her supervisor can have confidence that the QR is improving and will eventually rise above threshold as well.

In our example, the QR^w Trend line in Graph 1 indicates that the QR^w Trend will rise above threshold if the technologist is able to perform seven consecutive satisfactory exams.

 
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The following set of tables and graphs indicate the effect that this improved performance will have on both the QR^w and the QR:

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There are two things to notice about the QR Trend line.  The first is that it rises very slowly.  The second is that it rises in steps as dissatisfactory exams performed in the past eventually cease to be included in the calculation.  This trend line is particularly useful for setting medium or long-term goals while the QR^w trend line aids in the establishment and tracking of current, specific, and attainable short-term goals. 

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3.2    Applying QAISys™ Data 

The second mode of using the QAISys™ process is to analyze the data and apply it as the basis for image quality improvement initiatives.

The QAISys™ process yields a wealth of pertinent information that enables managers to:

• Identify problem areas where improvement is needed for individual technologists or groups of technologists
• Identify underutilized knowledge resources that reside in the experience of their current staff
• Implement effective quality improvement strategies
• Measure results

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3.21       Image Quality Indicators

The QAISys™ process provides two primary indicators – the QAISys™ Rating (QR) and the Dissatisfaction Factor (DF).  QR and DF Comparison Reports are the primary tools for analyzing QAISys™ data.  There are significant differences between the QR and DF indicators that cause them to provide distinct perspectives. 

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3.211       QAISys™ Rating

A QAISys™ Rating (QR) conveys an exaggeration of the rate at which radiologists are satisfied with image quality relative to the number of Completed Exams interpreted.  A high QR indicates that radiologists are generally satisfied with a high percentage of the exams.  Conversely, a low QR indicates a low rate of satisfaction with image quality.  For Example:  an Exam-type QR Comparison Report enables the user to compare the rate and severity of quality failures for each type of exam relative to the frequency of the performance of each type of exam.  Exam-types with low QRs warrant focused efforts at quality improvement.  This Exam-type QR Comparison Report indicates that facial bones x-ray exams have a low QR representing a low satisfactory rate.

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Since they take the number of exams performed into account, QR Comparison Reports are particularly useful for comparing performances between technologists.  This is important because performance comparisons often reveal those in your staff who are successfully applying effective imaging techniques in certain areas and those who are not.  The fact that QRs take exam volumes into account also makes them useful for making comparisons over time, or tracking.

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3.212        Dissatisfaction Factor

Dissatisfaction Factor (DF) is the sum of Dissatisfaction Values within a related group of exams.  It does not take the number of Completed Exams into account and is a raw factor in QR formulation.  However, it provides a useful perspective when analyzing QAISys™ data. 

Exam-type Dissatisfaction Factor (DF) Comparison Reports identify exam-types that have high frequency and/or severity of quality failure.  These reports are useful for isolating exam-types that might have relatively high QRs but warrant a focused quality improvement effort because they are performed frequently and contribute a significant amount of Dissatisfaction Factor overall. 

For instance, chest x-rays may have an average or even relatively high QR, but because they are performed frequently they may generate a comparatively large volume of DF.  In this case a quality improvement project aimed at reducing DF for chest x-rays would be worthwhile and may have a significantly positive impact on overall image quality.

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While DF comparisons are useful as indicators of areas where improvement is warranted, they are not a clear indication of performance.  This is because they do not take the number of Completed Exams into consideration and so fluctuations in exam volumes will tend to have an influence on DFs.  Therefore, tracking DFs is not informative.  Quality improvement efforts initiated because of elevated DFs are best evaluated for their effectiveness over time using QR or QR^e tracking (QR^e is explained in section 3.24).

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3.22      Drilling Down & Branching Out

QR and DF Comparison Reports can be used to compare data for exam-types, detraction-types, technologist performances, equipment performances, and patient-related factors.  They can have varying degrees of specificity by filtering on several levels. 

For example, we can have an Exam-type QR Comparison Report using a bar graph to compare the QR for each of the various exam-types performed in a modality.  This report can be narrowed to a Location-specific Exam-type QR Comparison Report, which compares the QR for exams performed in one specific location according to exam-type.  We can narrow this report again to see a Location/Technologist-specific Exam-type QR Comparison Report, which compares the technologist(s) QRs for exams performed according to exam-type at a specific location.

After reviewing any one of these reports, the manager might wish to explore data related to the rating of one of the exam-types shown in the report.  He/she can compare the exam-type specific QRs of all of the technologists who perform the exam-type, compare the QR for the exam-type at various locations, or review a Dissatisfactory Exams report including all of the dissatisfactory exams that contributed to the rating for the exam.  Any of these logical branches could lead to another set of logical drill-down or branch-out options.  A good QAISys™ Review Interface will make these and other reporting options readily available to the manager. 

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In the example in the previous section, chest x-rays were identified as needing improvement due to high levels of Dissatisfaction Factor.  Now that this exam-type is under investigation, the manager can compare Chest X-ray QRs and/or DFs for each technologist, location, or shift.  By comparing the DFs for chest x-rays performed at various locations, the manager is able to identify one particular site where DF on chest x-rays is disproportionately high.

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3.23      Detraction DF and QR Comparison Reports

Once the manager has identified an area to investigate, such as a technologist, location, or exam-type with a low QR or high DF, he/she will then want to know the predominant cause of radiologist dissatisfaction with image quality.  A Detraction DF Comparison Report will show the manager the amount of DF contributed by each of the various types of detraction within the defined group of exams.  For example, in the previous section, one particular location was identified as a primary contributor of DF for chest x-ray exams.  The manager can now produce a report that compares the amount of DF that is associated with the various kinds of detraction. 

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Following our scenario, we see in this graph that motion artifact is the most recurrent quality detraction for chest x-rays at the location where Chest X-ray DF is high.   Further investigation, possibly though review of the Dissatisfactory Exams Report or a Chest X-ray - Motion Artifact - Patient-related DF Comparison Report, might show that a large portion of this DF is assigned to patient-related difficulties due to a large number of chest x-rays performed on pediatrics patients referred from a nearby pediatric practice.

One possible quality improvement tactic could be to invest in a Pig-O-Stat or other pediatric immobilization device and/or provide an in-service training to technologists at this location on how to effectively use the device.  A review of the Dissatisfactory Exams Report showing the exams contributing to the four DF associated with motion artifacts may reveal that one particular technologist has recurrent difficulty with immobilizing pediatric patients.  Another technologist at this location may be experienced and able to help the struggling technologist improve in this area. 

While a DF Comparison Report might have been helpful in identifying this quality improvement opportunity, it will not be particularly useful for tracking the effects of improvement efforts.  This is because fluctuations in exam volumes will have a direct effect on the DF for each type of quality detraction.  QR or QR^e comparison and tracking will be more useful in assessing progress toward quality improvement. 

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3.24      QR^e Formulation for Comparisons and Tracking

In QR calculation at the detraction level of specificity, the collection of Dissatisfaction Values (DVs) contributing to the calculation is restricted but the body of Completed Exams used in the calculation is not.  This results in artificially elevated QRs giving a false impression of satisfactory performance and a decreased sensitivity to improvements.  In our example, if the QR calculation for chest x-rays is based on a CE component of 200 and a DF component of 10.  This translates to a QR of 0.5987 as described in the “QR Formulation” section (2.2).  It would not matter whether this body of exams represented work done by an entire modality, specific location/shift, or by an individual tech.  These components are plausible for any of those levels of specificity.  But in order to see how much DF each individual type of detraction contributed to the total DF for chest x-rays, we must compare the sum of the DVs

contributed by each type of detraction individually.  In our scenario, the total DF for all of the types of detraction at the outpatient location we are tracking is 10, but only 4 DF was from motion artifact, 2.5 DF was from over exposure, 1.5 DF was from under exposure, 0.75 DF was from exams being incorrectly marked, 0.5 DF was due to incorrect or missing information in the patient history documentation, 0.5 DF was from film/screen artifacts, and 0.25 DF was from processor artifacts (see Table 1 to the right). 

The standard approach to calculating a QR for each of the types of detraction is to compare the DF generated by each type of detraction with the CE of the exam-type in order to produce Satisfactory Rates (SR), then to take the SR of each type of detraction to the 10^th power to produce the QRs.  Table 2 shows that the standard QR for each type of detraction is significantly higher than the overall Chest X-ray QR of 0.5987.  This is misleading.  Further, the standard QR calculation is not adequately sensitive to indicate improvements at this level of specificity.  Therefore, the detraction QR calculations should be augmented to make them more reflective of the radiologists’ dissatisfaction and to make them more sensitive to improvements.

QR^e is essentially a QR calculation with a varied exponential component.  The standard exponential component for QR formulation is 10.  Increasing this component heightens sensitivity to dissatisfactory performance and to the effects of improvement efforts.  Following the presented scenario, we will increase the exponential component of the QR calculation to a factor of 40, denote the augmented rating as QR^e40, and produce the ratings in table 3.  

 
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This graph illustrates that the QR^e40 calculations more aptly reflect the fact that there is a problem with motion artifact than do the QR calculations. 

Now that we have a rating that is properly indicative of problems, sensitive to changes, and takes fluctuations in exam volume into account, we are equipped to track improvement in this area.

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QR^e calculations are appropriate for tracking ratings where the DF component is suppressed but the CE component is not.  As discussed, this occurs when calculating QRs for specific detractions.  This also occurs when tracking equipment performance or patient-related quality issues.

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3.25      Summary Reports

The free-ranging drill-down and branch-out analysis capabilities that the system provides are powerful tools for taking an investigative approach to defining appropriate objectives and tactics for quality initiatives.  Predefined summary report templates serve to provide logical structure to analyses and to automate production and reproduction of thematic reports.  Summary reports are designed to meet specific needs and follow logical themes.  The following outlines are overly simplified and presented here as basic examples. 

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3.251       Departmental Quality Assurance Report

This report is designed to provide a general overview of the performance of the department.

Department QR Tracking Chart

This graph tracks a QR for all exams performed in the department on a monthly, year-to-date, and cumulative basis.  This will help management to establish departmental goals and thresholds, to observe quality trends, and to compare the performance of the department with national benchmarks.

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Modality QR Comparison Chart

This graph compares QRs for each modality.  It calculates QRs on a year-to-date basis and uses stacking to compare each modality’s QR with the pertinent national benchmark.

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Modality QR Tracking Chart

This graph tracks QRs for one or more modalities.  It calculates QRs on a monthly basis and displays lines indicating the department’s established threshold and goal.

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Summary of Focal Points

• Low QR Exam-type
• High DF Exam-type

Dissatisfactory Exams Report – Specific to include only exams that are considered to have severe quality detractions

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3.252       Technologist Group Analysis & Action Plan

These reports are designed to identify logical objectives for groups of technologists and to track progress toward meeting goals.  Technologist groups can be defined according to modality, location, or shift.  Group objectives might focus on:  an Exam-type with a low QR, an Exam-type with a high DF, or a Detraction-type with a high DF.   For example:

Group Objective:  Improve the Overall Quality of Low QR Exam-type

Exam-type QR Comparison Chart

This graph compares the QRs for each type of exam performed by the group.  This enables management to readily identify low QR exam-types and target them for improvement. 

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Exam-type Tracking Chart

This graph tracks the QR of an exam once it has been targeted for improvement.  It tracks the QR calculated on monthly, year-to-date, and cumulative bases.

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Exam-type-specific Technologist QR Comparison Chart

This graph compares the QRs for each technologist calculated only for the specific exam under investigation.  This helps managers quickly determine where improvement opportunities exist regarding the abilities of the staff.

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Exam-type-specific Detraction DF Comparison Chart

This graph compares the DF associated with the various types of quality detraction.  It is specific to include only DF that is generated for the exam-type under investigation.

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Dissatisfactory Exams Report – Specific to include only dissatisfactory exams of the exam-type that is under investigation

These outlines serve only as examples and are not limiting.  An appropriately designed QAISys™ Review Interface will present users with many predefined report templates, allow users to customize them, and will allow users to construct their own custom report templates.  Users can define and save parameters of summary reports for each group and each individual technologist in the department.

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3.253       Other Useful Summary Reports

Technologist Performance Report – A summary report that tracks a technologist’s individual QR for all of the exams he/she performs, identifies areas for improvement, allows the supervisor to set and communicate logical improvement goals for the technologist, and tracks progress toward meeting those goals.

Equipment Performance Report – A summary report that tracks a QR^e based on comparing equipment-related DF with Completed Exams for each individual piece of equipment (location) in the department.

Patient-related QR^e Report – A summary report that compares QR^es generated using only DF assigned to patient-related issues for each location.  This report will help managers determine if there are special needs related to patient referral demographics that are not adequately addressed at specific locations.   

Time-of-Exam QR Analysis Report – Implementation models integrated with a RIS will be able to utilize the time of exam parameter to compare QRs for exams performed during specified time increments throughout the 24-hour cycle.  This will help identify recurrent lapses in quality possibly due to understaffing, changes in shifts, or employee fatigue.

Day-of-Exam QR Analysis Report – A summary report that compares QRs for exams performed during different days of the week.  This will help determine staffing needs as they relate to the quality of imaging exams produced.

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4.0   Implementation Options

Modern information technologies can enable a variety of formats for implementing the QAISys™ process.  This section describes three general Implementation Models that range from a simple stand-alone software application to a fully automated RIS/PACS-integrated system.  To explain, this writing breaks down the Process into specific tasks and then describes each model and how the various components contribute to the Process by accomplishing the tasks.

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4.1    Implementation Tasks

Implementing the QAISys™ process entails:

1. Collecting demographics for every medical imaging exam
2. Collecting feedback from radiologists for dissatisfactory exams
3. Translating radiologist dissatisfaction into a Dissatisfaction Value (DV)
4. Associating DV with the nature of the quality detraction(s) (i.e. over/under exposure, motion artifact, etc.)
5. Distributing responsibility for DV between the technologist, the imaging equipment, and/or to patient-related difficulties
6. Formulating and tracking QAISys™ Ratings (QR)
7. Conveying ratings and specific feedback from radiologists to supervisors and technologists
8. Facilitating analysis of QAISys™ data

The following should be noted concerning the difficulty of accomplishing the implementation tasks:

• Tasks 2 - 7 are performed only for exams that are in some way dissatisfactory to the radiologist.
• Task 2 is the only task that must directly involve the radiologist. 
• Tasks 3 - 5 involve a simple set of data inputs that can be quickly and easily performed by the radiologist or by a quality manager.
• Task 6 is an automated function. 
• Task 7 is automated in implementation models appropriate for large organizations. 
• Task 8 is an automated function of QAISys™ systems that places powerful information at the fingertips of management. 

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4.2    Implementation Models

The appropriate implementation of the QAISys™ process for a particular medical imaging organization will utilize existing or available technology infrastructures to maximize both efficiency and cost-effectiveness.  QAISys, Inc. anticipates many expressions of the QAISys™ process as various developers design implementations of the Process specific to their own systems.  Most, if not all, systems will fall within three general categories or model descriptions: 

1. RIS/PACS-integrated Implementations will utilize the infrastructure provided by a Radiology Information System/Picture Archival and Communication System (RIS/PACS) to automate the Process in nearly all aspects.  These implementations will effectively enable comprehensive image quality management for even the largest and most widely dispersed medical imaging organizations.
2. RIS-integrated Implementations will automate data inputs making the Process very efficient. 
3. Stand-alone Implementations utilize a simple stand-alone software application that operates on a PC.  This model requires manual data inputs and reports distribution but is readily available and very cost-effective for smaller medical imaging organizations. 

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4.21       RIS/PACS-integrated QAISys™ Implementation

As the name implies, Radiology Information Systems (RIS) are designed to organize pertinent patient and imaging exam information and to make this information readily available throughout the medical imaging service delivery process.  A RIS facilitates exam scheduling, patient arrival, workflow communications, film movement, diagnostic report generation/delivery, and billing.  RIS is well suited to supply a QAISys™ Database with the simple exam demographics that are needed for QR formulation and tracking.   

A PACS (Picture Archiving and Communication System) is designed to integrate digital medical imaging modalities such as computed or digital radiography, CT, MRI, ultrasound, digital mammography, nuclear medicine, etc. into one image network and database.  The electronic workstation that a radiologist uses with a PACS often provides him/her with options for illustrating and annotating points of interest or concern directly on the images.  PACS also gives technologists and supervisors convenient access to review images once they are acquired.  These attributes make PACS an excellent vehicle for conveying radiologist feedback to technologists and supervisors.

A PACS and a RIS with seamless integration between them provides an infrastructure that is perfectly suited to facilitate a highly efficient and almost completely automated implementation of the QAISys™ process.  The Process only requires these systems to perform the functions for which they are designed.  This diagram illustrates a RIS/PACS-integrated QAISys™ Implementation:

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All eight of the Implementation Tasks are accomplished through the four main QAISys™ components: 

1. Completed Exam Input Interface (CEII)
2. Dissatisfaction Value Input Interface (DVII)
3. QAISys™ Database
4. QAISys™ Review Interface

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4.211        RIS/PACS-integrated Completed Exams Input Interface (CEII)

The first task in the QAISys™ process is to collect basic demographics for every exam being rated including both satisfactory and dissatisfactory exams. 

A QAISys™ implementation that is integrated with a Radiology Information System (RIS) will use the RIS to feed Completed Exams data to the QAISys™ Database automatically; therefore, no human involvement will be required for Completed Exams input other than that which is already required for the operation of the RIS. 

The CEII will collect the following demographics for each exam:  exam modality, date of exam, exam-type, exam location, and the performing technologist.  Further, RIS automation makes it practical to include additional demographics that improve the analytical capabilities of the system such as the specific time of the exam, the age of the patient, and the interpreting radiologist.

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4.212        RIS/PACS-integrated Dissatisfaction Value Input Interface (DVII)

Dissatisfaction Value (DV) input involves Implementation Tasks 2 - 5: 

2.      Collecting feedback from the radiologist
3.      Translating expressed dissatisfaction with image quality into DV
4.      Associating DV with the nature of the quality detraction(s) (i.e. over/under exposure, motion artifact, etc.)
5.      Distributing responsibility for DV between the technologist, the imaging equipment, and/or patient-related complications

DV input is what drives the QAISys™ process.  The chief aim in the design of a DVII and its related workflow is to collect radiologist feedback by a means that is not complex or time-consuming and yet adequately conveys the radiologist’s quality concerns.  RIS/PACS is well suited to facilitate highly efficient and powerful modes of DV input.  The most obvious design would consist of a simple set of menus and dialogue boxes incorporated into the diagnostic workstation or on a separate PDA (Personal Digital Assistant).  This enables the radiologist to provide organized feedback quickly and easily.  For example, a DVII could consist of the following set of drop-down menus:

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The RIS/PACS-integrated DVII can readily facilitate a number of valuable communication options including immediate response messaging, report flagging, DV input that is dissociated from the diagnostic report, and feedback via separate audio files and annotated images.[vii] 

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4.213        RIS/PACS-integrated QAISys™ Database and Review Interface

A RIS/PACS-integrated implementation will provide an electronic QAISys™ Review Interface where technologists and managers can analyze ratings and review pertinent exams through appropriately restricted access to the QAISys™ Database.  The Database and the Review Interface effectively facilitate Implementation Tasks 6 - 8, which include:

6.      Formulating and tracking QRs
7.      Conveying ratings and specific feedback from radiologists to supervisors and technologists
8.      Facilitating analysis of QAISys™ data

QAISys™ Database – The QAISys™ Database stores an entry for each completed exam.  Radiologist feedback and Dissatisfaction Values for dissatisfactory exams are attached to the corresponding entries within the Database.  Along with the Review Interface, the QAISys™ Database facilitates Implementation Task 6 (Formulating and tracking QRs) and Implementation Task 8 (Facilitating analysis of QAISys™ Ratings).

QAISys™ Review Interface – The Review Interface provides direct access to the Database.  A RIS/PACS-integrated QAISys™ implementation might also provide a system of email communications.  Managers, supervisors, and technologists will utilize this interface to review:

• QR reports and graphs
• Images and feedback on unsatisfactory exams
• Instructional images and audio files from radiologists on interesting exams (not considered dissatisfactory)
• Email messages from management relaying departmental goals, changes in protocols, or other related issues

Users can track progress toward accomplishing group and/or individual goals at times convenient for them.  Preformatted reports and graphs, such as those illustrated in this booklet provide the user with quick, easy, and in-depth analysis of statistical data.  Access to data is restricted appropriately for each individual user.  The diagram on the following page illustrates a RIS/PACS-integrated Review Interface.

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This interface might reside in a review station located within the radiology department, or it might be a web-based application depending upon the design and preferences of the developers and/or the imaging organization.

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4.22       RIS-integrated QAISys™ Implementation

Typically, hospitals or imaging centers will employ a RIS prior to obtaining a PACS.   Though it is not diagramed or presented in detail in this document, we anticipate that RIS-integrated QAISys™ implementation (without PACS) will likely become a common form of implementation for many small to medium-sized medical imaging organizations that have not yet been able to transition to digital or computed radiography.

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4.221       RIS-integrated CEII

As with the RIS/PACS-integrated QAISys™ implementations, RIS-integrated systems will be able to feed Completed Exams data into the QAISys™ Database automatically from the RIS. 

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4.222       RIS-integrated DVII

The DVII might take several forms depending upon the setup at the radiologist’s workstation.  If a PC is available, a simple interface on the PC linked to the RIS will be able to provide the drop-down menu layout described in the RIS/PACS-integrated model.  Developers might find that providing their clients with a PDA-based DVII might be desirable and practical.

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4.223       RIS-integrated Review Interface

The Review Interface might be electronic as described with the RIS/PACS-integrated model or it could simply use paper reports generated and distributed by management.

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4.23      Stand-alone QAISys™ Implementation

The stand-alone mode of QAISys™ implementation does not require a PACS or RIS.  It uses a database software application that operates on a PC.  The software is designed to collect and organize data, formulate QRs, and generate reports for analysis and conveyance of radiologist feedback.  This simple software application effectively enables a complete implementation of the QAISys™ process and is readily available. 

This approach to implementation requires manual data inputs and does not facilitate automated conveyance of feedback in the manner a system-integrated implementation does; therefore, it is more suitable for use in small facilities with relatively low exam volumes or for targeted use in larger organizations.  This diagram presents an overview of the stand-alone implementation model:

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4.231       Stand-alone Completed Exams Input Interface (CEII)

As previously stated, the first task in the QAISys™ process is to collect demographics for every medical imaging exam performed.  Stand-alone implementation requires that this data be entered manually from exam logs.  The required information for each exam includes:  modality, date, location, exam-type, and performing technologist.  The design of the CEII in QAISys™ SA makes good use of the fact that most of these demographics are repetitive.  For each new entry, the CEII automatically repeats the demographics of the previous entry so that the user needs only to change demographics that are different between the previous and current exams.  Often, this only includes the “exam type” and “performing technologist.”  All of these entries are listed in drop-down menus requiring no typing and ensuring consistent entry formats, which creates an exceptionally efficient approach to manual data entry.  This picture illustrates the CEII in QAISys™ SA.

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This interface automatically saves data as it is entered.  The software allows multiple users to have password-protected, limited access so that non-management staff can perform Completed Exams data entry.  It is not required for this data to be entered at the time of the exam.  Rather, it can be done from exam logs at a time that is convenient to the user.

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4.232       Stand-alone Dissatisfaction Value Input Interface (DVII)

Dissatisfaction Value (DV) input involves Implementation Tasks 2 - 5: 

2.      Collecting feedback from the radiologist
3.      Translating expressed dissatisfaction with image quality into Dissatisfaction Value (DV)
4.      Associating DV with the nature of the quality detraction(s) (i.e. over/under exposure, motion artifact, etc.)
5.      Distributing appropriate responsibility for DV between the technologist, the imaging equipment, and/or patient-related complications

Collect Feedback (Task 2) - In order to accomplish task two, the radiologist must identify the exam as dissatisfactory, which is as simple as writing the exam number or the type of exam, patient name, and the exam date on a slip of paper.  The radiologist now has the option to simply refer the manager and technologist to the diagnostic report and images, or he/she may also indicate the severity and nature of the quality detraction on the note.   It is then a simple matter for the quality manager to obtain a copy of the report and enter the appropriate feedback into the DVII. 

Determine the Severity and Nature of the Detraction (Tasks 3 & 4) – If the radiologist opts to refer the manager to the diagnostic report and does not indicate severity or describe the detraction in the note, the diagnostic report will indicate the nature and severity of the quality detraction(s).  Examples of text indicating slight detractions might include:  “films are slightly over penetrated” or “somewhat oblique lateral.”  Text indicating moderate quality detractions might include:  “films are over penetrated” or “the lateral is not true.”  Text indicating severe flaws might include:  “films are too dark for adequate interpretation” or ” the lateral view is rotated to a degree that makes interpretation very difficult and uncertain.”  Some kinds of quality detraction such as “no ‘right’ or ‘left’ marker” or “incomplete patient history” will likely have a predefined level of severity associated with them.  The manager might occasionally need to consult with the radiologist and/or review the images in order to determine the severity of the quality detraction.

Distribute Appropriate Responsibility for DV (Task 5) – From the diagnostic report and the Dissatisfactory Exam note, the quality manager should be able to determine if the responsibility for the quality detraction lies solely with the technologist or if there is some mitigating circumstance involving the equipment or patient.  If this is unclear from the report and note, then the manager can leave 100% of the responsibility with the technologist.  If the technologist documented mitigating circumstances for the exam quality in the information sent to the radiologist with the images, then the tech can bring this to the manager’s attention when he/she reviews his/her Dissatisfactory Exams report and the manager can redistribute responsibility for the DV.

Once the note is complete, the manager is ready to enter the data into the DVII by performing the following eight simple steps:

1. Select the dissatisfactory exam in the Completed Exams list.
2. Click the DVII button to open the Dissatisfaction Value Input Box.
3. Open the Degree of Dissatisfaction drop-down menu and select the degree of dissatisfaction.

   
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4. Enter notes.  The “QAISys™ Exams Rating Notes” section of the dialogue box is an area where the manager can freely enter text.  Enter the specific words used as feedback from the radiologist along with any additional applicable notes or feedback.  This is also a good place to document follow-up – especially for severely flawed exams. 
5. Click the “Add” button in the Rating Flaws section to open the “Add Flaw Definition Description” dialogue box.
6. Using the “Flaw Definition” drop-down menu, select the appropriate type of flaw.

   
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7. Multiple flaws may be assigned to an exam, but the total weight of all flaws must equal 100%.  To enter multiple flaws, enter the first flaw as described in steps 5 & 6 and assign a weight.  Then follow the same procedure to enter additional flaws.  If the total weight distributed among all flaws does not equal 100%, the dialogue box will not close.
8. Distribute DV for each flaw between the technologist, equipment, and patient-related issues.  The total distributed DV must equal 100% or the dialogue box will not close.

   
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Once managers are familiar with the system, this process becomes powerfully efficient and versatile in accounting for quality issues.

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4.233       Stand-alone QAISys™ Database and Review Interface

QAISys™ SA is designed so that only the manager is able to access the database through a report-generating interface.  The manager tracks QRs, analyzes data, and generates paper copies of reports for distribution, which completes Implementation Tasks 6 - 8.  This interface allows the manager to select from a standard set of reports and to specify the body of exams to be included.

There are three basic steps to generating a report:

1. Select the desired report from the report directory by double-clicking it or by highlighting it and clicking the “Open Report” button.
2. Define the parameters of the report in the “QAISys™ Reports Params” dialogue box.
3. Use the “Filter Exams” button to open the “Exams Filter Configuration” dialogue box to further refine the set of exams to be included in the query.

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We believe that automated implementations using RIS and RIS/PACS systems are the preferred models of the QAISys™ process; however, automated implementations may be cost prohibitive or impractical for smaller facilities with limited exam volumes or even for larger organizations with the need for targeted quality improvement initiatives.  QAISys™ SA is readily available and may provide an affordable means to comprehensive quality management for these facilities and organizations.  QAISys, Inc. is striving to make QAISys™ SA a solid, user-friendly, and powerful application that will be distributed to interested parties as a free download from our web site – www.qaisys.com.

Regardless of the implementation model used to incorporate the QAISys™ process, all facilities and organizations using the Process will be required to interface with the QAISys™ Global Data Center, which is discussed in the next section of this booklet.

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5.0   QAISys™ Global Data Center

Although QAISys™ implementation can take many forms, as discussed in the previous section, the essential information collected and incorporated into the ratings Process is consistent.  This permits an exchange of key QAISys™ data over the Internet between a centralized data center and all organizations employing the QAISys™ process –regardless of the implementation model used.  This centralized data center is called the QAISys™ Global Data-Center, or GDC.

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5.01      Benefits Provided Through the GDC

By employing the GDC, we are able to generate and distribute benchmarks, collect valuable data for analysis, promote standardization of use, provide certification of active use, and license broadly.

Benchmarks - By collecting QAISys™ data into one “universal” or “global” data center we are able to formulate and provide benchmark ratings for comparison purposes.  These benchmarks are perpetually updated so that they remain current.  Upon each exchange between the GDC and the local QAISys™ application, current benchmarking data is sent to the local application so that the appropriate benchmarks are available throughout the end-user’s ratings analysis process.  This will assist managers of local imaging facilities as they gauge and prioritize their quality improvement efforts. 

National Analyses - Another important benefit derived from gathering QAISys™ data from end-users is that the large body of data continuously compiled on a national scale will be available to leaders in the medical imaging profession and to medical imaging technology developers for research.  Leaders in the medical imaging profession will be able to cross-analyze global QAISys™ Ratings to discover areas where they should initiate or focus upon improvement efforts.  They will then be able to convey pertinent industry “best practices” through continuing education articles and seminar courses and will be able to gauge the effects of their initiatives by tracking national QRs.  Medical imaging technology developers will be able to use global QAISys™ data to discover specific areas where they might initiate advances in technologies that will help to improve image quality. 

Quality Management Standardization - We believe that the medical imaging profession will adopt the QAISys™ process and seek to maximize its usefulness by creating recommended guidelines for quality rating.  These guidelines will develop over time as the industry gains familiarity with the practical uses of QAISys™ and its application to the more advanced imaging modalities.  QAISys, Inc., with the capabilities afforded by the use of the GDC, will be in a strong position to assist in the process of this development.

Certification of Use - The QAISys™ Global Data Center will facilitate a practical means to certify active use by medical imaging facilities.  Each facility or organization will have its own account established with QAISys, Inc. that will be used to facilitate billing on a per-exam basis and to certify that a medical imaging facility is actively using a QAISys™ application and corresponding with the GDC.  Certification of use is important for verification of quality management initiatives and efforts.  In the future, medical imaging organizations may reap benefits from QAISys™ certification such as higher reimbursement rates from healthcare payers, discounts or lower rates for medical malpractice insurance, and simplified verification of management initiatives to accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Broad Access – QAISys, Inc. operates in the belief that the QAISys™ process can and should be used to improve the overall quality of medical images in every medical imaging facility throughout the United States.  To that end, we seek to develop tools that enable cost-effective and practical implementation and to promote effective use of the Process.

The GDC enables us to charge fees on a per-exam basis.  This compensation approach has several significant advantages:

• By charging a low per-exam fee, we align our financial interests with our stated mission and with the interests of the general public, healthcare providers, and healthcare purchasers.
• By providing freely available software that facilitates standalone implementation of the QAISys™ process, and by charging fees on a per-exam basis, we make the expense of implementing the Process proportional to the size and exam-volume of each medical imaging organization.
• By dealing directly with the end-user, we are able to license broadly to all RIS, PACS, and RIS/PACS developers.  We believe that broad access to the Process will expedite its implementation and use.
• We believe that competing systems developers will continually strive to improve their products leading to new and innovative implementations of the QAISys™ process.

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5.02       Security

Security must be a concern whenever sensitive data is exchanged over the Internet.  For security risks related to the exchange of data from the QAISys™ process, it is important to note that there is no transfer of individual patient identifiers.  The only patient identifier that might be used in a local QAISys™ implementation would be the patient’s age but individual dates of birth will never be exchanged.  Additionally:

• Imaging organization identities will be encoded.
• The latest encryption technologies will be employed.
• Servers will be housed in a secure environment.

Further details will become available on this site.

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6.0   Conclusion

Effective use of the information provided through the QAISys™ process combines good medical practice with sound business principles.  We believe that patients, providers, and purchasers all have a vested interest in seeing its broad implementation.

“On average, more than 300 Million radiologic examinations are performed every year in the United States, at an annual cost of nearly $22 billion.  If only ½ of 1 percent of those medical images is not properly performed, this means that there would be more than 4,000 defective medical images performed every day of the year.” – ASRT Testimony to Congress February, 2000

[i] Cheryl Proval, What is Quality?; Decisions in Imaging Economics: November 2003 Back

[ii] The QAISys™ process is sometimes referred to as “the Process” or “Process” in this document. Back

[iii] Throughout this document, all technologists, organizations, and situations are fictitious.  Technologist’s names were fabricated using the names of signatories of the U.S. Declaration of Independence.  The names of organizations were fabricated using the names of battles in the U.S. War for Independence.  Any resemblance to real persons or organizations is purely coincidental. Back

[iv] Some other exponential degree besides ten can be selected in order to increase or decrease sensitivity to dissatisfactory performance. Back

[v] The description presented is an overly simplistic representation of many possible mathematical augmentations to QRs that can facilitate QR^w Trending. Back

[vi] The calculations in this graph are based on a more complex approach to increasing the weight of effect on the most recently performed exams than the approach offered as a simple explanation of the concept on page 11. Back

[vii]Immediate Response Messaging – Occasionally, a medical imaging exam is severely flawed to the point of being non-diagnostic.  On these occasions, a manager should quickly follow up with the patient in order to schedule a repeat examination or notify the referring physician that adequate imaging as requested is not possible.  The DVII in a RIS/PACS-integrated QAISys might provide the radiologist an expedient means to send an email message to the appropriate manager so that this process can be initiated quickly and in a manner that is convenient for the radiologist. Back

Report Flagging – QAISys requires that the radiologist provide feedback on dissatisfactory exams; but, organizing the feedback and entering it into the QAISys Database might be delegated to a supervisor or quality manager.  RIS/PACS-integrated DVIIs can allow the radiologist the option of electronically “flagging” an exam for review.  A single command will send an email containing a copy of the exam report and a link to the images to the quality manager or appropriate supervisor’s account.  This person will perform Implementation Tasks 3 - 5 based on the feedback provided in the diagnostic report and then forward it to the performing technologist.  This reduces the radiologist’s responsibility in the Process to noting the nature and severity of the quality detraction(s) in the diagnostic report, and flagging the exam as dissatisfactory. 

DV Input Dissociated From the Diagnostic Report – A RIS/PACS-integrated DVII can facilitate electronic DV input via a means other than the diagnostic radiology report.  While diagnostic report is the primary mode for conveying feedback in all models of QAISys implementation, it may sometimes be desirable to assign DV to an exam without involving the report.  This would be the case if the quality detraction should be improved, but does not necessarily negate the diagnostic value of the exam.  For example, suppose a radiograph completed on a CR (computed radiography) unit was not oriented appropriately for viewing or required windowing by the radiologist.  While these problems may be corrected by the radiologist and will not compromise the diagnostic value of the exam, they present inefficiencies and represent quality defects that should be mitigated by the technologist.  In this case, the radiologist might wish to convey his/her dissatisfaction with the presented image quality without involving the diagnostic report.  The DVII in a RIS/PACS-integrated model readily facilitates separate DV input that keeps the diagnostic report free from internal work-related issues. 

Feedback via Separate Audio Files and/or Annotated Images – With RIS/PACS integration, the DVIIDVII offers the radiologist the option of annotating and sending a copy of the image(s) for instructional purposes.  Utilization of these communication options can contribute significantly to the quality improvement process.  can offer the radiologist the option of dictating a separate note of instruction (not included on the diagnostic report), which would be sent as an audio file to the manager’s email account and then forwarded to the performing technologist’s email account.  This gives the radiologist an opportunity to provide feedback beyond that which he/she deems appropriate for the diagnostic report.  This communication can be further enhanced if the

Separate instructional notes and annotated images do not have to be associated with radiologist dissatisfaction.  For example, a radiologist might dictate instruction and annotate images on a satisfactory exam in order to help technologists begin to recognize abnormalities/pathologies that might warrant additional imaging views or scanning sequences at the time of the initial exam.  They might also use this mode of communication to update imaging protocols or to share interesting findings.