Quality and Safety Collection

PAB 2018 General Culture Metrics Trainees Safety Effectiveness Equitability Timeliness Efficiency Patient-Centered Care

How to Navigate the Collection
Click the blue box to access selected articles on each topic.

General (general QI methods and project ideas)
Culture (how to start a QI program, how to create a safety culture)
Metrics (performance and other metrics pertaining to QI and Safety)
Trainees (QI educations for residents, trainee-level QI)
Safety, Peer Review & Radiation Dose
Effectiveness (evidence-based, appropriateness, structured reporting, image quality, peer learning)
Equitability (vulnerable populations, disparities, access/opportunities)
Timeliness (wait times, access/appointments, report turn-around times)
Efficiency (waste/lean, daily management, standardization)
Patient-Centered Care (satisfaction, communications with patients, outreach, education, experience)

By Sara K. Meibom, MD, and Nadja Kadom, MD

The need for quality and safety initiatives in medicine arose after the 1999 publication of the Institute of Medicine (IOM) report "To Err is Human: Building a Safer Health System." Physicians and the general public alike were shocked to find that the number of deaths in the U.S. health care system due to preventable errors range between 44,000 to 98,000 per year. According to a later study, death rates due to medical error may be four times higher than the IOM’s estimate, closer to 400,000 annual deaths, raising medical error to the third leading cause of death in the United States. In a 2001 second report, "Crossing the Quality Chasm: A New Health System for the 21st Century [PDF]," the IOM identified a gap between what good health care should be and what patients actually receive.

To bridge this gap, the IOM recommends that U.S. health systems undergo a significant change. Developing safe health care systems requires a multifactorial approach including a culture focused on safety, the ability to recognize and address human error and system failures, the ability to identify root causes, and tools for improving the status quo. The IOM promulgated six crucial improvement aims for patient care (safe, timely, efficient, equitable, effective, patient-centered) that have become the guiding principles for anyone invested in health care improvement.

Radiology has embraced the imperative to improve patient care through culture and systems change. A culture of safety is driven by leadership and involves recognizing the role of human error and addressing systems issues that promote errors. In a just culture, certain behaviors that may result in errors (such as at-risk behavior or human mistakes) are paired with interventions (such as punishing, coaching, or consoling the individual). The just culture model recognizes that an environment of blame and punishment results in loss of confidence and leads to hiding mistakes. A traditional safety culture is defined as top-down (with directives coming from those in positions of authority), however innovative ideas often emerge from staff working in all stages of the workflow. In a just culture, frontline staff are empowered to discover problems and assemble teams of stakeholders to find viable solutions. As a tool for achieving improvement, radiologists have adopted effective strategies from other industries, such as the Model for Improvement and the Plan-Do-Study-Act cycle method.

Once a solution to problems has been identified and tested by the improvement team, there may be challenges in implementing these changes. Change management theory provides a set of insights and tools that guide radiologists through the process of implementing change, specifically minimizing and overcoming resistance. Another key driver of change and a means to sustain change is the use of performance metrics. Following the American College of Radiology (ACR) Imaging 3.0 initiative, which promotes a shift from volume- to value-based services in radiology, new radiology performance metrics were created that are geared towards patient outcomes, such as report turn-around time.

In this collection, we group articles into 4 categories plus a subcollection for each of the six IOM patient care improvement aims.

The IOM aims serve as a framework for optimizing the health care system. First, health care must be safe. While "Primum non nocere" is a mandate for individual health care providers, the IOM suggests that safety must be built into our care delivery system. Important safety skills include how to perform a root-cause-analysis. This requires a set of "why" questions to get to the root cause of the problem before thinking of solution or remedies. The Safety subcollection contains a number of improvement project examples in radiology, such as result communications and MRI safety [Shahriari 2016]. The subcollection also features two sections, one on peer review and how to transform this process into a learning tool for radiologists and another on radiation dose, which represents one of the most targeted areas for improvement in radiology based on the number of articles we found in JACR that related to this topic.

The second IOM improvement aim is for health care to be more effective. This concept indicates that scientific evidence should inform the use of the best available care, which could help in curbing overuse of ineffective methods and underuse of effective ones. In radiology, effectiveness can be achieved by using report templates, standardizing imaging techniques, and improving appropriateness. The Effectiveness subcollection features several successful project examples relating to these and other topics.

Next, the IOM recommends that care should be patient-centered. Patients need to be treated in the context of their culture and social environment. Patients’ special needs must be recognized and addressed, and patients need to participate in shared decision-making about their care. The Patient-Centered Care subcollection covers topics such as access to imaging services and results, as well as initiatives improving the patient experience. Another improvement aim is for care to be timely. This is straightforward and simply reflects the need to decrease delays in patient care.

The IOM also recommends that care should be efficient by reducing waste, such as supplies, equipment, space, capital, ideas, and time. The Efficiency subcollection features a variety of subjects, including optimization of protocols. Lastly, care needs to be equitable, meaning that everyone should have access to high-quality care. This is clearly a budding area of focus in radiology, so many articles in the Equitability subcollection are currently centered on the basic principles of bias, diversity, and inclusion.

For each subcollection, we have curated a set of top articles, which we found of particular value. These could be reviews, exemplary QI projects, or fundamental principles. In addition, we have featured excellent articles published since 2014 for those interested in quick access to a broader collection on a particular topic for additional targeted learning.

This collection is curated by Sara K. Meibom, MD, and Nadja Kadom, MD.

Read More About the Basics of Quality and Safety
Improving Diagnosis in Health Care
Critical Findings: Attempts at Reducing Notification Errors
Carlson’s Law and the Power of Frontline Innovation

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