What is Quality Radiology?
The 1999 Institute of Medicine report To Err Is Human¹ brought the extent and severity of medical errors to the attention of policymakers, hospital administrative staff, and health care providers. This landmark analysis sparked a broad change in the perception of how health care should be rendered to patients, with an increasing focus on safety and quality in the provision of medical care. Now, quality is the predominant theme in US health care policy, and nearly all medical specialties are under growing pressure to deliver high-quality services.
Brian Maher
The use of radiology services is pervasive throughout hospital operations and patient care, yet radiology has historically received far less quality scrutiny than other specialties. To date, most public quality-reporting efforts have focused primarily on inpatient care. This lack of attention is due, in part, to the fundamental difficulties inherent in measuring true quality outcomes in imaging. When radiology is compared with other disciplines, such as infection control and cardiac surgery, payors and watchdog organizations have far fewer scientifically validated imaging quality measures at their disposal. Confounding matters further, assessing clinical quality in radiology requires a costly, labor-intensive period of retrospective review to determine how diagnostic imaging affected the treatment outcome.
Shay Pratt, MA
Now, however, payors, CMS, regulatory agencies, professional societies, and radiology benefit managers (RBMs) have radiology quality in their crosshairs. Increased attention to quality presents imaging providers with several questions. What is the right response to quality pressure from CMS, payors, and RBMs? Are we measuring the quality of our imaging services accurately? What quality-improvement projects do we prioritize? What truly distinguishes a high-quality imaging provider? This year, The Advisory Board Co’s Imaging Performance Partnership, a strategic and best-practice research membership serving radiology departments at hospitals and health systems, conducted a six-month research study to address these challenges. Increasing Scrutiny The past decade has seen unprecedented growth in imaging services, with many modalities growing more than 5% per year. At the same time, according to Verispan², the number of imaging centers has increased from 4,773 in 2001 to 6,414 in 2007. This growth has not gone unnoticed. In 2007, CMS implemented a technical-component payment cap for nonhospital imaging providers, as directed by the DRA. In addition, commercial payors across the country have adopted precertification and provider-privileging programs—now permanent fixtures in the radiology world—to curb advanced imaging utilization’s growth and to regulate provider networks, respectively. With these measures in place, payors are now exploring new strategies for using quality measures to reduce utilization, influence provider selection, and regulate the number of imaging providers in the market. Imaging providers are now facing quality scrutiny on all fronts, each requiring a different strategic response. Quality reporting: CMS already includes a handful of metrics related to diagnostic and interventional for the Physician Quality Reporting Initiative (PQRI). Now, CMS is proposing four reportable metrics for hospital imaging departments. In July 2008, the 2009 Hospital Outpatient Prospective Payment System proposed rule included four new metrics for inclusion in the Hospital Outpatient Quality Data Reporting Program. The four measures are use of MRI of the lumbar spine, mammography call-back rates, and contrast use for pelvic and abdominal CT. Hospitals would be required to report these metrics to Medicare in 2009 to receive the full market-basket update in 2010, officially tying payment to quality reporting for hospital imaging. The four measures primarily focus on utilization, and they signal CMS interest in generating more data to scrutinize the imaging provided to beneficiaries. In addition, as the National Quality Forum (NQF) is currently evaluating eight imaging-efficiency measures for official endorsement, more measures may be on the horizon. Accreditation: Several payors, such as UnitedHealthcare, are now using accreditation programs to assess the quality of imaging providers. These programs set standards for physicians (both supervising and interpreting), technologists, and the imaging equipment itself. Most of these payors have focused their accreditation programs on nonhospital outpatient imaging providers. With the passage of the Medicare Improvements for Patients and Providers Act of 2008, Congress is requiring all imaging providers offering CT, MRI, nuclear medicine, PET, and PET/CT to be accredited by 2012 as a condition of Medicare reimbursement. Accreditation programs may work to improve the quality of imaging facilities, ensuring that centers are equipped with the necessary structure, personnel, technology, and processes to ensure safe care. These programs could help to bring subpar centers into compliance, and could even raise the bar on new market entries. Accreditation, however, also represents an unfunded mandate, adding costs to facilities that are already dealing with reduced reimbursement and slimmer margins. Provider quality comparisons: Consumers and referring physicians have few resources at their disposal for comparing the quality and cost of imaging providers. A few RBMs are developing online portals that address this void. For example, Chicago-based American Imaging Management has created OptiNet, which grades imaging providers on a number of structural measures. Next to the quality score, the tool also lists the price of the imaging service for each provider. The tool is designed to encourage consumers and physicians to choose the highest-quality, lowest-cost provider when seeking a radiology procedure. With these types of tools, commercial payors and RBMs are putting forth their own definitions of imaging quality. In the absence of true outcomes measures in radiology, RBMs and payors are focusing more on aspects of facility infrastructure to score provider quality. While assessing structural criteria such as MRI field strength, hours of operation, and volumes can provide relevant data for comparing provider services, many of these types of indicators are, arguably, proxy measures for true quality. Should these tools proliferate, imaging providers will have to decide how much of their time and resources to invest in improving their public quality scores. The Patient-safety Agenda At the same time that imaging providers are grappling with payor efforts to push quality measurement and transparency in radiology, they also are mobilizing to address a host of patient-safety concerns. Hospital imaging departments, in particular, must contend with ever-present risks such as patient falls, contrast extravasations and reactions, and infection. Now, additional patient-safety priorities are entering the public eye, including contrast-induced nephropathy and gadolinium-induced nephrogenic systemic fibrosis. Recently, the FDA issued a warning for CT imaging of individuals with electronic implanted devices. Perhaps more controversial, but garnering the most attention in the press, is the issue of radiation dose. Many recent studies have discussed the risk associated with radiation exposure, coupled with concerns about imaging overutilization. RBMs, professional societies, and CMS are now beginning to mobilize around managing radiation dose from CT and other irradiating modalities. While RBMs are developing tools to educate patients and referring physicians about the risks of radiation exposure, CMS is proposing two radiation-related reporting measures for inclusion in next year’s PQRI metric set. In addition, the ACR is in the process of developing a dose index registry that will serve as a data repository for information related to radiation doses for specific modalities and imaging procedures. Radiology programs continue to struggle with how best to manage radiation dose, and that struggle is now intensified due to the increased pressure from external organizations. For cardiac CT specifically, many programs are implementing dose-reduction strategies via software or acquisition techniques, while others are looking to the next generation of multimillion-dollar CT scanners to minimize exposure. The one thing that is clear is that the issue of managing radiation dose is not expected to disappear soon, and even greater pressure will be placed on centers to regulate radiation exposure for their patients. Radiology Safety and Hospitals Hospital radiology departments continue to face growing scrutiny from patient-safety watchdogs such as the Joint Commission. With the release of the new 2009 national patient-safety goals,3 the Joint Commission is placing greater emphasis on communication among health care providers, medication management and reconciliation, hospital-acquired infections, and patient identification. Nearly all national patient-safety goals are applicable to radiology, especially critical-test and critical-results communication policies and medication-management policies. Radiology departments are expected to demonstrate documented compliance in all areas addressed by the Joint Commission. As the Joint Commission continues to strengthen (and enforce compliance with) patient-safety protocols, it is also focusing greater attention on radiology services. In 2005, the Joint Commission added prolonged fluoroscopy with a cumulative dose of greater than 1,500 rad to the list of reviewable sentinel events, and it recently released a sentinel-event alert related to preventing accidents and injuries in the MRI suite. Radiology programs are now expected to safeguard against a laundry list of traditional and emerging patient-safety concerns. First, programs that are at the forefront of ensuring patient safety in daily practice have been found to develop comprehensive critical-test/results communication policies in a multidisciplinary environment with key stakeholders, enumerating the specific conditions deemed critical, the manner in which these conditions are to be communicated, the timeframe in which the order or findings are to be communicated, and the appropriate escalation steps for lapses in communication. Second, these programs implement regimented policies and protocols for patients undergoing MRI to screen for contrast contraindications, ferromagnetic items on or in the body, and the risk of gadolinium-induced nephrogenic systemic fibrosis. Third, such programs collaborate with pharmacists to determine the appropriate roles of radiology staff in medication management and reconciliation procedures in accordance with Joint Commission requirements. These steps are only a small subset of common patient-safety strategies in progressive radiology programs; however, they represent activities that can be relatively easily employed through coordinated efforts, with a greater emphasis on radiology safety. The Importance of Metrics With increasing scrutiny from payors, regulatory agencies, and other watchdogs, radiology quality-improvement programs are quickly developing a lengthy to-do list. At the same time, imaging providers are currently focusing on numerous priorities (including emergency order response time, interventional complication rates, and inpatient report-turnaround time) not currently on the payor and watchdog radar. With growing internal and external pressures placed on radiology programs to measure their quality, it is increasingly important for centers to develop a standard set of metrics for routine evaluation of department operation and patient care. As part of our research study on imaging quality, we identified more than 250 indicators that can be used to assess the clinical and operational quality of a radiology program. To assist our members further in navigating the complex quality terrain, we developed an online tool to collect, organize, and rank these quality indicators in accordance with the specific priorities of individual radiology departments. We chose to exclude most metrics that focus on service quality; while these metrics are certainly vital to assessing the overall customer experience, they have reduced bearing on true clinical quality. The 250-plus clinical quality metrics were first organized into three major classifications: structure, process, and outcome. Structural indicators measure components of the department infrastructure and are commonly used by payors, third-party organizations, and the Joint Commission to measure department organization. Fortunately, structural indicators are relatively easy to evaluate, and questions about them can frequently be answered with a yes or no response. Two examples of structural indicators are the presence of a standard critical-results communication policy and the percentage of radiologists who are board certified. Process indicators measure compliance with the standard of care. How often did the tasks that should be completed in the care and treatment of the patient actually take place? Process indicators can provide valuable information regarding quality of care, but they can be significantly more time consuming and resource intensive to measure. Process indicators are likely to be more isolated to a specific section or individual procedure type than a department-wide structure indicator. An example of a process indicator is the time from order to completion for an emergency CT study. Outcome indicators measure the results of the care provided, focusing on discrete clinical events, such as the rate of contrast extravasations per CT contrast injection or the diagnostic accuracy of a procedure with respect to a reference standard. Unfortunately, while they are often the most meaningful to patient care, outcome indicators are infrequent in radiology and are commonly the most difficult to measure, requiring either real-time or extensive retrospective analysis. Of the indicators that we collected, only 21% were classified as outcomes measures (see figure). In contrast, 45% measured the process of care and 34% measured structural quality.
Classification of 257 collected quality indicators.
The prevalence of so many structural indicators (in general, the least rigorous quality measures) speaks to the difficulty of measuring imaging-related outcomes. The efforts underway by organizations such as the ACR and the NQF to develop more process and outcomes measures will be vital to the further advancement of quality measurement in radiology. A Quantitative Approach For more efficient organization and analysis, quality metrics were also grouped into subcategories pertaining to their content area, such as communication, patient safety, and diagnostic accuracy. Then, using a five-point Likert scale, all indicators were scored on three criteria: clinical relevance, ease of measurement, and breadth of services measured. This scoring exercise brought 27 high-value quality metrics to the surface, including:
  • critical-results communication timeliness,
  • time to diagnostic mammography,
  • the contrast extravasation rate,
  • the mammography call-back rate,
  • the peer-review rate of agreement,
  • emergency and inpatient report– turnaround time,
  • structured reporting frequency,
  • the medication list documentation rate,
  • the radiation dose-exposure documentation rate, and
  • the interventional radiology complication rate.
It is certainly not expected that radiology programs would monitor all 257 quality metrics identified in our research, or even the shorter list of 27 high-value metrics. It is critical, however, for imaging providers to establish an ongoing process for selecting the metrics that are most meaningful to their facilities and departments for use in a quality dashboard. Starting points should include measures that are required by a regulatory agency, payor, or CMS; structural metrics should also be included in the department’s quality dashboard, since little effort is required to compile data for, update, and report on these quality indicators. Beyond mandatory measures, programs should select indicators that align with the mission and vision of the program. Metrics that simply are easy to measure, but have little meaning to the department’s purpose, will not be meaningful measures. To facilitate metric selection, we recommend an objective indicator-ranking system using several different evaluative criteria. A regimented approach to metric identification and selection can help to ensure that radiology programs are monitoring the most pressing quality-improvement priorities specific to their organizations. The High-quality Program While it is one thing to develop and measure a standard list of quality indicators, it is another to develop a culture of quality that fosters the continual improvement of department operations and patient care. Investing in the right quality infrastructure can be an expensive proposition, but a business case can be made for imaging quality, considering the emergence of reporting-based reimbursement for imaging, a reduction in the cost of medical errors, lower malpractice expenses, and the opportunity to differentiate the practice from its competitors. In the course of The Imaging Performance Partnership’s research this year, we attempted to identify the attributes of a high-quality radiology program: a department that has the organizational structure, processes, personnel, and ambition needed to excel in an era of quality and safety scrutiny. From research and interviews with leading institutions in the field, seven key characteristics were identified (see table).
Key Characteristics of a High-quality Radiology Program
Among these attributes, creating a culture of quality (through the hospital-wide recognition of the importance of quality in radiology) and engaging radiologists in quality-improvement activities beyond peer review help to drive the overall quality initiative in radiology; the remaining five attributes lend support to the ongoing quality agenda. While these characteristics refer specifically to hospital radiology departments, variations on the same elements can be recommended for outpatient centers as well. The implementation of any one of these attributes is a step in the right direction, but radiology programs that possess a combination of several or all of these attributes will be poised to prosper as more emphasis is placed on quality and patient safety in the years ahead.