Structured, easy-to-read radiology reports provide significant value, but getting radiologists on the same page is often easier said than done. Specialists at one large academic healthcare system launched a quality improvement (QI) project to reduce variation across their own enterprise, sharing its experience in the American Journal of Roentgenology.
The authors wrote about their QI project from beginning to end, providing valuable insight. These are five key steps the team took on its journey toward improved consistency:
1. Assess the problem
The researchers recognized the value of producing an actionable report that was “predictable, reproducible, succinct, organized and precise”—yet their own health system wasn’t accomplishing that goal. And considering their system is responsible for more than 800,000 imaging examinations each and every year, the authors knew it was a serious problem that needed to be addressed.
A key issue, the team agreed, was “marked variation” with their system’s imaging protocols and radiology report templates. Radiologists had the ability to create their own personalized report templates, which led to high levels of variation across the board.
“There was marked variability in the structure, formatting, language, and length of reports for the same imaging study performed at different locations, even when performed to evaluate the same patient's clinical presentation,” wrote Tony W. Trinh, MD, Brigham and Women’s Hospital in Boston, and colleagues. “This variability confused and frustrated referrers and patients.”
2. Gather teams to address the problem
The team created an oversight committee focused on standardizing report templates for the entire system. Twenty-four different work groups were established, and each one included a chair and two to five members “representing various divisions with a stake in that work group’s templates.” The oversight committee met weekly from September 2017 to May 2018 to discuss the QI project and what needed to be done.
3. Built report templates to be used throughout the health system
Before the process began, the system found that it had more than 19,000 report templates on file, all connected to one of its attending radiologists. Nearly 50,000 other templates that belonged to former employees or trainees were deleted.
“The committee started by creating a common template framework to be used across all divisions and study types,” the authors wrote. “The framework consisted of default sections and formatting guidelines. This document was circulated to everyone involved in the process and to all radiologists in the department. Each work group then used this standardized framework to create their harmonized report templates.”
Each work group was assigned with “modifying, creating and deleting” older templates. New templates were created from scratch as needed.
“Whenever possible, the report templates were linked to specific examination codes to facilitate autopopulation once a specific examination was selected from a PACS worklist,” the authors wrote. “The intent was to streamline the report dictation process, save time for the radiologists by obviating the need to manually select the report with the correct template, and thus ensure that the correct report template would always be used to dictate a given imaging study.”
4. Implement the changes—but not too quickly
A new team was established to manage the implementation of these new templates. The process included four steps, purposefully staggered “to minimize large-scale disruptions” and allow radiologists to seek help as needed with specific issues.
5. Put actions in place to stop the problem from repeating
“To prevent divergence from the harmonized templates after implementation, radiologists are no longer allowed (by departmental policy) to create personal templates or modify harmonized templates,” the authors wrote. “All templates are available only at the enterprise level, and all personal templates are monitored and removed from personal accounts via intermittent (at least quarterly) audits.”
However, the team noted, radiologists were still able to use personal “macros,” or phrases used as shortcuts to insert text into a specific report.
So…was the team’s QI project a success? Overall, the number of report templates was reduced by 97%. In addition, the specialists stuck with the new templates. The researchers selected 320 radiology reports at random and noted that 94.7% were completed using one of the newer templates with no additional modifications. Of the 17 reports that did include a modification, 10 had “altered or deleted subheadings” and seven had combined the “findings” and “impression” sections of the report.
“Multifaceted interventions, including early involvement of stakeholders, a well-designed structure, a process to resolve potential conflicts, careful implementation to avoid disruptions in workflow, leadership engagement, and continuous monitoring, were the keys to successful implementation of this quality improvement project,” the authors concluded.