Final EQUIP slides 4.25.17 used for handout with title ... · Enhancing Quality Using The...

A Critical Mammography Update:The Impact of EQUIP

April 25, 2017

© 2017, Bonnie Rush, RT(M)(QM) 1

EQUIP Webinar made possible through an educational grant fromVolpara Solutions, Inc.

Presented by

Bonnie Rush, RT(R)(M)(QM), President Breast Imaging Specialists (BIS)Advancing Early Detection Thru Quality ImagingAuthor ofMQSA Made Easy

Who, What, Where, When, and

WHY and HOW of EQUIP

Enhancing Quality UsingThe Inspection Program

Three new inspection questions

Focus on image quality (IQ)…

with a review of your process to monitor overall quality

• WHO is mandating EQUIP?o The Division of Mammography Quality Standards (DMQS)

• WHOmust meet EQUIP? o Every Certified Mammography Center o Involved personnel = IP, RT, Lead IP or other designated individuals

• WHERE will EQUIP take place? o At your Center during each annual inspection.

• WHEN does EQUIP go into effect? o EQUIP criteria “education” during 2017 inspections. o Non‐compliances begin during 2018 inspections.

• Q1: IP feedback when clinical images (CIs) are of poor quality.

• Q2: RT and IP Image quality (IQ) compliance with the standards of the accreditation body (AB).

• Q3: Lead IP oversight of QA/QC records.

EQUIP relies on existing CFR (900.12):

Q1 (d)(1)(ii)(A)

Q2 (i)

Q3 (d)(2)


April 25, 2017


The DMQS determined current compliance issues are from the clinical image review (CIR) process,

not from inspection findings.

Facilities are ….“requested to submit

what they consider…

to be their best representative images”.

National AB FailuresACR

92% initial accreditation79% reaccreditation

State AB Failures91% in Iowa100% in Texas

Web Search ‐MQSA Insights

Since 2001.. Level 1 violations triggered 117 AMRs

CIQR of 30 random images to Certified Reviewers

Of 81 AMRs reviewed ‐ ONLY 10 PASSED

Shelly Lille’, Wende Marshall, ASRT Mammography Community Forum, December 2016

84.4% with passing positioning

66.3% with failed positioning

Taplin SH, Rutter CM, Finder C, et al. Screening Mammography:Clinical Image Quality and the Risk of Interval Breast Cancer. AJR 2002; 178: 797‐803.

“All of us have had experiences where, just based on positioning,

we see something or don’t see something.”R. James Brenner, MD, JD


April 25, 2017


Courtesy VuComp

Increasing Cancer Detection Rates “…high quality mammography from every facility every day.”

Helen J. Barr, MD Director DMQS

…frequently develops in an organization that is committed to quality.

Web Search – CQI Strategies to Optimize Your Practice A Primer Provided By: The National Learning Consortium (NLC)

• The DMQS does not mandate a specific approach

• The facility may design any process to meet the criteria

• Does the facility have procedures for C/A when CIs are of poor quality? (Yes / No)

o Does it include a mechanism for:• providing ongoing IP feedback on IQ to RT’s or other designated facility personnel? (Yes / No)

• Documenting needed C/As and effectiveness? (Yes / No)

• Does not need to be written o Involved personnel must be able to explain the process

• No mandated o Mechanism or threshold

• No timeframe for:o C/As or maintaining of any C/A records or o feedback to RTs from LPs

• Any C/As performed o Must be documented with effective resolution


April 25, 2017


• Is not acceptable for Q1 daily review o RT not IP is determining

viability of images

• BUT data of value for CQI

Available in the 2016 ACR Digital Mammography QC Manual Courtesy of ACR Mammography Accreditation Program

• The IP reviews imageso If IQ acceptable = interprets images

o If not – records C/As in QA notes

• Designated individual monitors notes o Notifies the involved RT

o RT documents QA follow up

• Original IP reviews the exam with repeat images o If C/A is completed interprets exam

• We track call backs for each RT

• Interpretation held for 2 weeks • 3 calls to initiate return appointment

• If unsuccessful the case is dictated BI‐RADS 0 • a letter is sent to patient to return

• If the patient returns• Exam dictated – patient provided w/results

• If patient does not return• Certified letter to patient/referring physician

“

”

• Reporting system follow‐up reporto Unresolved

o Repeat reason

o Notes

• Worklist per selected criteriao Exams for review

Courtesy PenRad – Fictitious names

• Do clinical images comply with the quality standards established by the accreditation body? (Yes / No)

o Does it include a regular review (CIQR) of a sample of mammograms?

• performed by each active RT? (Yes / No)

• accepted for interpretation by each active IP? (Yes / No)

o Does it Include documentation of review(s) since the last inspection? (Yes / No)

• No SOP required for CIQRo Daily review (Q1) does not suffice

• Each RT and each IP reviewed at least annuallyo No minimum number of images required

o C/As not required

• Written documentation that CIQR was performed o At least annually

o Needs to be dated

o Does not need to be signed


April 25, 2017


Personnel Working At Multiple Centers Will be included at more than one site

Not Required To Include All RTs And IPs In Each CIQR

Personnel Split Into Review PeriodsRTs and IPs A & B ‐ QTR 1 & 3 RTs and IPs C & D ‐ QTR 2 & 4

Separate RT And IP Periodic Reviews All RTs ‐ QTR 1 & 3 All IPs ‐ QTR 2 & 4

• Assesses if IP interprets images that do not meet the AB Image Quality standards o Not intended to include interpretive quality

o Does not require C/A

• IP peer reviews meet the CIQR o If assessing the IQ accepted

for interpretation is included.

Any designated person, group of individuals, or organization, working in conjunction with an IP,

can be designated to perform the CIQR.

Lead IP has ultimate responsibility to ensure the CIQR is completed.

The individual(s) perform the review and

communicate the results to the IP for concurrence

Or

The IP and the designated individual(s) review images at the same time

• Work‐list of images for each active IP and RT

• Designated CIQR IP reviews imageso Determines if images produced and/or interpreted meet AB standards

• Designated IP communicates findings to each IP

• Designated individual communicates findings to each RT

• Lead IP ultimately signs off the process was completed.

• Managers recommend RTs based on performanceo Lead techs may/may not be chosen.

• RT Images randomly selectedo scored according to mammography rubric (attributes).

• Results are reviewed at monthly QI Team meetings.o Meeting notes are entered into QA manual.

ASRT Mammography Community


April 25, 2017


• Written statement by Lead IP

and/or

• Signed review of: o A summary report,

o CIQR meeting records,

o memos of results to RTs and IPs, or

o any other manual or electronic summary report

Web search – Ann Cheesman and/or Mammonewslinehttp://mammonewsline.blogspot.com/2005/09/are‐we‐perfect‐yet‐assessing‐our_26.html

“Due to the variations in the body habitus and ability to cooperate, it is not possible to attain ideal

positioning and compression in all women.”

1999 ACR QC Manual Pg 79http://marathon.csee.usf.edu/Mammography/DDSM/thumbnails/benigns/benign_12/case1843/A-1843-1.html

Conformance training will help in developing a team approach to IQ.

Standardization of positioning helps to improve image quality.

Correction rather than repetition is the key.


April 25, 2017


Courtesy ACR Mammography Accreditation Program

Available in the 2016 ACR Digital Mammography QC ManualCourtesy of ACR Mammography Accreditation Program

• When are they going to do it?o At time of exam interpretation

• How much time will it take? o IP time is precious

• Will every IP assess the same? o Not necessarily objective

• No communication pathway

o Between RT to IP and vice versa

Courtesy Breast Imaging Specialists

The RT and IP may use electronic tools, to help communicate internally

when and/or why CIs are of poor quality.

Final EQUIP slides 4.25.17 used for handout with title ... · Enhancing Quality Using The...

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