QA and CQI:QA and CQI:How?How?

Merri L. Bremer MEd, RN, RDCS, FASEMerri L. Bremer MEd, RN, RDCS, FASE

DisclosuresDisclosures

Relevant RelationshipMember, ICAEL Board of Directors

Off Label UsageNone

Learning ObjectivesLearning Objectives

Define QADefine QA

Discuss ideas for development and Discuss ideas for development and implementation of Echo Lab QAimplementation of Echo Lab QA

QA: What is it?QA: What is it?

Many names (QA, QI, CQI)Many names (QA, QI, CQI)

Method of continuously Method of continuously examining processes and examining processes and making them more effectivemaking them more effective

Focus is on Focus is on the processthe process, not the , not the individualindividual

QA: What is it not?QA: What is it not?

PunitivePunitive

DemeaningDemeaning

DemoralizingDemoralizing

DivisiveDivisive

BusyworkBusyworkOR…..OR…..

When you watch me,

they want me to do it

differently…

BenefitsBenefits

Develops and maintains Develops and maintains quality in your practice quality in your practice

Ensures uniform, consistent Ensures uniform, consistent standards for interpretation and standards for interpretation and reportingreporting

Excellent Excellent continuingcontinuing educationeducation tooltool

Standards and GuidelinesStandards and Guidelines

ICAEL StandardsICAEL Standards

ASE Guidelines and StandardsASE Guidelines and Standards

SDMS Position StatementsSDMS Position Statements

ASE Sonographer Minimum ASE Sonographer Minimum StandardsStandards

ICAEL QA ComponentsICAEL QA Components

Written policyWritten policy

AUCAUC

Instrument Instrument maintenancemaintenance

Procedure Procedure volumesvolumes

CMECME

Peer reviewPeer review

CorrelationCorrelation

Report Report TimelinessTimeliness

ConferencesConferences

Record Record keepingkeeping

Writing a QA PolicyWriting a QA Policy

Identify required elements Identify required elements (ICAEL (ICAEL Standards)Standards)

Figure out how Figure out how YOUR TEAMYOUR TEAM can can accomplish them and write them accomplish them and write them downdown

Sample policies on ICAEL websiteSample policies on ICAEL website

Try them….revise and try again if Try them….revise and try again if necessarynecessary

Communicate! Frequently!Communicate! Frequently!

Appropriate Use Criteria (AUC)Appropriate Use Criteria (AUC)

Mandatory requirement for accreditation Mandatory requirement for accreditation effective effective January 1, 2012January 1, 2012

Appropriate use must be measured in a Appropriate use must be measured in a minimum of 30 consecutive TTE, 30 minimum of 30 consecutive TTE, 30 consecutive TEE and 30 consecutive Stress consecutive TEE and 30 consecutive Stress patientspatients annually annually ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and Appropriateness Criteria for Transthoracic and Transesophageal EchocardiographyTransesophageal Echocardiography

Percentage of appropriate, inappropriate and Percentage of appropriate, inappropriate and uncertain indications for testing must be uncertain indications for testing must be measuredmeasured

Appropriate Use CriteriaAppropriate Use Criteria

A program for education and reporting must A program for education and reporting must be developed and include:be developed and include:– Baseline rates of adherenceBaseline rates of adherence– Patterns of adherence Patterns of adherence – Goals for improvement Goals for improvement – Measurement of improvement Measurement of improvement – Confidential reports on patterns of adherence Confidential reports on patterns of adherence

Ordering physicianOrdering physician

Ordering practice Ordering practice

Interpreting practiceInterpreting practice

Instrument MaintenanceInstrument Maintenance

Recording of method and frequency of Recording of method and frequency of maintenance maintenance

Establishment of and adherence to a Establishment of and adherence to a policy regarding routine safety policy regarding routine safety inspections and testing of all laboratory inspections and testing of all laboratory electrical equipmentelectrical equipment

Establishment of and adherence to an Establishment of and adherence to an instrument cleaning scheduleinstrument cleaning schedule

Instrument MaintenanceInstrument Maintenance

Use institutional resources if you Use institutional resources if you have themhave them

If you don’t have them, create a If you don’t have them, create a policy using the manufacturer’s policy using the manufacturer’s guidelines and follow itguidelines and follow it

Ask your equipment reps for help!Ask your equipment reps for help!

Maintenance LogMaintenance Log

Procedure VolumesProcedure VolumesAnnual individual and laboratory statsAnnual individual and laboratory stats

Records of individual procedure Records of individual procedure volumes should include volumes from volumes should include volumes from all laboratories where staff all laboratories where staff perform/interpret echocardiogramsperform/interpret echocardiograms

Methods of tracking Methods of tracking – ScheduleSchedule– Procedure listProcedure list– BillingBilling

Sonographer Procedure Volume Sonographer Procedure Volume LogLog

MD Procedure Volume LogMD Procedure Volume Log

CMECME

Documentation of echocardiography-Documentation of echocardiography-related continuing education for all related continuing education for all medical and technical personnel medical and technical personnel mustmust be be maintainedmaintained

Keep in central location; update annuallyKeep in central location; update annually

Materials Materials – CD, journal, Internet, videotape materials CD, journal, Internet, videotape materials – Departmental, local, regional and national Departmental, local, regional and national

conferences and coursesconferences and courses

CMECME

15 15 echo-relatedecho-related CME credits required CME credits required for all staff (3 year period)for all staff (3 year period)

Category 1 AMA creditCategory 1 AMA credit

Other approved non-category 1 Other approved non-category 1 credit (ASE, SDMS or ARRT) that credit (ASE, SDMS or ARRT) that have have content specific to content specific to echocardiographyechocardiography

CME LogCME Log

Peer ReviewPeer Review

Feedback is essential for Feedback is essential for improvement!improvement!

Intermittent peer review of both Intermittent peer review of both performance and interpretation of performance and interpretation of studies studies shouldshould be performed be performed

Optional QA measure, but very usefulOptional QA measure, but very useful

Both physicians and sonographers Both physicians and sonographers should be involved should be involved

Peer ReviewPeer Review

Differences in interpretation styles Differences in interpretation styles and performance should be and performance should be reconciled reconciled

Individual vs group reviewsIndividual vs group reviews

Confidentiality Confidentiality

Document it!Document it!

MD Peer Review MD Peer Review

Variability

EF, wall motion analysis and degree of regurgitation/stenosis must be assessed on a minimum of two cases per modality per quarter to be reviewed in quarterly conferencesRepresent as many physicians as possiblePolicy to address discrepancies

Variability WorksheetVariability Worksheet

Variability SummaryVariability Summary

CorrelationCorrelation

EF, wall motion analysis and degree of regurgitation/stenosis will be correlated on a minimum of two per modality per quarter with other imaging modalities in quarterly conferences Represent as many physicians as possiblePolicy to address discrepancies

http://www.icael.org/icael/pdfs/Correlation_Form.pdf

Report ReviewReport ReviewMinimum of 10 random reports per quarter Time from performance of study to report sign-off– Inpatient: 24 hours– Outpatient: end of next business dayReport completeness (Standards)Represent as many physicians as possiblePolicy to address discrepancies

QA Conferences QA Conferences

Quarterly conferences Quarterly conferences mustmust be held be held to review the results of variability, to review the results of variability, correlation and report timelines, to correlation and report timelines, to address discrepancies and to discuss address discrepancies and to discuss difficult casesdifficult cases

Attendance by the medical and Attendance by the medical and technical directors or their designees technical directors or their designees is required at all meetingsis required at all meetings

QA Conferences QA Conferences

All medical and technical staff are All medical and technical staff are required to required to attend at least two of the attend at least two of the fourfour meetingsmeetings

Minutes of the meetings and Minutes of the meetings and attendance must be recordedattendance must be recorded

Record KeepingRecord Keeping

If you don’t document it, If you don’t document it, it didn’t it didn’t happenhappen

Keep data in a central location Keep data in a central location and and back it upback it up

Annual summary of information Annual summary of information requiredrequired

Requirements for SuccessRequirements for Success

Leadership Commitment

Commitment ofResources

IndividualCommitment

BUY-IN

Accreditation/QA ResourcesAccreditation/QA Resources

http://http://asecho.orgasecho.org//

http://http://www.icael.org/icael/index.htmwww.icael.org/icael/index.htm

http://http://www.sdms.orgwww.sdms.org//

http://www.asq.org/learn-about-quality/indhttp://www.asq.org/learn-about-quality/index.htmlex.html

Merri’s RulesMerri’s Rules for QAfor QA

Keep it Keep it SIMPLESIMPLE and practical and practical

Involve lotsInvolve lots of people and ideas of people and ideas

StealSteal shamelessly from others shamelessly from others

AdaptAdapt what you’ve stolen what you’ve stolen

Be methodicalBe methodical

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