QUALITY IMPROVEMENT

Personnel Policies Revised/Approved Date:

1 POLICY

The pursuit of continuous quality improvement (QI) will guide the activities and decision making of the vascular laboratory.

2 PURPOSE

To ensure that the Texas Tech School of Medicine, Texas Tech Physicians Non Invasive Vascular Laboratory provides high-quality studies and appropriate services to meet the needs of the referring physicians.

3 PROCEDURE

Using the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) ten-step process, concepts of continuous QI were incorporated into the following ten-steps.

3.1 Assign responsibility:

The entire staff of the vascular laboratory should be involved in this self-evaluation. Although the medical director is ultimately responsible for the process, the types of indicators, the system of data collection, and the method of evaluation should be designed by the laboratory personnel. The staff's understanding and acceptance of, and willingness to participate in QI are critical to success. The final stage requires a discussion of all findings by the entire staff.

3.2 Delineate the scope of care:

The scope of care includes the types of patients served, the range of conditions/diagnoses, the diagnostic modalities used, the range of other activities involved in serving patients, staffing requirements, and the hours that services are available.

3.2.1 Patient population:

Generally middle-aged to elderly.

3.2.2 Range of conditions:

A variety of anatomic and physiologic peripheral arterial, venous, cerebrovascular, and

abdominal problems. Tests are utilized to screen patients for the presence of vascular disease, to provide baseline information for follow-up, and to evaluate surgical intervention.

3.2.3 Types of diagnostic modalities:

Ultrasonography with spectral analysis of Doppler velocity signal; Doppler evaluation of peripheral arterial, venous, and deep abdominal vasculature flow characteristics; air

plethysmography; photoplethysmography; ocular pneumoplethysmography; and segmental blood pressure determinations (with or without exercise).

3.2.4 Range of other activities:

Coordinate all appointments requiring noninvasive studies and consultation with a vascular surgeon, triage all requests for testing, incorporate risk factor modification in patient interview process, and clarify the disease process/no operative treatment/surgical intervention or other issues that may arise during the testing. The administration of pain medication and monitoring of IV and oxygen therapies may also be necessary when hospitalized patients are in the laboratory.

3.2.5 Staff requirements:

Will differ depending on institutional policy. For example, one registered nurse, an appropriate number of well-trained ultrasound technologists to provide timely services, and a clerical support person may be considered suitable.

3.2.6 Hours of operation:

Will differ depending on institutional policy. For example, 7 am to 6 pm Monday through Friday;

8 am to noon on Saturday; available on Sunday and holidays for urgent venous imaging studies according to a specific protocol by the medical director of the laboratory.

3.3 Identify important aspects of care:

The identification of high-risk, high-volume, and problem-prone types of care includes any services that could result in harm to the patient (e.g., misdiagnosis, inappropriate testing, or complication from testing). Although quality has many components, the following factors are considered to reflect the most important aspects of care provided by the department:

3.3.1 Accessibility:

Is it easy for the patient to make an appointment?

3.3.2 Timeliness: How long a wait will the patient have before the appointment date? How long will the referring physician wait before the results are available?

3.3.3 Effectiveness:

Is the testing done correctly?

3.3.4 Efficacy:

Does the testing provided do what it's intended to do?

3.3.5 Appropriateness:

Is the test chosen correctly?

3.3.6 Efficiency:

Is testing provided with minimum effort, cost, and waste?

3.3.7 Continuity:

Is testing coordinated among the practitioners?

3.3.8 Privacy:

Is the privacy of the patient maintained (limited traffic and disturbances in the examination areas)?

3.3.9 Confidentiality:

Is privileged information secure?

3.3.10 Participation:

Is the patient involved in decisions?

3.3.11 Safety:

Is the patient free from danger?

3.3.12 Support:

Are rooms, equipment, and supplies available when needed?

Following identification of the most important aspects of care, the laboratory must determine whether basic processes are available to provide these features. For example, the provision of timely services in a hospital-based facility may require that a method of prioritizing requests for studies is available: Are studies scheduled according to the effect the results have on the medical or surgical management of the patient; e.g., is a carotid duplex study on a patient admitted with multiple episodes of amaurosis fugax scheduled before a study to evaluate vertebrobasilar symptoms? An example of a basic requirement in the outpatient setting might be the availability of angiographic findings necessary to evaluate the efficacy of the

noninvasive diagnostic information.

Determining appropriate scheduling in the hospital setting requires a collaborative effort among the medical director, technical director, and referring physicians. Table 1 includes some possible scheduling guidelines.

Although it is much more challenging to work collaboratively in the outpatient or mobile setting, it is critical to develop a mechanism of obtaining radiologic correlation. In addition to the

previously described team members, primary-care physician and radiologists may also be involved. Figure 1 represents one method of obtaining angiographic findings.

The resolution of these types of issues are important QI activities fundamental to good laboratory management.

3.4 Identify indicators:

Indicators are well-defined objective statements describing the focus of what is being

reviewed. Although every process should be evaluated, time and personnel limitations dictate that the monitors/indicators reflect the high-risk, high-volume, or problem-prone types of care.

See Table 2 for some examples of appropriate indicators for the noninvasive laboratory.

3.5 Establish thresholds:

The thresholds (levels of acceptable performance), used in Table 2 have been derived from the literature and from the advice of a biostatistician.

3.6 Collect and organize data:

Existing sources of potentially useful data include the medical record, laboratory reports, pathology reports, angiography/venography results, department logs, questionnaires, interviews, and direct observation. The interaction with the vascular surgeons provides the most important feedback on the accuracy of the studies comparison with angiography or operating room findings. The methods of collection include worksheets (log or questionnaire), designated personnel, daily collection. If sampling is appropriate (e.g., high-volume cases), data from approximately 10% of the activity should be collected. Sampling is not appropriate for an indicator that describes an infrequent but serious complication.

3.7 Evaluate the care provided:

The method of evaluation is peer review and objective comparison, i.e., angiography or surgery. Although the technologist should be privately informed of positive or negative correlation as soon as that information is available, addressing the issue at the next staff meeting is also necessary. If the thresholds are met, monitoring for the next quarter is necessary. If no practice patterns requiring modification are identified, the indicator can be eliminated after the staff has been complimented on their compliance. If modification is required, proceed to the next step.

3.8 Take actions to solve the problem:

Determine who/what is to change. A plan of action should be designed with the input of the entire staff, with plans to re-evaluate the situation in the next quarter. An important component of problem identification is a review of the staff's level of understanding (e.g., are they familiar with the correct protocol/procedure?), their acceptance of QI activities, and their willingness to participate in the process. Before making any attempt at problem resolution, make sure that all the facts are available so that the right action is taken. The action plan requires a systematic approach that is realistic, allows appropriate time for resolution, and is developed with the cooperation of the staff.

3.9 Assess the corrective action:

After allowing enough time for the corrective actions to work, a follow-up evaluation is necessary using the same process that identified the problem.

3.10 Communicate relevant data to the appropriate personnel:

All information should be disseminated to the appropriate staff members as soon as that information is available, e.g., the individual technologist, the laboratory staff, the medical

director, and the QI department. Immediate feedback, whether positive or negative, is critical in any problem situation. The official reports should always include conclusions,

recommendations, actions, and follow-up. In addition, documentation of staff meetings related to QI issues should be routed to the QI department. Also, it is imperative that every document addressing a QI issue be marked/stamped as confidential information.

4 DOCUMENTATION