PAUL NAGY, PHDQUALITY MATTERS

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Performance Quality Improvement Projects:Suggestions for Interventional Radiologists

Fred Moeslein, MD, PhD, Paul Nagy, PhD

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Interventional radiology (IR) is sur-rounded by complex processes andpotential quality issues that can af-fect the ability to ensure optimalpatient care. Interventional radiol-ogy combines all the challenges ofan operating theater with the chal-lenges of implementing highly ad-vanced imaging technologies. Inspite or perhaps because of the largenumber of issues that affect thesepractices, it is often difficult to de-cide how to start an interventionalquality project. Often, we resignourselves to a chaotic environmentand then try the best we can to servepatients. How then does one scopeout a project that can gain traction?

As a start, some good genericguidelines for quality improvementprojects can be found in the Na-tional Quality Forum’s guidelines[1]. These criteria are intended toevaluate the effectiveness of a qual-ity measurement but can also pro-vide insight into thinking aboutsolid quality projects.

1. A metric should be importantfor the patient and meaningfulto you. Nothing trumps a vestedinterest in ensuring ownershipof a project.

2. There should be a gap in perfor-mance that can be improved.There is a natural tendency forpeople to select projects thatmake them look good and donot need improvement. That’scalled marketing, not qualityimprovement.

3. The project should be feasible,whereby data can drive action-able information. The simplerthe measure you are trying to

improve and the closer it is di- r

2011 American College of Radiology1-2182/11/$36.00 ● DOI 10.1016/j.jacr.2011.04.014

rectly tied to the patient, thebetter.

4. There should be repeatable met-rics that can be examined overtime. Data are the only antidoteto anecdotal perceptions andemotions.

To provoke further thinking andaction, the following are examplesof projects in IR that can be man-ageable and yet make a significantimpact on your practice and pa-tients. It is our goal to help you“prime the pump” when starting tothink about how to select a practicequality improvement project thatinterests you, makes good businesssense, and improves the care of yourpatients.

INFERIOR VENA CAVAFILTER REMOVAL (ABRCATEGORY: PRACTICEGUIDELINE)Nationally, there is a large perfor-mance gap, with only 7% to 8% ofretrievable inferior vena cava filtersbeing removed within the durationrecommended by the device manu-facturers [2]. Filters that are not re-

oved put patients at an unneces-ary risk for fracture or migration.he longer a filter is in place, thereater the risk to the patient. Aroject on this issue could entailracking all patients with inferiorena cava filters, notifying patientsnd their physicians about schedul-ng removal, and following up andnsuring that filters are removed.his is not only good patient careut good business. Consider the ad-itional revenue from a follow-uponsult and the procedure, not toention the benefits of the refer-

ing physician’s appreciation.

DIALYSIS (ABR CATEGORY:PRACTICE GUIDELINE)Dialysis access, whether it is an ini-tial tunneled dialysis line or main-tenance of arteriovenous grafts andfistulas, has become a mainstay ofmany IR divisions. However, inmany instances, we find that we arechallenged as the local experts onthese procedures. A quality im-provement project could be to ini-tiate tracking of arteriovenous fis-tula and graft patency and flowrates at dialysis after maintenancetherapy. Analysis of these datawould improve patient outcomesby identifying potential areas ofpractice weakness, especially whencomparing outcomes between op-erators and published Kidney Dis-ease Outcomes Quality Initiativestandards [3]. This project servesfurther to strengthen referring phy-sician relationships. To obtain thenecessary data, direct contact withthe referring nephrologist is obliga-tory, and this dialogue acknowl-edges the important roles of boththe nephrologist and the interven-tionalist.

A further worthwhile project in-volves dialysis catheter (or for thatmatter any tunneled catheter) man-agement. Too often, IR physiciansrelinquish their position as theleading venous access experts intheir local communities, be theytertiary care centers or small com-munity hospitals. Line infectionsare a major source of morbidity andmortality in medicine today. Inap-propriate management of poten-tially or definitely infected lines hassignificant consequences, includingenormous cost to the health caresystem and venous injury to indi-

vidual patients. Instituting a hospi-

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tal-wide improvement project tobring catheter management in linewith the Kidney Disease OutcomesQuality Initiative criteria wouldlikely minimize hospital costs andpatient morbidity [3]. This project

ould require providing line man-gement algorithms to various ser-ices within the hospital and mostikely preparing grand rounds onhe pitfalls of inappropriate lineanagement. It would also require

ollecting line placement and re-oval history. Although this is

learly not a simple project, the po-ential impact on the IR practice,ospital costs, and patient out-omes cannot be understated.

FIRST-CASE START TIME(ABR CATEGORY:TURNAROUND TIME)This project involves the construc-tion of or participating with a mul-tidisciplinary team to improve dailyoperational procedures in IR.When the first case of a busy day isdelayed, there is invariably a cas-cading delay to every case lined upin queue behind it. This frustrateseveryone and ultimately may harmpatients. This project starts withconstructing a list of delay codesand building a clear method to en-sure documentation of every casethat is delayed. An electronic re-porting system like a radiology in-formation system would be theideal place to document this infor-mation. Analyzing these data willreview systemic delays and helpprovide an understanding of theircauses. You will move beyond theanecdotal perception of outliersthat cause delays and gain an un-derstanding of real systemic“bleeds” that hurt your practice andaffect your patients. Improving theefficiency of IR goes directly to thebottom line of a hospital’s finances,and this project should generate in-

terest and investment.

CASE TRACKING ININTERVENTIONALONCOLOGY (ABRCATEGORY: PATIENTSAFETY)Interventional oncology is a grow-ing specialty within IR with greatpotential to influence clinical care[5]. However, cases are usuallycomplex, requiring the input ofmultiple oncologic and medicalspecialties. Creating a unified sys-tem of patient tracking, which in-cludes immediate postoperativefollow-up, necessary imaging, and“automatic” communication withreferring physicians and patients,has the potential to both decreasemedical errors and strengthen tieswith referring physicians. This sys-tem may not be essential for smallergroups, but for larger groups or ac-ademic practices, in which multiplephysicians are involved with com-plex cases, a system that automati-cally contacts and schedules pa-tients for follow-up imaging andclinic visits will eliminate, or at leastreduce, the number of patients lostto follow-up. This system will alsoallow for earlier detection of treat-ment failures, especially in lesscompliant patient populations. Au-tomatically generated physicianmailers, treatment plans, and post-operative notes and courses shouldsystematically be forwarded to re-ferring physicians and patients (ifappropriate). This undoubtedlywill improve IR exposure withinthe oncology community and re-duce the fear and uncertainty of re-ferring patients for advanced lo-coregional therapies.

PERCUTANEOUS DRAINAGES(ABR CATEGORY: PRACTICEGUIDELINE)Percutaneous drainage proceduresare clearly one of the less exotic pro-cedures performed on a routine ba-sis in IR. However, these proce-dures are of great importance to our

patients, and there is ample litera-

ture to support the premise thatminimally invasive drainage proce-dures improve patient outcomesand decrease associated morbidityand mortality [4]. Large institu-tions and busy practices may fallprey to our success because the per-formance of these procedures leadsto a large number of indwellingdrains and lines in patients whotend to be on other services. Manyservices, including surgical special-ties, do not know the best methodsof catheter maintenance and appro-priate follow-up. Therefore, it is in-cumbent on the IR service to as-sume control of these devices. Asimple project is to institute a sys-tem of drainage catheter tracking,with automatic scheduling of fol-low-up visits for outpatients androutine inpatient rounding to assessdrain function and output. On theinpatients, the role of IR would beto provide recommendations to thereferring services on the removal,revision, maintenance, and fol-low-up of indwelling catheters. Onoutpatients, drain revision, mainte-nance, and removal are driven en-tirely by IR. Both the inpatient andoutpatient IR services provide moremethodical care for patients withdrains and may dramatically reducethe number of drains that are pre-maturely removed or lost to follow-up, resulting in prolonged drainagecatheter dwell times. Added bene-fits are the improved communica-tion between IR and the referringservices and the “offloading” ofdrain maintenance from the refer-ring services to IR.

REFERENCES

1. National Quality Forum. Report on the guidancefor evaluating the evidence related to the focus ofquality measurement. Available at: http://www.qualityforum.org/Measuring_Performance/Improving_NQF_Process/Evidence_Task_Force.aspx. Accessed April 1, 2011.

2. Dabbagh O, Nagam N, Chitima-Matsiga R,Bearelly S, Bearelly D. Retrievable inferiorvena cava filters are not getting retrieved:where is the gap? Thromb Res 2010;126:

493-7.

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3. Eknoyan G, Levin N. K/DOQI clinical prac-tice guidelines for chronic kidney disease:

evaluation, classification, and stratification.Am J Kidney Dis 2002;39(suppl):S1-266.

4. Lorenz JM, Funaki BS, Ray CE Jr, et al. ACRAppropriateness Criteria on percutaneous

catheter drainage of infected fluid collections.J Am Coll Radiol 2009;6:837-43.

5. Smith KA, Kim HS. Interventional radiol-ogy and image-guided medicine: interven-

tional oncology. Semin Oncol 2011;38:151-62.

Fred Moeslein, MD, PhD, is from the Department of Radiology, University of Maryland, Baltimore, Maryland.Paul Nagy, PhD, Johns Hopkins University, Russell H. Morgan Department of Radiology, 600 N Wolfe St, Baltimore, MD,21287; e-mail: pnagy2@jhmi.edu.