XXXXNuclear Facility
Quality Improvement (QI) Policy
Objective: XXX facility is committed to providingquality patient care. The quality improvement policy outlines the mechanism to measure and improve our processes to achieve this goal.
Purpose:
To establish guidelinesfor continuous process improvement of our images and reports leading to high-quality nuclear medicine studies and interpretationswhich will help to ensure better patient outcomes.
QI Oversight
The Medical Director of thisfacility provides oversight of the QI program which includes but is not limited to:
- Review of all documentation of the QI measures:
- Test Appropriateness
- Technical Quality Review
- Interpretive Quality Review
- Final Report Completeness and Timeliness
- Correlation
- Addresses any deficiencies
Test Appropriateness
Test appropriatenesswill be evaluatedxxxx per year on 30nuclear medicine studies and categorized as, appropriate, may be appropriate, rarely appropriate. Results are documented, reviewedand discussed at the QI meeting.(Clinical indication will be used to determine appropriateness for those studies which criteria has not been established.)
Technical Quality Review
A minimum of 30 nuclear medicine studies are reviewedto assess and improve the technical quality of the images.This review will consist of the evaluation of the clinical images for suboptimal images or artifact, reproducibility of processed images and/or quantitative results, image display/labeling, correct patient preparation, verification of administered dose to prescribed dose listed in the protocol, and adherence to imaging protocol.The results are documented,then reviewed and discussed at the QI meeting.The Medical Director addresses any deficiencies in the quality as well as adherence to the protocol.
Interpretive Quality Review (Physician Interpretation Variability)
A minimum of 30 nuclear medicine studies are reviewed per year to evaluate the quality and accuracy of the interpretation based on the acquired images (e.g. interobserver agreement (peer review), and/or intra-observer variability).The results are documented, then reviewed and discussed at the QI meeting. As many physicians as possible will participate in the review. The Medical Director addresses any differences in interpretation to achieve uniform study interpretations.
Final Report Completeness and Timeliness
A minimum of 30 random reports per year are evaluated and the results documented for report completeness (must include all elements listed in the standards)and timeliness of reporting.The results are documented, then reviewed and discussed at the QI meeting.The Medical Director addresses any incomplete reports and reports not interpreted and finalized in the required timeframelisted belowwith the interpreting physician.
Timeframe:
- the interpreting physician will verify and sign the final report within 48 hours after completion of the study.
Correlation
Myocardial perfusion imaging results are correlated with the results obtained by coronary catheterization annually. Correlation of intended therapeutic effects with patient response to therapy will also be assessed (if applicable). The results are documented, then reviewed and discussed at the QI meeting.The Medical Director addresses major discrepancies.
Biannual QI Meetings:
A minimum of two QI meetings per yearare held to review/discuss the results of the QI measures, other QI related topics and any additional topics (i.e. interesting cases).All staff will participate in at least one meeting per year. Staff attendance and meeting minutes will be documented.
QI Documentation and Records
Data documented/recorded for the required QI measures, meeting minutes and attendance/participant list (may include remote participation and/or review of minutes) will be maintained and available for staff review.