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Vol. 37 No.

3 May/June 2015 173

A Systems Approach to Evaluating Ionizing


Radiation: Six Focus Areas to Improve
Quality, Efficiency, and Patient Safety
Jonathan B. Perlin, Laura Mower, Chris Bushe
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Background Abstract: Ionizing radiation is an essential component of the care


Ionizing radiation is an integral part of process. However, providers and patients may not be fully aware
modern medicine. Patients have seen of the risks involved, the level of ionizing radiation delivered with
enormous benefit from its use, including various procedures, or the potential for harm through incidental
the identification of previously undetect- overexposure or cumulative dose. Recent high-profile incidents
able pathology, more effective diagnoses demonstrating the devastating short-term consequences of
and treatment, and improved monitoring. radiation overexposure have drawn attention to these risks, but
The introduction and proliferation of applicable solutions are lacking. Although various recom-
newer and more advanced technologies mendations and guidelines have been proposed, organizational
over the past several decades have stimu- variability challenges providers to identify their own practical
lated demand from patients and physi- solutions. To identify potential failure modes and develop sol-
cians, resulting in a steady increase in utions to preserve patient safety within a large, national health-
the number of procedures per year care system, we assembled a multidisciplinary team to conduct
(Amis et al., 2007; The Morgan Company, a comprehensive analysis of practices surrounding the delivery
2010). Consequently, patients’ cumulative of ionizing radiation. Workgroups were developed to analyze
exposure to ionizing radiation has existing culture, processes, and technology to identify deficien-
increased (Board on Radiation Effects cies and propose solutions. Six focus areas were identified:
competency and certification; equipment; monitoring and audit-
Research & National Research Council,
ing; education; clinical pathways; and communication and mar-
2006; Brenner & Hall, 2007; Mettler,
keting. This manuscript summarizes this comprehensive,
Huda, Yoshizumi, & Mahesh, 2008), which
multidisciplinary, and systemic analysis of risk and provides ex-
could affect long-term cancer risk (Board
amples to illustrate how these focus areas can be used to
on Radiation Effects Research & National
improve the use of ionizing radiation. The proposed solutions,
Research Council, 2006; International
once fully implemented, may advance patient safety and care.
Commission on Radiological Protection
[ICRP], 2005).
Overshadowing this long-term risk are
high-profile incidents involving inappro- dose levels at the time of these events was Keywords
priate or excessive radiation doses that re- “as low as reasonably achievable” (ALARA) ionizing radiation
sulted in acute patient injury (Bogdanich, (Alliance for Radiation Safety in Pediatric patient safety
2010; Landro, 2010; Steenhuysen, 2010; Imaging, 2013; Amis et al., 2007). Sub- process improvement
Szabo, 2009). As tragic reminders of the sequent recommendations to improve systems improvement
short-term consequences of radiation radiation safety and reduce exposure were Journal for Healthcare Quality
overexposure, these incidents captured issued by national organizations, including Vol. 37, No. 3, pp. 173–188
the attention of the mainstream media, the U.S. Food and Drug Administration
© 2015 National Association for
Healthcare Quality
contributing to growing concern and (FDA), the Medical Imaging and Tech- This is an open access article
demand for action by the public and reg- nology Alliance (MITA), and the American under the terms of the Creative
ulatory agencies. Standard guidance for College of Radiology (ACR, 2009; Center
Commons Attribution-
NonCommercial License, which
for Devices and Radiological Health, 2010; permits use, distribution and
MITA, 2011; FDA, 2009). Other groups reproduction in any medium,
Disclaimer: “HCA,” “Company,” “we,” “our” or “us,” as provided the original work is
used herein refers to HCA Inc. and its affiliates unless expanded upon these recommendations, properly cited and is not used for
otherwise stated or indicated by context. including ICRP (2007, 2012) and The Joint commercial purposes.

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
174 Journal for Healthcare Quality

Commission (2011). In addition, the Methods


Centers for Medicare and Medicaid
Service (CMS) has implemented out-
patient imaging efficiency measures to
Setting
This systems analysis was conducted within
drive reductions in combination studies
a large healthcare organization that
or inefficient examination protocols
(CMS, 2011). includes 166 hospitals, 124 surgical and
Although recommendations and imaging centers, and more than 650 phy-
guidelines are useful in theory, providers sician practices. Together these facilities
are challenged with translating these into handle over 18 million patient encounters
operating principles for daily clinical per year and provide approximately 5% of
major hospital services and medical pro-
practice. This includes the design of
cedures involving ionizing radiation in the
systems-level layers of controls, processes,
United States.
and preventative “fail-safe” mechanisms
to defend against patient harm caused by In this organization, enterprise level
human factors, including judgment and functions such as financial operations,
operator error, or technological failures. organizational and clinical goals, and sup-
Yet as described by James Reason’s “Swiss ply chain management are coordinated at
cheese” model of system accidents, these the corporate level. Clinical operations and
market strategy are managed by 15
individual defensive layers are imperfect.
regional divisions, which provide daily
Because of the complexity of the work
operating leadership for facilities. Division
environment, potential holes and gaps in
these barriers and defenses can align and leadership is responsible for facility per-
allow errors to perpetuate throughout the formance as supported by corporate tools
system (Reason, 2000; Reason, Carthey, & and resources. Facility leadership is
de Leval, 2001). Thus, efforts to identify responsible for all aspects of facility per-
gaps and create redundancy are crucial to formance, including achievement of divi-
sion and corporate goals.
ensuring patient safety.
Accordingly, we proposed a comprehen-
sive analysis of existing radiation safety
processes in a large healthcare system. This Evaluation of Current Practices
evaluation revealed that ionizing radiation The evaluation was coordinated at the
has become a standard and expected, if not enterprise level with input from facilities
defensive and reflexive, component of and the field. Central to this was the cre-
medical care. Diversity in services and pro- ation of the Radiation Right Steering
cesses, variation in equipment types and Committee. The goal of this committee
available controls, inconsistencies in edu- was to facilitate communication, encour-
cation, and limited patient radiation expo- age collaboration between various groups,
sure tracking were some of the observed and ensure that proposed solutions are
weaknesses that suggested a need for mul- reflective of practical needs at the local
tifaceted, systems-level solutions. Six focus level while meeting national and organi-
areas were identified to guide the devel- zational guidelines.
opment of projects that could improve Key members of this committee included
the safety of ionizing radiation use while quality and patient safety experts as well as
aligning with changing regulatory re- clinical contacts from various levels of the
quirements. This paper describes the organization, including experts in imaging
observed deficiencies and proposed and cardiovascular services. These in-
solutions for these six focus areas. Results dividuals led the assessment of processes
of initial implementation efforts are also and the development of practical solutions
presented in order to assist other that reflected the needs of the various facil-
healthcare providers in analysis of their ities. The Radiation Right Steering Com-
own systems, with the ultimate goal of mittee also included representatives from
preventing patient harm. risk management, education, leadership,

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
Vol. 37 No. 3 May/June 2015 175

Figure 1. Role and Responsibilities of the Radiation Right Steering Committee.

and information technology to assess all self-reporting and audit by providers,


proposed solutions. The Steering Com- comprehensive review of existing event re-
mittee coordinated with corporate execu- ports, surveys and site visits, and evaluation
tive leadership, facility leadership, and of current vendor-provided solutions. This
internal expert advisory panels, and incor- was enhanced by patient safety data from
porated guidelines and requirements from facilities when available, and com-
regulatory agencies. Through this process, plemented by a survey of peer-reviewed,
the Steering Committee acted as the dis- evidence-based literature. Best practices
cussion group that assigned tasks, ensured from the literature and from facilities were
continuity, coordinated workgroups, and evaluated for their applicability across the
provided overall direction for the entire entire enterprise.
initiative (Figure 1).
The Steering Committee directed the
formation of workgroups consisting of ex- Development and Implementation of
perts in various areas. Each workgroup had Solutions
a specific role in the analysis of current The development and implementation of
processes and the development of solutions solutions based on workgroup reports are
(Table 1). These groups drew upon the an ongoing organizational goal. All proj-
expertise of corporate clinical leaders, divi- ects are prioritized by the Radiation Right
sion quality leadership, and facility-based Steering Committee based on potential
subject matter experts. In addition, these patient risk as assessed by expert opinion
groups consulted with risk management, and workgroup recommendations.
audit, human resources, supply chain, pro- Workgroups use information gathered
ject management, and information tech- during their assessments to develop initial
nology as well as external vendors and opinions that are submitted to the Radiation
additional facility-based experts as needed. Right Steering Committee. The Radiation
Workgroups assessed the current state Right Steering Committee initiates program
of radiation services through directed development and deployment based on the

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
176
Journal for Healthcare Quality
Table 1. Workgroup Roles and Participant Categories
Workgroup Role Participant Categories*
Radiation Right Core Team Participate in all workgroups to provide Operations leaders
oversight and ensure continuity of projects. Subject matter experts
Technology Develop new tools to monitor and track Information technology experts
radiation dose. Work with vendors to Risk management experts
assure the appropriate adoption of new technologists. Vendor representation
Reporting/monitoring/auditing Develop and monitor effectiveness and Supply chain contact
direction of tools. Assure that that data collected Quality experts
leads to performance improvement and Patient safety experts
increased patient safety. Risk management experts
Clinical analytics expert
Clinical compliance expert
Audit expert
Clinical (CVL/IR/EP) Provide direction and leadership for the CVL/ Clinical personnel
IR/EP lab regarding education, competency, Interventional radiologist
and privileging policy development. Registered nurses
Cardiovascular technician
Radiology technologist
Radiation safety officer
Interventional cardiologist
Privileging/credentialing Assure appropriate enterprise-wide processes CVL team members
are used for credentialing and privileging of all Quality standards experts
physicians using or ordering ionizing radiation
procedures.
Communications Develop, pilot, and distribute communication Communications specialist
tools. Work with physician marketing services to Graphic artist
assure a consistent message to the provider Radiology oncology subject matter expert
market. Physician marketing services
(Continued)

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
Table 1. (Continued)
Workgroup Role Participant Categories*
Education Develop content of Radiation Safety University. Education specialists
Patient safety expert
CVL team members
Policy Develop and release policies on CT radiation Quality expert
dose reduction, governance of radiation safety CVL team members
officers and equipment monitoring, and Legal experts
fluoroscopy dose reduction and monitoring. Risk management experts
Patient safety experts
Quality standards experts
Human resources experts
Clinical pathways Assure that all medical imaging pathways take Electronic health record experts
radiation safety into consideration in future Education experts
order sets. Meaningful use team
Physician advisors
Expert review Oversee the increasing body of evidence-based Physicists
literature and regulatory information then Interventional radiologists
provide input, analysis, guidance, and direction. Radiologists
Hospitalists
Surgeon
Cardiologist
Dosing Establish a tool that will collect radiation dose Information technology experts
and make these values available for use in Risk management experts
radiation reduction safety measures. Vendor representation
Radiology representatives

Vol. 37 No. 3 May/June 2015


Note. CVL, cardiac catheterization laboratory; IR, interventional radiology; EP, electrophysiology.
*
Individual participants may contribute to more than one workgroup.

177
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178 Journal for Healthcare Quality

existing literature, media reports, federal Results


regulations, and workgroup recom- This comprehensive analysis resulted in (1)
mendations. The Steering Committee coor- the development of standard policies for
dinates the development of tools and the use of ionizing radiation, and (2) the
communication guides with input from identification of six key focus areas for
leadership, facility-based teams, expert advi- improvement (Table 2). The deficiencies
sory panels, and regulatory agencies (Figure identified, proposed solutions, and the re-
1). Acknowledgement and approval are ob- sults of initial implementation efforts (Table
tained from the appropriate workgroups, 3) are discussed for each focus area.
leadership, and expert panels prior to the
development of implementation timelines.
Programs are approved by executive lead-
ership and assigned an executive sponsor. Policies
Implementation teams are developed based Three company-wide policies were im-
on the work required, with both facility plemented in all facilities that utilize ioniz-
representation and ad hoc subject matter ing radiation: Radiation Governance,
experts. The Steering Committee facilitates computed tomography (CT), and fluoros-
communication and continuity of informa- copy. The Radiation Governance policy
tion between the teams as work progresses. expanded and standardized the roles of the
The Steering Committee also engages front- Radiation Safety Committee (RSC) and
line practitioners to aid in the development Radiation Safety Officer (RSO) at each
of solutions in order to maximize practicality facility. Responsibilities of the RSC include
and acceptance into the workflow. Individual monitoring occupational dose policies,
facilities are engaged to pilot solutions prior approving authorized users and radioactive
to system-wide implementation. material usage, approving changes to radia-
The recommendations and policies tion safety programs, reviewing equipment
developed by the corporate-level work- service records and audit findings, and re-
groups include opportunities for manage- viewing all dose quality records to assure
ment at the division and facility level. In ongoing compliance with policies and
general, implementation follows the estab- ALARA principles. The primary responsibil-
lished organizational structure (corporate, ity of the RSO is to ensure that all radiation
division, field). Policies and guidelines are safety activities across the entire facility are
established at the corporate level. Tools and performed with approved procedures and
resources are also developed at the corpo- meet regulatory requirements. This includes
rate level with input from experts in the areas outside of radiology (e.g., cardiology
field. These materials are provided to divi- services, surgical services, and oncology).
sion leadership for implementation. Divi- The Radiation Governance policy also
sion leaders are held accountable for included guidelines for equipment service
initiating implementation within their and repair. In brief, equipment is to be
facilities and monitoring progress. Respon- tagged “Out-of-Service, Do Not Use” dur-
sibility for implementation of individual ing downtime. This tag offers a process to
items is at the facility level. With assistance bridge the gap between the completion of
from division leadership, facility leaders can service and the receipt of electronic service
interpret recommendations, adapt tools, or documentation, which could be up to
adjust timelines based on local needs, state 72 hr after completion of service. The field
regulations, or other factors. Facilities service technician uses this tag to confirm
within a division share best practices related the reported equipment issue, the repair
to regional characteristics, and all facilities performed, and the recalibration of the
provide feedback to division and corporate equipment to the manufactures original
leaders. Guidelines were established to specifications. No equipment can be re-
observe implementation progress through turned to service until this information is
division monitoring, facility monitoring and acknowledged by a responsible staff
tracking, and compliance monitoring. member (e.g., certified technologist,

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Vol. 37 No. 3 May/June 2015 179

Table 2. Focus Areas Identified and Proposed Solutions for Observed Deficiencies
Implementation Status
Focus Area Observation Proposed Solution (Project Owner)
Competency and No standard training Provide skills and Created standard CT tech
certification regarding operation or knowledge training on competency tool (C)
interpretation of dose equipment operation
display
Assessing and determining
local needs (D/F)
Privileging guidelines vary Develop privileging and Working with experts to
by service area credentialing guidelines establish guidelines (C)
to meet current and future
requirements
Lack of structured training Stage follow-up training Cooperating with national
after initial equipment sessions; ensure training of organizations and vendors to
install vendor field service develop training programs
technicians and requirements (C)
Equipment Dose reporting unavailable Encourage upgrade to Created Equipment Risk
on some equipment equipment with dose Assessment Tool,
reporting capabilities provided results of risk
and manage type of assessment to divisions (C)
procedures scheduled
on equipment
Using results to inform
equipment decisions (D/F)
Maintenance and Define standard Created standard policy for
calibration services vary by expectations for equipment maintenance and
vendor; no standard check maintenance and return to service (C)
routine calibration services
Monitoring and Deviations in individual, Establish monitoring and Created standard policies (C)
auditing process, and system auditing guidelines
performance are often to review performance Evaluating potential
undetected at time automation tools (C)
of scan Using existing tools for
ongoing monitoring (D/F)
Measurement criteria varies Establish standard metrics Created standard policies for
by facility, service area, for monitoring CT, fluoroscopy (C)
scan type Determined top five CT
procedures by volume (C/D)
Implemented manual
monitoring of fluoroscopy
time (D/F)
Prevention of and response Encourage event reporting Clarified event definitions and
to events depends on emphasized importance of
knowledge of risk event reporting (C/D)

(Continued)

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180 Journal for Healthcare Quality

Table 2. (Continued)
Implementation Status
Focus Area Observation Proposed Solution (Project Owner)
Education General lack of Educate staff, physicians, Designed courses with
understanding about technicians through assistance of experts and
recommendations, “Radiation Safety vendors (C)
effectiveness, cancer risk University”
Clinical pathways Physicians need options for Integrate radiation safety Ongoing as part of electronic
reducing dosage/ principles into CPOE, health record
alternative to radiation order sets implementation (C)
Communication Ineffective distribution of Establish compelling Created and distributed
and marketing safety message to staff, campaign to inform materials (C)
patients stakeholders
Need proper identification Encourage patient Implementation in progress
of patient characteristics participation in (D/F)
for care planning identification and care
plan
Note. Project owner: C, corporate; D, division; F, facility.

department supervisor, director, or desig- These assure a standard base of knowledge


nated representative). and training within the department.
The CT policy set baselines for CT Implementation and results: The first
Technologist certification and competency, competency tool designed was for annual
provided guidelines for the adoption and assessment of CT technologists. The
review of standardized protocols, and es- competencies checklist directs the evalu-
tablished parameters for monitoring, audit- ation of key knowledge points and skills
ing, and reporting radiation dose for CT that must be demonstrated before job
patients. The fluoroscopy policy established assignment without direct supervision.
safety strategies to reduce radiation expo- This includes reference levels, required
sure, including privileging and competency documentation, allowable deviation from
expectations, radiation dose thresholds for established procedural protocols, use of
fluoroscopy, and the development of sys- shielding, and appropriate equipment
tems for the monitoring, auditing, and re- settings for specific patient populations
porting of patient dose. and scan types. Competency is evaluated
by a combination of observation, pro-
ficiency testing, demonstration, or verbal-
Focus Areas
ization. Results are recorded for the
Focus area 1: Competency and certification. employee’s personnel file and serve as
Problem and proposed solutions: Our com- a framework for training, if necessary.
prehensive analysis revealed a lack of Privileging criteria are currently being
standardized competency and certifica- established for interventional radiology,
tion programs as well as a fragmented electrophysiology, and cardiac catheteriza-
system of vendor training and basic radi- tion laboratory personnel. As part of bian-
ation safety courses (Table 2). Proposed nual privileging, physicians who perform
solutions included defined standards for procedures or otherwise utilize radiation
privileging of personnel, competency (such as interventional cardiologists who use
guidelines that accommodate regulatory fluoroscopy) will need to complete a course
requirements, and training standards for on radiation safety. Course work is being
field service technicians and physicists. developed by internal and external subject

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Vol. 37 No. 3 May/June 2015 181

Table 3. Barriers to Implementation and Successful Solutions


Project Barrier(s) Solution(s)
Standardize certification and Certain certifications require Support additional schooling
competency requirements for advanced schooling Encourage local flexibility in
technologists establishing date of
compliance
Implement standard process for Resistance from certain vendors Query vendors on reasons,
returning equipment to service develop processes that met
both policy and the vendor
needs
Assess risk associated with No upgrade path available for some Designate nonupgradable
current equipment equipment equipment for low-risk
situations (low-dose
procedures performed by
trained personnel)
Implement guidelines for Manual process relies on self-reporting Pilot automated reporting and
monitoring radiation doses monitoring processes
Work with vendors to design
and develop solutions
Improve education of providers Need high-quality courses that are Help experts develop courses,
applicable to providers’ work provide CE where
appropriate
Vendor training often requires off-site Consolidate training courses
travel or attendance outside of work into centralized online
hours education system
Ensure that data are being Data collection is manual and episodic Encourage use of data as tool
utilized to improve processes for reacting to outliers and
evaluating patient
experience
Develop plans to incorporate
data into CPOE
Create and distribute tools and Materials not reaching intended Engage physician sales team to
other communications audience and not being utilized as lead education of physicians
materials expected and increase staff awareness

matter experts with additional input from A challenge facing the implementation
vendors for specific equipment-related skills. of these competency and certification ef-
These courses will present relevant infor- forts has been variation in educational
mation and best practices while also meet- backgrounds (Table 3). For instance,
ing all minimum state licensing and while the goal is for all technologists that
certification requirements. Participation in routinely provide radiology services in CT
this course, as part of the privileging pro- to achieve advanced certification, certain
cess, would only be required for those who certifications required advanced academic
do not have documented completion of preparation. Individuals without this aca-
radiation safety education during their demic preparation should be accommo-
residency training. dated through support for additional

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182 Journal for Healthcare Quality

Figure 2. Sample of an Equipment Risk Assessment Tool report.

training and alternative mechanisms to validated and updated the inventory list,
ensure competency. and answered questions about utilization,
including frequency of use and type of
Focus area 2: Equipment. Problem and procedures. The results were summarized
proposed solutions: Installed equipment into a report that displayed (1) dose
varies greatly in capabilities and controls. technology (ability to automatically adjust,
Newer equipment features improved monitor, and record dose); (2) frequency
speed and image quality but may increase of high-dose procedures; (3) utilization;
the risk for harm, either through inad- (4) useful life of the equipment; and (5)
vertent misuse (due to the inherent available upgrade options. A portion of
complexity of the equipment) or accel- this report is presented in Figure 2.
erated injury (due to the intense amount Results were provided to senior lead-
of radiation that can be delivered). ership promoting discussion and assisting
Although software controls can aid in in decision making regarding utilization,
dose control and monitoring, the cost of dose reduction practices, and capital
upgrades can be significant and certain expenditures. In total, the Equipment
equipment may not accommodate new Risk Assessment Tool provided an under-
software. Staff must also be adequately standing of both equipment abilities and
trained to use equipment features, soft- human factors that affect equipment
ware controls, and upgrades. operation. For instance, an older piece of
There is a need for a more complete equipment may have a similar level of risk
understanding of available equipment. to a newer piece of equipment if used for
This would allow for the development of routine procedures and by a highly skilled
a standard set of expectations for tech- operator. This knowledge contributes to
nology, linked to effective processes and the strategic utilization of equipment and
training requirements, which could bol- related operational and behavioral
ster against risk and allow all providers to changes to reduce risk and protect patient
meet safety regardless of equipment type safety.
(Table 2).
Implementation and results: This analysis Focus area 3: Monitoring and auditing.
utilized the Equipment Risk Assessment Problem and proposed solutions: Although
Tool—an existing vendor tool that was equipment safety controls and procedural
modified to evaluate the full inventory of guidelines are immensely important, an
current equipment and characterize risk incomplete understanding of systems ca-
factors. Preliminary data were collected pabilities can impede appropriate use of
from purchasing records. Facilities safeguards. In an effort to complete a task,
received a prepopulated document listing operators may inadvertently circumvent
all equipment, and designated personnel technology and employ creative but

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Vol. 37 No. 3 May/June 2015 183

unintended use of equipment. Therefore, technologists viewed the presentations


it is necessary to have mechanisms for offered by vendors and knowledge leaders
monitoring radiation dose at delivery and as a useful review of techniques and
reporting any irregularities, whether or equipment use, this analysis revealed the
not patient harm occurred. need for coherent educational processes
Various organizations have proposed with adequate oversight and a defined
evidence-based guidelines or consensus curriculum. In addition, there was a need
recommendations, such as the appropri- for additional instruction on specific as-
ateness criteria from the ACR (2011) and pects of radiation safety, including dosing
diagnostic reference levels from the ICRP and advanced equipment usage.
(2001). The creation of standard policies Accordingly, clinical experts and vendors
and guidelines for auditing and monitor- coordinated to design educational courses
ing, as well as increased internal reporting, for radiation safety. These courses present
were proposed (Table 2). topics such as new practices, event report-
Implementation and results: Currently, ing, protocols, and physicians’ roles in fos-
monitoring is a manual process due to tering a culture of safety at the unit level.
technology constraints. The dose delivered Implementation and results: Educational
to the patient is monitored for appropri- programs were developed by external
ateness based on ordered exam, with quality subject matter experts, internal technical
assurance processes to verify that the best experts, and relevant technology vendors.
image is produced using the lowest dose of The programs were tailored to specific
radiation. Guidelines for acceptable per- specialties and designed for economy
formance have been established, and the and consistency across practice areas.
process is supported and verified by internal Materials were produced in a variety of
survey and audit teams. The long-term goal formats—from online webcasts to re-
is to integrate automated systems for dose corded instructor-led presentations—to
reporting and cumulative dose reports into meet audience needs.
standard care processes, which could allow In retrospect, previous vendor-
physicians and providers to monitor out- provided training courses had several
comes, better plan for future care, and have limitations, including inconvenience (e.g.,
informed discussions of risk with patients. travel to vendor site, weekend training),
Several products are currently being pilot little ability to track participation, and no
tested and the results will be shared with the universal curriculum. The consolidation
vendors to improve the design and devel- of training courses to a centralized online
opment of automated solutions. education system both standardized con-
Modifications were made to the existing tent with the most current evidence and
event reporting system to encourage the reduced employee burden by allowing
reporting of events related to radiation them to participate whenever their work
safety and provide additional information schedule allowed.
about risk. Corporate clinical leaders up- Currently four courses have been de-
dated guidelines to clarify what types of ployed with a total of 2,100 completions.
events are considered reportable. This These courses provide CE credit as
included defining reportable variances in applicable in order to help technologists
dose limits for fluoroscopy; additional meet requirements for continuing edu-
guidelines will follow as dose limits are cation. Future plans include educational
determined for different modalities. Divi- courses with CE or CME credit, courses
sion and facility leadership were encouraged specific to equipment operation, and
to reinforce reporting behavior and to pro- education sessions targeted to particular
vide training for personnel in the event re- groups, such as referring physicians. The
porting process. first course with CME credit was launched
at the end of 2012. This course was de-
Focus area 4: Education. Problem and signed for physicians who perform fluo-
proposed solutions: Although radiologic roscopy, with the ultimate goal of

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184 Journal for Healthcare Quality

integrating it into privileging criteria at provide physicians with current patient


the facility level. characteristics and history, including
exam frequency and dose, at the time of
Focus area 5: Clinical pathways. Problem exam ordering. The development of order
and proposed solutions: The tracking of appropriateness guidelines, including cri-
radiation dose and patient exposure in teria for ordering pathology-specific pro-
electronic health records would help cedures, is an ongoing project.
physicians and prescribers develop
appropriate care plans that consider the Focus area 6: Communications and
necessity of particular tests. The utility of marketing. Problem and proposed solutions:
such systems has been shown by various The importance of these proposed sol-
providers, such as the pioneering efforts utions must be communicated to key
by Massachusetts General Hospital to stakeholders including leadership, clini-
send alerts based on collated dose cians, technicians, patients, and the general
(Massachusetts General Hospital, 2012). public. Accordingly, communication and
Creating radiation-specific order sets marketing strategies to promote radiation
that are available, appropriate, and offer safety were developed. Dubbed “Radiation
alternatives to high-dose procedures is an Right,” these campaigns presented a con-
institutional and provider responsibility. sistent safety message to all stakeholders.
These order sets should be evidence-based Implementation and results: The commu-
and informed by the dose range for the nication campaign for imaging featured
intended test as well as patients’ prior the tagline “Right Exam. Right Site. Right
exposure. System developers should be Dose.” Materials were specifically designed
prepared to incorporate and respond to for staff, patients, and the public with
current and future regulatory require- messaging about safety efforts including
ments, such as the imaging efficiency dose reduction, dose tracking, and
measures being developed by CMS equipment maintenance. For patients, this
(Magellan Health Services, 2010). included materials to increase awareness
Implementation and results: The pre- about their responsibility for ensuring
viously described policies for CT and fluo- radiation safety, such as telling care pro-
roscopy included recommended protocols viders about their previous radiation
as a preliminary step toward evidence-based exposure history. Additional materials for
order sets. Physician advisors encouraged technologists, physicians, and staff dis-
adoption of these protocols within facilities, played updates in regulatory requirements
using event reporting and available data to or provided reminders of imaging alter-
drive awareness of risk and the potential natives. A similar campaign was also
effect on patient safety. In this way, the developed for therapeutic radiation.
existing manual data system was leveraged With corporate guidance, one division
to monitor and evaluate the entire patient created and piloted a “Radiation Right”
experience, from determining if care was webpage to be presented as a community
appropriate to reacting to outliers. The educational resource on the publicly avail-
implementation of these recommended able websites for each facility within that
protocols also brought forth several issues division. The webpage was designed to be
that could affect the success of Computer- easily adapted to any facility and featured
ized Provider Order Entry (CPOE) and educational messaging about the use of
evidence-based order sets, including vari- ionizing radiation and radiation safety ef-
ability in equipment and the clinical pref- forts. A social marketing vendor was
erences of radiologists. engaged to post articles on social media sites
Order sets will be designed by physi- with links to facility websites for more
cians and multidisciplinary experts to information. This concerted campaign
maximize acceptance and address current effort by all facilities within the division may
needs. When automatic data collection is have increased its effectiveness; post-
fully developed, the CPOE system will campaign feedback from physicians and

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
Vol. 37 No. 3 May/June 2015 185

staff indicated that patients had fewer organization enabled the proposed solutions
questions and concerns regarding radiation to reflect the practical needs of the field and
through imaging. In addition, using social include the most up-to-date regulatory and
media to drive patients to facility websites evidence-based practice requirements. The
capitalized on publicity due to concurrent solicitation of feedback and guidance by the
reports of radiation overexposure in the lay Steering Committee improved communica-
media. The template for this webpage has tion and collaboration that was crucial to the
been offered to all facilities, and is fully im- success of the proposed solutions. Input
plemented within eight divisions. from physicians and other clinical experts
supported the development of privileging
requirements and encouraged adoption
Discussion within facilities. Similarly, leadership support
The broad availability and high utility of was vital. This was cultivated by providing
ionizing radiation services have desensi- open access to data, soliciting and respond-
tized providers, prescribers, operators, ing to feedback, and allowing for flexibility in
and even patients to the associated risks and implementation to meet local needs. Finally,
potential for harm. This presentation of many of the proposed solutions, from
areas for improvement, proposed solutions, equipment repair policies to ongoing per-
and initial implementation efforts provide sonnel training, depend on maintaining an
a framework for minimizing risk through effective working relationship with vendors.
the development of appropriate processes, Facilities are conducting pilot tests and pro-
utilization of available technology controls, viding feedback to help vendors develop
and the creation a culture of safety. products that are evidence-based, appropri-
The broad and comprehensive scope of ate to the workflow in various environments,
our assessment confirmed the complexity and include the required process checks,
involved in providing high-quality, safe, such as dual sign-offs on dose calibration.
effective, and efficient delivery of ionizing With continued process improvement,
radiation. We expect that all our proposed further reductions can be made in radiation
solutions will ultimately build upon each dose while still providing high-quality diag-
other. For instance, upgraded equipment nostic exams to the radiologist. Sharing
and software will require knowledgeable this information with a national database
operators as well as dose standards and can effectively drive new industry stand-
tracking of patient exposure. The consol- ards. Future efforts will refine the col-
idation of educational courses into a cen- lection, monitoring, and utilization of
tralized online system will help eliminate data. Automatic data collection will
many of the barriers to training, creating expand availability of information about
a better educated workforce that is more the patient experience and allow for
able to safely operate equipment and integration with CPOE. Radiation dose
evaluate the appropriateness of ionizing tracking systems will need to be designed
radiation. Increased availability of patient and implemented, with attention to the
radiation histories could lead to more goals and guidelines for health informa-
informed decision making and ordering, tion technology that result from national
potentially reducing the tendency to standards-determination processes (U.S.
overprescribe scans, especially in the con- Department of Health and Human Serv-
text of “defensive medicine.” ices, 2009). Additional considerations
Yet these changes will not be possible include state regulatory requirements for
without the support of stakeholders from radiation controls through equipment
throughout the ionizing radiation delivery maintenance and monitoring policies as
process. The Radiation Right Steering well as the establishment of databases for
Committee was essential to coordinating this the tracking of delivered doses, such as
process and eliminating barriers to commu- those required by the California legislature
nications between various groups. The (California State Legislature, 2010). The
inclusion of experts from all levels of the solutions presented here will continue to

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
186 Journal for Healthcare Quality

evolve with additional state legislation and improvement cross a variety of functions,
changing regulatory requirements. the importance of cooperation from lead-
ership, providers, and vendors cannot be
Limitations overemphasized. All personnel must be
The facilities involved may have benefited empowered—and expected—to voice their
from resources inherent to a system as large concerns and contribute to creating an
and interconnected as ours, such as access to open and constructive culture of safety.
training materials or assistance with vendor In total, improvements in the quality,
negotiations. Although some challenges are safety, effectiveness, and efficiency of ion-
universal, such as variability in equipment izing radiation use for patient care are
and the need to evaluate rapidly emerging possible and achievable. A comprehensive
vendor products, our implementation of review of radiation policies, procedures,
proposed solutions benefited from the abil- and utilization can identify potential areas
ity to move equipment and technology for improvement where more robust and
purchasing toward a centralized system. It systematic layers of processes could reduce
should be noted, however, that the integra- the risk of harm. By maintaining diagnos-
tion of these system-wide benefits was tically useful examination while minimizing
dependent on local support and acceptance harm, providers can fulfill their responsi-
of the proposed solutions. As facilities within bility to provide the best possible care for
this system are highly diverse, primarily patients when using ionizing radiation.
community-based hospitals in a variety of
locations, it is likely that the findings pre- Acknowledgments
sented here would be applicable to a wide The authors wish to acknowledge the fol-
range of unaffiliated facilities. lowing individuals for their contributions:
Kimberly Korwek, PhD, manuscript prepa-
Implications for Practice ration and editing; Jane Englebright, PhD,
In order to maximize risk reduction, the RN, document revision; Anthony Roberts,
solutions developed as a result of this analysis RN, MBA, MSN, CCRN, Jason Hickok,
focused on forcing functions, automation of MBA, RN, Barbara Olson, MS, RN, FIMSP,
processes, and standardization when possi- and Tamithia Winn, ARRT (R)(CT),
ble (Reason, 1997). Higher level solutions ARDMS, expert guidance, technical review,
such as dose monitoring, software controls, and document revision; Jill Fainter, techni-
and standard protocols were preferred. As cal and standards review; Joseph Haase,
our evaluation demonstrated, maximizing technical and document review; Cathy
the safety of ionizing radiation delivery will Florek, Rita Baldwin, Stephen Slack, MD,
require such interventions due to the inher- Michael F. Scott, RT, MBA, Dennis Watts,
ent complexity of the processes involved. Jenine Hilton, Andrew Trovinger, In K
These efforts could also improve patient Mun, PhD, and Kim Harrison, data
satisfaction, as improved access to protocols acquisition, interpretation, and technical
and patient data could reduce provider review; Steven Manoukian, MD, data
workload, allowing more time for patient– review and expert guidance; Cindy
provider interaction and care planning. Borum, data review; Kathryn Mitchell,
However, these high-level solutions were patient safety culture and reporting
not always feasible due to factors such as guidance; Carol Corder, Crockett Boone,
technology limitations and the cost of and Chuck Nagel, technical and data
equipment upgrades. Accordingly, sol- review; Kristen Barber, project manage-
utions related to the human factors involved ment; Patrick Hoye, technology review;
in care delivery, such as checklists, policies, Susan Goodwin, privileging guidance.
and education, were necessary to foster Additional consultation on components
a culture of safety. Efforts to change atti- and document review was provided by the
tudes and behaviors, such as education and Medical Imaging Steering Committee
communication campaigns, complement and the Radiology Physician Advisory
these strategies. As the identified areas for Council.

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.
Vol. 37 No. 3 May/June 2015 187

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188 Journal for Healthcare Quality

Authors’ Biographies Chris Bushe, MSHA, MT(ASCP), is the Director of


Jonathan B. Perlin, MD, PhD, MSHA, FACP, Laboratory Services of the Clinical Services Group of
FACMI, is the President of the Clinical & Physician HCA.
Services Group, and Chief Medical Officer of HCA.
The authors declare no conflict of interest.
Laura Mower, MS, is the Vice President of Outpatient
and Ancillary Services of the Clinical Services Group For more information on this article, contact Jonathan
of HCA. B. Perlin at Jonathan.Perlin@HCAHealthcare.com.

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.

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