Professional Documents
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174 Journal for Healthcare Quality
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Vol. 37 No. 3 May/June 2015 175
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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)
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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
177
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178 Journal for Healthcare Quality
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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.
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Vol. 37 No. 3 May/June 2015 181
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
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
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184 Journal for Healthcare Quality
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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
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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.
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Vol. 37 No. 3 May/June 2015 187
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188 Journal for Healthcare Quality
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