Non-Random Reviews
These will be initiated by radiologists who come across a quality issue while pursuing their daily reading duties. All radiologists will be instructed to fill out a “Non-random Review Sheet.” A packet of these will be provided to each radiologist by our QA department. We are working on making this process automated on our PACS. When this is accomplished, a button push will provide the Non-random Review sheet on a particular study with demographic data already populated—this is a work-in-progress.
Quality Issues
If a quality issue is discovered outside of the reading radiologist’s domain—— radiology administrators at the various hospitals and clinics will be instructed to fill out a “Radiology Care Quality Concern Form.” This will be submitted to our QA department directly from the hospital administrator or the Radiology Medical Director. These quality concerns may come directly from the administrator of the department or from one of the referring clinicians, emergency rooms or clinics. We expect to be informed about standard missed cases by this method but this form also provides a vehicle to communicate feedback concerning availability of care, delay of care and allows for feedback concerning difficulties interfacing with the Foundation System of Care. Utilizing this model mandates that every Department administrator/Department Medical director locally serve as the first line of feedback for quality concerns at their respective medical center. The clinicians we serve will be instructed to direct all quality concerns to the Radiology Administrator/Radiology Medical Director for the appropriate feedback to our Quality Control Panel.
Random Reviews
Random Reviews will be mandated by our Quality Control Panel. Every radiologist will have a dedicated Quality Folder within the Emageon PACS. It will be their responsibility to empty this folder weekly and submit Random Review forms to Foundation for each of these reviewed cases. The Quality Control Manager and his staff will ensure that each radiologist has the appropriate cases in the Quality Folder and will provide the appropriate forms with demographic data populated to ensure that the radiologist’s time is maximized. This process will promote prompt flow of quality data back to the Foundation office. Random Cases will be assigned to each radiologist on a Weekly basis by the Quality Control manager under the direction of the Quality Control Panel. This will average out to approximately 10 cases-15 cases / week for each radiologist. This will allow the Quality Control Panel to ensure that all radiologists are participating in the Quality Assurance Process. When we establish a PACS system that is universal and utilized at all institutions we will conduct random reviews utilizing an automated system such as Rad Peers or Commissure to facilitate random reviews.
QC Reviews
Currently we have a button on the Emageon PACS system that allows radiologists to comment on Quality Issues that center around the production of a particular radiology study. These Quality Control issues may be related to improper functioning of a particular machine, poor technologist quality control, or artifacts from a variety of sources. This information will be provided directly to the Quality Control panel on a real time basis and will be addressed daily by someone assigned to the Quality Control Panel. This information will then be discussed with the appropriate Radiology Department Administrator to ensure timely resolution. The data will be collated and be part of the quarterly report to the hospital. As a back-up and for those hospital who do not use Emageon PACS we do have QC forms that can also serve as a vehicle to communicate Quality Control Issues.
All addendums are monitored
All addendums are monitored and evaluated for possible significant patient care issues. If significant concerns are found, the addendum is converted to a non-random review.