SAFRSM Proactive Quality Program
The "foundation of Foundation" is quality — literally the cornerstone of everything we do. Our clinical quality assurance and issue review goes above and beyond what typical radiology groups perform. In fact, we are the first multi-institutional Joint Commision accredited radiology group. The Strategically Aligned Foundation Radiology Proactive Quality Program, or SAFRSM, is designed to deliver what is needed — not just what is required — for premium service and quality.
SAFRSM Clinical Quality Assurance
Quality Control Panel
Our SAFRSM Quality Control Panel is comprised of our Chief Medical Officer, The SAFRSM Quality Control Manager, The Medical Director of the "Pittsburgh Center for Radiology Excellence," and two at-large radiologists. The SAFRSM Panel meets once/week to review, discuss, collate and categorize quality review data. Specific problems are handled and responsibility is assigned to ensure resolution of specific problems. Feedback to the referring institution about a particular patient's problems is delivered at the discretion of the Chief Medical Officer. For recurring problems, this Panel serves as the venue for radiologists to be counseled and discussions aired. A weekly report of this meeting is also reviewed by the CEO of Foundation Radiology Group. Additionally QA data is collated across the Foundation system and quarterly reports submitted to the hospital's radiology medical director and QA department. Every attempt is made to provide representation to the QA governing board of the hospital.
The Chief Medical Officer
The Chief Medical Officer of Foundation serves as the primary administrative liaison to the hospital's QA governing board and provides ongoing support to the hospital's QA initiative along with support from the Quality Control Panel. This includes ensuring that each hospital is aware of the dedication that Foundation devotes to providing the highest level of radiology care and expertise.
The SAFRSM Clinical Quality Assurance program undergoes comprehensive initial review by a dedicated health care attorney. Additionally, yearly reviews by appropriate legal counsel are undertaken to ensure that all safeguards are in place to protect the radiologists and the company from any unforeseen legal issues with respect to the inappropriate discovery of QA data.
Rapid Response Team Approach
SAFRSM employs a Rapid Response Team approach when appropriate. The SAFRSM rapid response team approach allows critical quality issues to be dealt with on a real time basis within 12-24 hours. We strive to provide fast and appropriate communication as needed to the referring clinicians from the SAFRSM Rapid Response Team. Additionally, we facilitate formal and prompt feedback to the hospital/clinic administrative and QA infrastructure.
Reviews & Issues
Proactive Non-Random Reviews
SAFRSM promotes proactive continuous improvement ideals with the program. Radiologists are encouraged to initiate proactive, non-random reviews when they come across a quality issue while performing daily reading duties. When a quality issue observation occurs, radiologists document variances by completing our "SAFRSM Proactive, Non-Random Review Sheet." Packets of these SAFRSM sheets are provided to each radiologist by our QA department as well as made available within our SAFRSM Quality Program intranet. The process works hand-in-hand with our PACS and related systems. Automated workflows provide SAFRSM Proactive, Non-random Review sheets on a particular study with demographic data to be auto-populated.
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 "SAFRSM Care Quality Concern Form." These are 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. SAFRSM mandates that all department administrators and department medical directors serve locally as the first line of feedback for quality concerns at their respective medical center. The clinicians we serve are taught to direct all quality concerns to the radiology administrator and radiology medical director for the appropriate feedback to our SAFRSM Quality Control Panel.
The SAFRSM Clinical Quality Control Panel mandates Random Reviews for each radiologist (typically at a higher rate than usually seen in the industry). Every radiologist has a dedicated SAFRSM Quality Folder within the PACS. Radiologists must empty this folder weekly and submit Random Review forms to Foundation for each of these reviewed cases. The SAFRSM Quality Control Manager and his/her staff ensure that each radiologist has the appropriate cases in the SAFRSM Quality Folder. They also provide the appropriate forms with populated demographic data to ensure that the radiologist's time is maximized. This process promotes prompt flow of quality data back to the Foundation office. The SAFRSM Quality Control Manager, under the direction of the SAFRSM Quality Control Panel, assigns random cases to each radiologist on a weekly basis. This averages approximately 10-15 cases/week for each radiologist and allows the SAFRSM Quality Control Panel to ensure that all radiologists are participating in the SAFRSM Clinical Quality Assurance Process. When possible, we will conduct random reviews through our PACS utilizing an automated system to facilitate random reviews.
Currently, we have an automated method within our PACS 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 is provided directly to the SAFRSM Quality Control panel on a real-time basis and will be addressed daily by an appropriate individual assigned to the SAFRSM Quality Control Panel. This information is discussed with the appropriate radiology department administrator to ensure timely resolution. The data is collated and is part of the quarterly report to the hospital. As a back-up – and for those hospitals who do not use a PACS with automated capability – we 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 proactive, non-random review.