Taking Charge of Change to Standardize Care Across Many Sites

2019 Imaging Innovation Award Winner: Standardization of Clinical Imaging Through Novel Multi-Council Development Within a Large Integrated Healthcare System

By Integrated Imaging Consultants

The concept of standardization in medicine, both in terms of cost and quality, has risen to the forefront in the constant pursuit of optimized patient care. Multiple journal articles have advocated for a more standardized approach in the delivery of imaging in the pursuit of improved outcomes. To this end, Advocate Health Care (AHC), the largest integrated delivery network (IDN) in Illinois, developed a stated goal to standardize systemwide medical care across its 12 hospitals and multiple clinics. Given the wide variability of practice settings within the enterprise, including level 1 trauma centers, safety net and community hospitals, as well as outpatient imaging centers, standardizing imaging practices presented unique challenges that were not addressed in previous studies. Integrated Imaging Consultants (IIC) was formed in January 2016 to create a single independent corporate entity bringing together 140 radiologists practicing at various sites throughout the enterprise. In order to meet the system’s stated goals, IIC sought to innovate internally, with central buy-in from AHC, to improve the quality of care delivered primarily through standardization.

Aims and objectives. The project’s main aim, shared by Integrated Imaging Consultants and Advocate Health Care, was to optimize and standardize imaging policies and protocols throughout the system. A focus on standardization strongly helps reduce human error and therefore safety events, refine imaging professionals’ skills, improve quality and add value. A consistent approach to patient care promotes more reliability and therefore less ambiguity in serving patients, thus enhancing the patient experience. Our efforts are aligned with the core values of Advocate Health Care and the principles of a high-reliability organization. Secondary goals included disseminating our success story and collaborating with other hospitals and/or imaging facilities to improve population health. Another important secondary aim was to promote consistency in performance behavior by hardwiring the attitudes, skills and behaviors required in a robust safety culture.

Leadership and project management. This project was a joint effort co-led by IIC radiologist physician leaders and their AHC dyad administrative partners. We brought together content experts to form subspecialty/modality councils in CT, MRI, ultrasound, nuclear medicine, breast imaging and interventional radiology, including a dedicated council for imaging safety. The project included recruitment of existing and newly created site-specific physician leaders and lead administrative directors to create these councils. Site-specific participation by these established dyad partnerships was mandated per council, assuring individual site buy-in, communication and implementation. We also established a feedback mechanism to report back to system-level leadership.

Key steps. After identifying physician and administrative leaders from each site to serve as dyad partner council leaders with expertise per modality/subspecialty, we established individual council charters with formal statement of goals, objectives and rules of engagement. We recruited radiologists, administrators and technologists at each site to participate as site-specific representatives on the councils, then standardized council workflows including, but not limited to: prioritization of policy/protocol standardization; identification of evidence-based best practices; review of existing practices per individual site; formulation of new policies/protocols; creation of a robust, reproducible and transparent communication platform on policy/procedure/protocol modifications and implementation throughout the system; and formalization of consistent monitoring and reporting of site implementation based on metrics established by the councils.

Leveraging the talent, skills, funds of knowledge and experience provided by the dyad partnerships to engage in numerous collaborative grant-funded IRB-approved research projects, we presented our research and outcomes nationally and internationally at seven or so conferences and meetings. We published our results in scientific and business journals and presented them via webinars and videos. We provided/maintained a comprehensive educational platform for technologists mandating completion of didactic courses to maintain performance proficiency. Finally, we monitored outcomes to assess post-implementation changes.

Positive outcomes. Our efforts yielded standardization of multiple imaging workflows, which helped us achieve many good outcomes. These included: dose reduction strategies/protocols for pregnant/pediatric patients; using estimated glomerular filtration rate in determining renal function before administration of IV contrast for CT/MRI; electronic interference policy for implantable devices in CT; algorithmic weight-based delivery for administering CT contrast, resulting in decreased contrast volume administered; potential decreased contrast-induced nephropathy; decreasing the number of delayed-sequence abdomen/pelvis acquisitions, reducing up to 50% of administered dose in some facilities, with average delivered dose by as much as 40% less than the ACR’s recommended diagnostic reference levels for select studies; reducing repeat examinations on a single patient within a pre-determined time period, decreasing imaging utilization up to 80% at some facilities; CT contrast extravasation/pre-medication policies for at-risk patients; ultrasound study acquisition techniques system-wide, including renal, right upper quadrant and vascular studies, allowing error reduction, improved acquisition efficiency and optimized comparison studies between sites; CT protocols for imaging/reporting of specialized pancreatic and hepatobiliary studies and low-dose CT lung cancer screening; dictation templates; utilizing 3D breast tomosynthesis at every site; dense breast caveat for additional screening with ultrasound/MRI; pre- and post-patient education/instructions in therapeutic nuclear medicine studies system-wide; MRI screening sheets/gadolinium safety screening; and establishing radiation dose committees at each site.

These efforts culminated in our obtaining ACR Imaging 3.0 site distinction, ACR Diagnostic Imaging Center of Excellence distinction twice and ACR CT Lung Cancer Screening Designation.

Innovative elements. IIC chose to be proactive to improve and maintain the quality of our imaging studies and improve patient safety. In order to isolate the best proposals, we brought together established administrative and modality/subspecialty experts from each site within a large independent delivery care network, with historically disparate practice patterns, to achieve greater standardization. Leaders formed system-wide clinical councils with broad site representation to replace site-specific clinical teams in establishing a consistent and standardized imaging practice. By creating a diverse team of engaged leaders identified by colleagues from across the enterprise, participant trust and buy-in was established, easing the inherent difficulties of changing long-standing practices. In order to disseminate council decisions, a centralized SharePoint site was developed, which served to enhance communication, monitoring and reporting of newly established standardized policies/protocols.

We also realized that we needed a robust training system to help staff remain abreast of system-wide changes. To meet this need, we established an online educational platform to maintain technical proficiency and safety standards. In order to monitor the success of our project and guarantee its sustainability, we established a rigorous accountability system utilizing feedback mechanisms to monitor and ensure our progress. AHC compares our outcomes with national and international benchmarks to ensure quality and safety performance outcomes. Although previous groups have evaluated standardization in medical imaging, the principles, methodology, implementation model and accountability feedback mechanism developed by IIC for use in a large hospital system composed of multiple practice setting allows for generalized applicability, regardless of patient population or system size.

Submitted by Abraham Bogachkov, MD, a radiology resident with Advocate Health Care in Chicago.