Quality Management (Revised 12-12-19)

QM 1.0 - Quality Management System

Standard: The entity has a quality management system that is a framework for continuous quality improvement.

Elements of Compliance:

• QM 1.1 The entity has implemented and maintains an effective Quality Management system.

• QM 1.2 The QM system ensures corrective and preventive actions are implemented, measured, monitored and documented.

  • 1.2.1 The QM system has a methodology for how quality and performance are measured, monitored, analyzed and improved.

QM 2.0 - Quality Outline

Standard: The entity clearly outlines its methodology, practices and policies for addressing how quality management is conducted.

Elements of Compliance:

• QM 2.1 The entity maintains a Quality Manual that should include:

  • 2.1.1 Statement of Quality Policy

  • 2.1.2 Measurable Quality Objectives

  • 2.1.3 Goal Measurement/Prioritization of activities

• QM 2.2 The entity reviews the Quality Manual at least once annually.

QM 3.0 - Quality Manager

Standard: The entity has a designated Quality Manager

Elements of Compliance:

• QM 3.1 The entity has designated a quality manager with the responsibility and authority to accomplish the requirements of the QM system.

QM 4.0 - Measurement, Evaluation and Analysis

Standard: As part of the Quality Management System, the entity should evaluate all services and processes. Evaluation should include monitoring through internal audits or reviews at scheduled intervals. Measuring requires use of established measures that can detect variation, identify problem processes, and identify outcomes and effectiveness of actions. Frequency and detail of measurement must be established.

Elements of Compliance:

• QM 4.1 The entity conducts performance improvement projects annually in proportion to scope/complexity of operations/services.

  • 4.1.1 Projects are documented and include rationale for selection and progress achieved.

  • 4.1.2 Facility or department based projects must be conducted as well as individual projects specific to radiologists, technologists and nurses.

    • 4.1.2.1 Practice Quality Improvement (PQI) projects for Maintenance of Certification (MOC), RADPEER or equivalent, participation in Physician Quality Reporting Initiative (PQRI) as applicable.

    • 4.1.2.2 Technologists must participate in performance improvement projects relevant to their roles.

• QM 4.2 The entity participates in Image Gently and Image Wisely as appropriate to modalities available (CT, fluoroscopy and interventional procedures).

• QM 4.3 The entity uses GRID and DIR reports/benchmarks for performance improvement projects

• QM 4.4 The entity must define the frequency and detail of measurement but at minimum the following functions should be measured:

  • 4.4.1 Threats to patient safety

  • 4.4.2 Medication use

  • 4.4.3 Procedures- wrong site, wrong patient, wrong procedure

  • 4.4.4 Sedation

  • 4.4.5 Effectiveness of pain management system for interventional procedures including all biopsies.

  • 4.4.6 Infection control system

  • 4.4.7 Patient flow issues, excess wait time

  • 4.4.8 Customer satisfaction (clinical and administrative areas). Satisfaction surveys should be developed both for patients and referring providers.

  • 4.4.9 Discrepant radiology reports: The ACR Practice Guideline for Communication of Diagnostic Imaging Findings recommends expedited reporting of non-routine communications such as discrepant preliminary and final interpretations.

  • 4.4.10 Deaths, non-sentinel event, sentinel event, near-miss

  • 4.4.11 Other adverse events

  • 4.4.12 Medical record delinquency

QM 5.0 - Patient Safety System

Standard: The entity has a means for establishing clear expectations for patient safety.

Elements of Compliance:

• QM 5.1 The entity must clearly identify methods for detecting prevalence and severity of incidents impacting patient safety, including medical errors and adverse patient events. This patient safety system should address:

  • 5.1.1 Preventive/corrective action

  • 5.1.2 Defined processes to reduce risk

  • 5.1.3 Implemented action plans

  • 5.1.4 Ongoing measurement

  • 5.1.5 Management review of response and resource allocation to results of adverse event analysis

  • 5.1.6 Policy/practice for informing patients and families about adverse events

• QM 5.2 If interventional procedures are performed; the facility should have a tracking system for complication rates and outcome monitoring.

Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes