IMPROVING COMPLIANCE AND DOCUMENTATION...
Transcript of IMPROVING COMPLIANCE AND DOCUMENTATION...
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IMPROVINGCOMPLIANCEANDDOCUMENTATIONOFCTQUALITYCONTROLUSINGANELECTRONICQUALITYASSURANCE
PRACTICEMANAGEMENTTOOL
Phuong-Anh Duong MDRebecca Neill MS, Matthew E. Zygmont MD,
Pratik Rachh MD, MBA
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BACKGROUND
• Periodicqualitycontrol(QC)testsarerequiredforcomputedtomography(CT)andothermodalities
• Trackingcomplianceacrosslargerhealthcaresystemscanbechallenging– Time-constrainedtechnologistsmayforgettoperformQCtests
– Resultshistoricallywererecordedonpaper– Oversightandmonitoringofresultsinfrequent– Correctiveactionsareoftendelayed
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CURRENT (BASELINE) CONDITIONS
• DailyQCmaintainedonpaperrecordfrom3/2015to3/2016• PaperlogsauditedbyCTphysicistquarterly• ActualQCperformancewastrackedusingsoftware
(Radimetrics,Bayer)todetectthepresenceofadailyphantomscan
• CTphysicistforwardedactualperformancedataonamonthlybasistositeQCleadtoencouragedailycompliance
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Duringthebaselineperiod(3/2015to3/2016)themedianactualcompliancewithdailyQCwas89%,asmeasuredbythedailyphantomscan.Thisdatachallengedthenearly100%reportedcompliancedocumentedonpaper.
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GOAL: AIM STATEMENT
• ImplementaQCmanagementsystemthatallowsonlinedocumentation,remindersforlateresults,andnotificationofaberrantresults
• ImprovecomplianceanddocumentationofdailyCTQCteststo100%by4/2017usinganonlinemanagementsystem
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ONLINE QA PLATFORM
Acommerciallyavailablequalityassurancemanagementsoftware(ZapIT!Medical)wasimplementedtotrackdaily,monthly,andannualQCfor25CTscanners.
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DOCUMENTATION
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DATA ENTRYStarting3/2016,technologistsweretrainedtoperformdailyandmonthlyQCperACRrecommendationsandrequiredtologresultsinthesystem.
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QA HISTORY & APPROVAL
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GRAPHICAL VIEWS
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NOTIFICATIONS
• Notificationsareconfiguredperindividualpreference• Emailortextremindersareavailable• AlertsremindtechnologistsifQCwasnotperformedby
aspecifiedtime• MedicalphysicistalertedoftestfailuresandmissingQC
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QC NOTIFICATIONS IN-PATIENT SETTING
Ifby7AM,QCnotperformedanddocumented,responsibleShift1TechnologistemailedQCreminder.
Ifby8AM,QCnotperformedinShift1,Shift2supervisorreceives
reminder.AssignsQCtoShift2Technologist.
Ifby11AM,QCnotperformed,MedicalPhysicistreceives
notification.MedicalPhysicistescalatestosupervisorandmanager.
SupervisorormanagerassignsQCtoShift2Technologist.
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METRICS/RESULTS
• After8/2016,therunchartshowedashift inthemediancomplianceratefrom89%pre-implementationto97.5%postimplementation.
• 24abnormalresultswererecordedandcorrectiveactionsweredocumentedintheonlinetool
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24 ABERRANT RESULTS ADDRESSED
ResultNo.ofOccurrences Action
QC ValueIncorrectlyRecorded 8 • Retraining• Exclude resultandrepeatQC
measurement
RingArtifactIdentified 4 • AirCalibrationperformedand/orservicecontacted
QCValueoutoftolerance 4 • RepeatTest• ContactService
QCProtocol requiresadjustment– baselinenoiselevellowerthanselectedrange
6 • Physicist correctedQCprotocol
BrokenPhantom 2 • Siteordered newphantom
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CONCLUSIONS
• TheonlineQCmanagementtoolimprovedcompliancewithdailyQCfrom89%to97.5%.
• Abnormalresultsandremediationstepsareeasilydocumentedforauditorreview.
• ThesoftwaretoolenabledasinglephysicisttoeffectivelytrackQCfrom25CTscannersacrossmultiplesites.