Progress through accreditation, still room for quality improvement
Accreditation has become a key measure of healthcare quality and is sought for a variety of activities within medicine, including specific medical tasks (nuclear cardiology procedures, echocardiography), clinical service lines (stroke care, myocardial infarction), healthcare facilities (chest pain centers, trauma centers), and for medical education (undergraduate, graduate, and continuing medical education). The goal of most accreditation processes is to provide mechanisms for improving the quality of services provided through the adoption of standards, with subsequent verification through an independent review process.
Institute of Medicine Six Domains of Clinical Quality
In order to aid the individual clinician, multiple organizations have developed practical solutions to support and maintain high-quality nuclear cardiology, including practice guidelines, written by trusted members of our professional societies,2,3 and Appropriate Use Criteria (AUC), which serve to fill the gaps in guidelines and offer guidance about which patients may benefit from MPI.4 Data collected through registries, such as ImageGuide, allow us to investigate real-world patterns of care for MPI.5 Finally, several pathways are available for accreditation in nuclear cardiology, which allow for an objective assessment of quality: the Joint Commission, the American College of Radiology, and the Intersocietal Accreditation Commission (IAC).
The process of accreditation likely contributes to higher quality of care in a different manner than guidelines, AUC, and anonymized data reporting. Simply by committing to become accredited, a facility or practice undertakes a process of self-reflection and goal setting. This may include critical review of MPI reports, evaluating imaging protocols, assessing workflows to optimize timeliness, and reaching out to referring providers for feedback.
In the current issue of the Journal, Maddux et al. present data on MPI reporting standards from facilities seeking three sequential cycles of nuclear laboratory accreditation from the IAC. A number of important messages emerge from the data. On the positive side, many of the quality metrics improved following the initial accreditation cycle. Comparing the first and second cycles for these facilities, dose information, report dates, test indications, typographical errors, and report signatures, revealed substantial improvement. The number of deficiencies per facility was also decreased. Some metrics did not improve or even worsened, including defect quantification and report timeliness, the latter of which has been an expectation for over a decade.6
The authors note that during the period under study, accreditation standards became more rigorous. This would potentially help explain some of the unfavorable findings; however, 20.8% of facilities in the third cycle did not report defect quantification and 11.9% did not issue timely reports. Maddux et al. were not able to identify individual facility factors responsible and therefore not able to explain why these problems would arise. It seems unlikely, however, that failure to adequately document the size, severity, type, and location of defects is a result of lack of understanding as to the importance of perfusion defect characterization. Irrespective of the reason behind this deficiency, it is incumbent on interpreting physicians to include these descriptive elements as part of generating a high-quality report.
A MPI report that includes incomplete characterization of perfusion defects could lead to adverse outcomes from both overuse and underuse. A report that describes a perfusion defect but fails to note that the defect likely represents scar could generate an unnecessary coronary angiogram, exposing patients to bleeding, stroke, and kidney injury with minimal likelihood of benefit. A report that describes ischemia but not the precise location could lead to a procedure that revascularizes the wrong myocardial territory. A report describing ischemia that fails to note the defect is large and severe could result in a referring provider thinking that angiography is not warranted, possibly putting the patient at elevated risk of cardiovascular events.
Maddux et al. also noted other reporting deficiencies, including the date of report approval, signature, and radiopharmaceutical dose in 8%–10% of facilities. Of note, these data only reflect the performance of facilities choosing to be IAC accredited; non-accredited facilities may fare even worse on these metrics. Of note, these issues are considered mandatory for accreditation and should be easily corrected.
Accreditation may be a motivating force in establishing a culture of quality or it may be a capstone achievement for a practice with a commitment to quality. In either case, accreditation is a process that does not end when a final endorsement is issued. Individual physicians and the laboratory must still fulfill their professional duty to provide high-quality care that includes generating MPI reports which do not omit the necessary data for making accurate patient-centered decisions.7 This presents a serious challenge for the healthcare system, because system-based thinking and quality improvement have only recently become standards for medical training. Some facilities have addressed this by involving graduate trainees in QI projects.8 While this type of activity is part of training the curriculum for a growing number of housestaff, QI projects can be undertaken by physicians without formal training.
Another important challenge is that many physicians in practice are already overworked and do not wish to become involved in learning new skills or working on QI or accreditation. External demands for quality care, however, continue to grow and accreditation provides an objective measure of dedication to this goal. Furthermore, federal legislation mandates clinicians’ and healthcare systems’ involvement in a variety of quality activities. The Protecting Access to Medicare Act mandates the use of AUC at the point of care when an advanced imaging test is ordered. The Medicare Access and CHIP Reauthorization Act (MACRA) is a substantial redesign of Medicare reimbursement which will reward providers of high-quality care and cut reimbursement for those who fail to improve. Finally, the Centers for Medicare Services mandates that diagnostic imaging facilities be accredited by one of the three aforementioned bodies. Most physicians are aware of public reporting of clinical outcomes, now accreditation processes may be subjected to similar scrutiny. A recently proposed Medicare rule states that accreditation providers must publish accreditation survey reports and corrective action plans publicly on their websites.9 Medicare already makes available reports from regional and state agencies; this rule change is being sought to “enable health care consumers…to make a more informed decision regarding where to receive health care thus encouraging health care providers to improve the quality of care and services they provide”.9 With this public reporting, both facilities and reporting agencies will be under additional scrutiny. While it may be debated whether such regulation is necessary and if the quality mission is accomplished with this approach, there is little doubt that quality in all aspects of cardiac imaging remains a critical journey, one which has yet to be completed.
Dr. Winchester is a member of the American College of Cardiology Accreditation Management Board. Dr. Hendel is a member of the American College of Cardiology Board of Trustees. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government. This material is the result of work supported with the resources and the use of facilities at the Malcom Randall VA Medical Center.
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- 9.Fiscal Year (FY) 2018 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule, and Request for Information CMS-1677-P. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-04-14.html. Accessed June 6, 2017.