Framing the Issues

Quality and safety is increasingly ascendant in medicine as systems are focused on delivering better value and outcomes to patients and payers. However, even with the many checks and balances being introduced into clinical workflows, medical systems are still challenged to deliver consistent, evidenced-based best practices at the point of care. In the United States, the Institute of Medicine believes that close to 100,000 deaths/annum are created by medical error and some opinions believe that number to be closer to 400,000 lives. There is no known worldwide statistic but it almost certainly runs into the millions. While radiological procedures may usually seem non-life threatening, there is still considerable risk, real or perceived. Certainly, invasive interventional procedures do carry significant risk, even death (i.e., angiography or percutaneous biopsy). Other procedures have theoretical risk such as the effects of radiation dose exposure (even at lower doses) mainly from Computed Tomography, discussed elsewhere in this book. Furthermore, there is widespread variation in the use of appropriate examinations (imaging tests) for a particular condition, sometimes referred to as appropriateness (see other chapters in this book). In fact, despite much evidence on the use of appropriate best practices for radiological procedures (usually promulgated by national radiological societies), variation in the practice of radiology abounds, usually with no two departments alike delivering similar practices and operating procedures. What might seem appropriate in one department is often not seen in another—for instance, what is viewed as an acceptable radiation dose varies across regions, towns, and sometimes even within the same health organization. Given this widespread variation, legislative, payer, and professional bodies are now finding this scenario unacceptable and are introducing legislation or pay-for-performance measures to drive organizations to deliver more consistent and better care with outcomes that meet certain predetermined standards. Furthermore, patients themselves are now demanding better outcomes and less variation, particularly as it has become more evident from the press that outcomes can significantly vary from one organization to another. This has come at a time when demand for imaging services is busier than ever as referrers continue to see imaging as a key tool to reach a diagnosis earlier, monitor therapy more closely, and/or cure and palliate patients through innovative interventional therapies. This significant increase in radiological volume has sometimes come at the cost of quality (and even safety) as radiologists and departments are busier than ever trying to keep up with demand of simply performing and interpreting the procedures. Often departments are just too inundated with the workload to take a step back to rethink fundamentally how quality and safety initiatives can be reorganized in a meaningful and systematic way to drive the delivery of care towards better practices and outcomes. Quality and safety measures, which are often difficult to measure, let alone deemed as meaningful in the first place, are then sometimes seen as an afterthought. Even experts often struggle to define standards and then agree upon them. Furthermore, measures put in place to monitor quality and safety are frequently imposed from afar, often by payers (i.e., large bureaucracies such as the Center for Medicare and Medicare Service or the National Health Service) and therefore deemed onerous and unnecessarily imposing by front-line providers. This can result in frustration and ambivalence towards the quality and safety agenda. The approach of many radiologists to many of the quality and safety measures is to simply “check the box” so they can either meet their mandatory compliance standards or, in increasing circumstances, actually get paid. There is a common belief that many of the quality and safety standards are either only tangentially relevant or sometimes not meaningful at all. Added to this frustration, the practice of medicine and radiology keeps changing and even experts find it difficult to keep up with new technologies, treatments, and new care pathways such that creating meaningful, up-to-date, and relevant metrics inevitably lags the innovation. Finally, although pay-for-performance measures are now tying part of payments to performance (sometimes quality and safety), much of what can be achieved through quality and safety initiatives is not reimbursed. Considering the numerous other non-remunerated regulatory and compliance measures required from radiologists, quality and safety initiatives are often viewed as overly burdensome and are relegated to the domain of just “doing the right thing” for the patient rather than a compelling reason to do so.