Putting quality first: The value of technology in underpinning quality assurance

In this article, David Howard of McKesson examines some of the common misconceptions around quality assurance within the NHS. He also outlines how NHS organisations can learn from examples internationally where technology has helped to address some of the quality standards that the Royal College of Radiologists has recently published

If the health service really is serious about ensuring quality of service, NHS organisations are going to need to look seriously about strengthening their procedures because current approaches are falling short

The Royal College of Radiologists (RCR) recently published new standards for the communication of radiological reports and fail-safe mechanisms. This follows previously-published data revealing that 12% of UK hospitals don’t have an agreed policy for alerting clinicians when X-rays or scans contain critical or urgent findings. Worse still, only 7% of hospital departments surveyed boast an electronic system that not only alerts doctors, but also escalates activity and assures it’s actioned.

The revelations are an uncomfortable fit with an NHS whose Five-year Forward View places ‘quality improvement’ at the heart of its aspirations.

If the health service really is serious about ensuring quality of service, NHS organisations are going to need to look seriously about strengthening their procedures because current approaches are falling short.

The RCR audit suggests that the vast majority of UK hospitals have inadequate quality systems and processes in place to prevent delayed diagnosis and suboptimal patient management. The implications are significant. The solution, however, is rather pain-free, easy to implement and proven to work across an entire country.

Sweet success

In October 2014 an RCR survey of radiology departments in England revealed that tens of thousands of suspected cancer patients were being made to wait over a month for scan results due to delays in their reporting. The snapshot study of 50 hospitals showed that 81,137 X-rays and 1,697 CT and MRI scans had not been analysed for at least 30 days, raising serious concerns for patient safety.

At the time, the well-documented shortage of NHS radiologists was acknowledged as a contributory factor. 18 months on and, with the UK still having one of the lowest populations of trained radiologists per capita in Europe, the potential for delayed diagnoses remains high.

Clearly, workforce planning is a major challenge in radiology. However, NHS leaders also know they need to reinforce operations with more-robust systems to support quality assurance. Failure to do so places patient care at risk.

Sadly, despite major advances in technology, there are still examples of discrepancy and avoidable delays in reporting where NHS patients have paid the ultimate price.

So, how can NHS organisations mitigate the risk of delayed diagnoses?

One option might be to look at the recent work that’s been carried out in Ireland, where a radiology quality improvement plan orchestrated by the Health Services Executive (HSE) has transformed radiology services.

Sadly, despite major advances in technology, there are still examples of discrepancy and avoidable delays in reporting where NHS patients have paid the ultimate price

The plan – which involved multiple stakeholders including senior radiologists, the cancer control board, RCSI and the HSE – put in place guidelines and mechanisms to address a long-standing, country-wide challenge of delayed diagnoses. It drew inspiration from the quality processes the American College of Radiology had established to support discrepancy management, in particular introducing the element of an automated, fair and objective peer feedback process to help identify discrepancies and escalate review appropriately as well as areas for quality improvement and learning.

The Radiology QI programme in Ireland is enabled by a centralised system that integrates with all imaging systems being used in local hospitals. That system now functions across the entire country and means that, each day, over 300 imaging studies in Ireland are peer-reviewed, escalated and actioned accordingly. The impact on the patient experience and patient outcomes is unquestionable.

UK hospitals can learn much from the Irish experience.

With access to good diagnostics widely heralded as the key to cancer survival, trusts must be pro-active to address the critical issue of discrepancy management. Radiology departments undoubtedly need support. Each year, clinical radiologists issue reports on millions of X-rays and scans – and these reports play a crucial role in the diagnosis and management of UK patients.

Although only a small minority of reports will demonstrate urgent or unexpected findings, it’s vital those that contain these results are escalated expediently and tracked to ensure communication is complete and the loop is closed. As pressure on NHS resources intensifies, the risk of human error will naturally increase. As the prospect of a seven-day NHS services looms large, it's no surprise that the RCR has now published its new guidance on communication standards, effectively requiring trusts, health boards and other providers of imaging services to review their processes and ensure that the systems used to communicate test results are robust and timely. Technology is there to help, but without appropriate alert systems, escalation management tools and wholesale interoperability, hospitals will still be exposed to the risk of failure. Yet it can easily be avoided.

The answer will not be dependent on local RIS, but on the implementation of a centralised system that sits above it and focuses entirely on quality

The NHS’s focus on quality improvement is an essential ongoing requirement. However, in a highly-pressurised environment it can be difficult for NHS staff to support quality initiatives when they typically create additional work that may not be recognised as part of an individual’s day job. Historically, quality assurance has relied on highly-manual processes that have a major impact on workflow and are prone to human fallibility in busy hospital environments. The shift from quality assurance to quality improvement may be a subtle nuance, but it’s one that underlines a collective responsibility among NHS staff and drives the need for collaboration, transparency and visibility across the enterprise. Radiologists and their peers need systems and processes that make quality integral to their day jobs without adding to their burden of work. Despite rhetoric to the contrary, utopia is possible.

Major quality

A common misconception within radiology is that quality assurance is too hard. With a national shortage of radiologists and increased pressure on the system, the profession understandably argues that measuring quality takes a disproportionate amount of time and is unsustainable. Likewise, a concurrent belief that the problem can be solved by the alignment of Radiology Information Systems (RIS) through a uniform set of quality measurement standards is equally misplaced. These myths must be debunked. The answer will not be dependent on local RIS, but on the implementation of a centralised system that sits above it and focuses entirely on quality.

If, therefore, the NHS really is putting quality first, then it’s clear that the 93% of hospitals currently lacking robust and dedicated quality assurance systems need to strengthen their procedures accordingly

Ireland’s Radiology QI programme endorses this approach. The Irish HSE took the strategic decision to keep quality and clinical information entirely separate. Its rationale was to implement a dedicated system for quality assurance rather than force additional functionality onto the back of existing RIS. The centralised quality system would, however, draw information from existing RIS and be accessible across multiple jurisdictions, locations and organisations. As such, radiologists from the whole region can now collaborate around quality issues, reinforcing peer review capabilities and ensuring discrepancies are managed efficiently and effectively. Although public and private healthcare organisations across Ireland – rather like their UK counterparts – use a variety of RIS and PACS, the centralised system joins them together to provide a standardised platform and an optimal mechanism for quality management. The approach keeps quality metrics entirely distinct from clinical information and, crucially, supports radiologists’ workflow rather than adds to it.

Quality street

UK hospitals know they must do more to drive quality improvement and that, with increased pressure on diagnostic services, radiologists need support to ensure they manage their work burden and mitigate the risk of human error. If, therefore, the NHS really is putting quality first, then it’s clear that the 93% of hospitals currently lacking robust and dedicated quality assurance systems need to strengthen their procedures accordingly.