Quality and Risk Management
The Department of Diagnostic Imaging (DI) relentlessly pursues innovative solutions to meet the needs of each and every patient and achieve the highest quality of patient care. We are committed to the provision of exceptional services while recognizing and respecting the diversity of the patients and other customers we serve. We take a systematic approach to visualize the future in the context of internal and external business environment, build organizational capacity for innovation and formulate strategies to overcome challenges and maximize future opportunities. Comprehensive strategies are developed to continually improve quality of care, enable equitable and timely access to services, further enhance patient safety, introduce advanced technology and equipment, create value for patients and their families, and promote clinical, academic and research excellence.
The key drivers of the DI Quality and Risk Management program include the Quality Assessment and Improvement Committee, DI and Image Guided Therapy (IGT) Morbidity and Mortality Review Rounds, MR Safety Committee, Equipment Quality Control Committee, Radiation Safety Committee, dedicated Quality Management Leader, and various project teams and work groups. Peer review process is integrated seamlessly into the daily workflow to ensure high level of competence amongst our radiologists, safeguard patient safety and improve overall standards by identifying unperceived discrepancies and educational needs. The peer review process allows for the random selection of studies to be reviewed on a regularly scheduled basis, supports rapid identification of trends and reveals opportunities for quality improvements. Effective application of quality concepts, principles, and methods requires an inclusive, engaging, and empowering team environment, systems thinking, information sharing, interdepartmental collaboration, and decisive action based on systematically obtained evidence. Continually refined quality indicators used to measure, evaluate, and improve effectiveness of our processes are at the core of the DI Quality and Risk Management Program. Every effort is made to enable sound decision making and promote evidence-based solutions by creating selective, reliable, responsive, valid, and cost-effective measures of performance.
In order to adapt to a rapidly changing operating environment, align resources with key priorities, support hospital strategic directions, and ensure a coordinated approach to continual quality improvement, we have developed and implemented a customized, dynamic and integrated Quality Management System (QMS). The QMS provides a framework for seamless integration of quality planning, quality assurance (QA), quality control (QC), process improvement, risk management, innovation, and a number of other structured, systemic and planned activities designed to improve quality and patient safety. The QMS operates in conjunction with other organizational systems, enables efficient planning, allocation and utilization of resources, provides robust structure to facilitate generation of new ideas, and creates a harmonized network of interdependent processes, procedures and elements required to drive organizational performance improvement.
Success in achieving the highest quality of patient care and providing timely access to services at lower cost depends significantly on effective management and continuous improvement of complex, interconnected and cross-functional processes. Therefore, we have developed a robust, data-driven and patient-focused process improvement framework to engage employees in a meaningful way, reduce process variation, improve flow, solve recurring problems, minimize wasteful activities, and create value from the viewpoint of patients and other stakeholders. We strive to adapt, integrate and appropriately contextualize Lean, Six Sigma, Human Factors, Project Management, Plan-Do-Study-Act (PDSA) Cycle, and other complementary methodologies, disciplines, and best practices while taking into account specific goals, organizational culture and overall capabilities. The various process improvement methodologies are not mutually exclusive and they bring unique perspectives, approaches, tools, and techniques that can be effectively combined to achieve and sustain operational excellence. Rapid changes in imaging and information technology, increasing complexity of patient care, high cognitive demands, and large volume of information arising from research present unique challenges to radiologists, technologists, nurses, and administrative staff. In response to these challenges, the discipline of Human Factors Engineering is applied to optimize system performance, reduce opportunities for errors, and design systems, processes, tasks, jobs, and work environment that take into consideration the needs and abilities of people.
Diagnostic Imaging has adapted and introduced the Quality and Safety Leadership Walkarounds across all modalities. This tool was originally developed by the Institute for Healthcare Improvement (IHI) and Dr. Allan Frankel. The DI Quality and Safety Leadership Walkarounds are designed to foster an environment of trust by engaging leaders and front-line staff in an open dialogue concerning quality and patient safety, directly inform the leaders about existing organizational barriers, and demonstrate commitment to building a culture of safety, service excellence, innovation, and continuous quality improvement. Results of this process are communicated to all relevant stakeholders and corrective or preventive actions are initiated as required.
Quality Manager: Zoran Bojic