Understanding the requirements of a Quality Improvement (QI) program

Maintaining a successful and accredited nuclear lab requires a consistent Quality Improvement program. However, many practices may be intimidated by what they believe to be a highly detailed and complicated process. The truth is, maintaining a successful QI program is easier and more straightforward than you think.

The accreditation process is intended to be adaptable in order to continuously accommodate medical advancement. As such, there is a lot of flexibility to enable your program to work within the parameters of your own lab, no matter what the size.

Six components of a successful Quality Improvement program

There are six components of a successful quality improvement program. Let’s look at each one and discuss them in a little more detail:

1. Test appropriateness

While there is not a specific process required to assess test appropriateness, it is important that you have a process in place that confirms the appropriateness of tests in a way that works for your particular lab. For example, a smaller lab might review all studies at the end of a week to determine whether or not the tests fit the diagnoses; a larger lab might sample a specific number or a percentage of studies each month and document as appropriate, not appropriate, or questionable. If you need more information or assistance with test appropriateness, there are tools available via the IAC website. You can also use the guidance given in the Appropriate Use Criteria guidelines.

2. Technical quality and safety of images

This component requires you to define the protocol for the use of your imaging equipment and document it daily. This could be as simple as a checklist on your daily log sheet that confirms proper camera operation prior to seeing patients each day.

3. Interpretive quality review

This checks-and-balance system continuously audits the procedures performed in your lab. It ensures that there is consistency in the data and adherence to the protocol for each study performed by each technologist. The review can be done via committee, or perhaps a process whereby doctors review a sample of each other’s reports.

4. Report timeliness and completeness

Keep accurate and complete records. The IAC offers guidelines for information that should be included in reports. At a minimum, all reports should have a final signature within 48 hours of the test completion. They should also be reviewed regularly to determine that all personnel are maintaining consistent data.

5. Correlation between tests/studies

This step can be the most problematic as it requires comparison of studies that might have been completed outside of your lab, in a hospital or another lab, for example. Establish a protocol to review and compare the correlation between the results of the various tests.

6. Semi-annual review of this data

A semi-annual review of the data is required and should include all appropriate members of your staff: physicians, technologists, and other staff, and include a detailed discussion of shortcomings and areas in which to improve. Meeting minutes are required from these reviews, and the results are required to be distributed to all team members to be used as an ongoing learning opportunity.

Documentation, maintenance, and support

One of the most important components of accreditation maintenance is consistent documentation. But it’s also critical to understand that the IAC, the ACR, and the other accreditation bureaus are there to help you maintain your accreditation. Use them as a resource, to field questions, to offer guidance, to tell you what the next steps are.

Don’t allow the fear of disclosing something you’re doing incorrectly be a what keeps you from finding out how it should be done or how it could be done more quickly or more efficiently. Yes, these governing organizations are the authorities, but they are in the business of supporting those that are already accredited and helping them meet and exceed the standards.


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