Biomed Imaging Interv J 2007; 3(3):e21
© 2007 Biomedical Imaging and
Leadership and management in quality radiology
LS Lau, FRANZCR, FRCR, FAMS
International Radiology Quality Network, Canterbury, Victoria,
The practice of medical imaging and interventional radiology
are undergoing rapid change in recent years due to technological advances,
workload escalation, workforce shortage, globalisation, corporatisation,
commercialisation and commoditisation of healthcare. These professional and
economical changes are challenging the established norm but may bring new
opportunities. There is an increasing awareness of and interest in the quality
of care and patient safety in medical imaging and interventional radiology.
Among the professional organisations, a range of quality systems are available
to address individual, facility and system needs. To manage the limited
resources successfully, radiologists and professional organisations must be
leaders and champion for the cause of quality care and patient safety. Close
collaboration with other stakeholders towards the development and management of
proactive, long-term, system-based strategies and infrastructures will underpin
a sustainable future in quality radiology. The International Radiology Quality
Network can play a useful facilitating role in this worthwhile but challenging
endeavour. � 2007 Biomedical Imaging and Intervention Journal. All rights
Keywords: Quality and safety; quality systems; accreditation; medical imaging; interventional radiology
A changing environment
Medical imaging and interventional radiology have been
undergoing rapid advances in recent years. Patients now enjoy the benefits of
earlier diagnosis and less invasive treatment alternatives with lower morbidity
and mortality. The volume and complexity of work are steadily increasing but
the supply of the professional workforce is not growing sufficiently to meet
this increasing demand. From this perspective, modern radiologists are the
victims of their success. This workload/workforce imbalance is one of the
factors, which could potentially threaten the quality of care and patient
The workplace environment and arrangements are changing.
There are technological advances in diagnostic and interventional techniques.
Picture Archive and Communication Systems (PACS) are becoming more available.
These changes in infrastructure together with faster internet communication and
more secure Virtual Private Networks are driving new service delivery models by
applying clinical teleradiology.
Globalisation of healthcare, progressive corporatisation of
radiology providers and threatening commoditisation of radiology services are
emerging [1, 2]. International clinical teleradiology is at the leading edge of
this global healthcare model. Policy regulators and other healthcare providers
are monitoring this evolving model with keen interest. Commercialisation and
corporate ownership of radiology practices by large listed companies are taking
place in some communities. To meet budget expectations from the shareholders
, pressure is mounting on radiologists to do more for less. Skyrocketing
healthcare costs lead to outsourcing of services , which is not limited to
medical imaging and interventional radiology. Some observers comment on the
maturing commoditisation of international clinical teleradiology, treating the
profession like commodities such as cotton or sugar, which could be traded with
futures contracts .
In some countries, there is an increasing number of
radiologists placing greater emphasis on lifestyle, electing to balance work
with family commitments and opting out of after hours call duties if possible,
despite the increasing demand in 24-hour services.
Further convergence of clinical radiology and medicine has
created battlefields of new turf. For example, cardiac imaging joins vascular intervention and ultrasound as another front where clinicians and radiologists jostle for control.
Workforce shortages that
are not meeting the increase in service demands is a major dilemma confronting
radiologists when considering turf debates.
These changes are evolving and will, no doubt in some way,
impact on the quality of service delivery. Radiologists and professional
organisations must provide leadership, manage these challenging conditions effectively
and ensure that the quality of care and patient safety are not compromised as a
result of these major changes.
Quality medical imaging and interventional radiology
Quality in medical imaging and interventional radiology may
be defined in many ways and from different angles. One of these is: �A timely
access to and delivery of integrated and appropriate radiological studies and
interventions in a safe and responsive facility and prompt delivery of
accurately interpreted reports by capable personnel in an efficient, effective
and sustainable manner.�
The above statement captures the desirable performance
parameters of the National Health Performance Framework , i.e.:
Access: the ability of a patient to obtain medical imaging and interventional
radiology at the right place and right time irrespective of income, physical
location and cultural background;
Integrated: the ability to provide uninterrupted and coordinated care
across facilities and practitioners. In medical imaging and interventional
radiology, the availability of and access to relevant clinical history,
indications and findings of previous radiological studies or interventions, and
the opportunity to discuss with the referring physician or patient are
essential components, which can significantly influence the diagnostic study,
intervention selection, interpretation and follow-up management options;
Appropriate: the care, intervention or action provided is relevant to a
patient�s need and is based on established standards. The radiologist is the
consultant assisting the referring physician and patient in selecting the most
appropriate radiological study or intervention for the clinical condition,
based on evidence-based practice guidelines;
Safe: the avoidance or minimisation of actual or potential harm from
medical imaging or interventional radiology, including radiation exposure,
magnetic fields, contrast media etc.;
Responsive: the primacy of a patient is recognised and respected. The
facility is patient-oriented and practices these aspects: respect for patient�s
dignity and confidentiality, participation in choices or decision-making,
prompt, and good quality of amenities and choice of provider;
Timely report and accurate interpretation: the medical imaging report
should be accurately interpreted and the interventional procedure precisely
documented and delivered to the referring physician in a timely manner for
optimal patient management. Reliable means of report delivery and confirmatory
mechanisms are essential especially in the case of urgent or unexpected
Capable: the facility�s and individual�s capacity to provide medical
imaging and interventional radiology based on skill and knowledge;
Efficient: achievement of the desired results with the most
cost-effective use of resources;
Effective: the care, intervention or action should be effective in
achieving the desired outcome;
the system must be capable in providing infrastructure such as workforce,
facilities and equipment, and be innovative and responsive to emerging needs.
In practice, the reality could be a departure from the above
ideal parameters. There are potential threats to quality and safety due to
workplace, workload, workforce and budget challenges. These examples include
inadequate capital funding for the replacement of rapidly outdated equipment in
the workplace, escalating workload with increasing complexity, recruitment and
retention of radiology professionals due to a global shortage, efficiency and
productivity expectations from facility managers, and the shrinking budget that
is not keeping up with inflation.
The performance bar
Radiologists must lead and convince facility managers and
lay administrators that the quality, workload and performance metrics, i.e.,
access waiting list, workload, accuracy, turn-around time, quality and safety
issues, etc. are interlinked . At any given level of workforce, the staff
output is, by and large, finite to maintain quality and safety. Radiologists
must be the leading members of the decision-making team in relation to the
allocation of resources and ensure that the mix is optimised and realistic
(Figure 1a). Increased demands and/or expectations on the performance of one,
e.g. workload, will, by definition, impact adversely on one or more of the
remaining deliverables with the same resources (Figure 1b). It is thus
essential that decisions on resource allocation and performance expectation
reflect this reality to minimize the facility�s risks. The output �pie� is,
after all, only so big! The challenge for the providers is to try and achieve
the best and realistic outcome within the limited resources.
Quality leadership and management in medical imaging and
To survive and be successful under the changing environment
and to ensure quality and safety outcomes, leadership from the profession and
collaboration with other stakeholders to jointly develop and manage long term
system-based strategies, are required. It is important to strike a balance
between quality, safety, cost, sustainability, and clinical and patient outcome
Radiologists as leaders
Radiologists are committed to the principles of
professionalism and professional responsibilities. The professionalism
principles include the primacy and autonomy of the patients and social justice
. Professional responsibilities cover scientific knowledge, professional
competence, quality of care, access to services and just distribution of finite
Consumers expect professional leadership by self-regulation
in the first instance, i.e. by addressing workforce training and professional
development issues, and by setting quality standards and developing service
delivery models, which are in the consumers� best interests . Radiologists
must be the leaders for the promotion of quality, and consumers� advocates for
quality improvement, appropriate and sustainable use of medical imaging, and
In addition to professionalism, there are other reasons for
radiologists to be leaders for quality. For example, quality is acknowledged as
a marketing differentiator in an increasingly competitive environment.
Malpractice insurers recognize the link between quality and risk management. In
fact, some insurers offer premium reductions to individuals or practices
participating in quality improvement activities.
Governments and payers as leaders
Some health policy regulators and payers use quality and
evidence-based radiology as levers to manage the increasing demand for
services. They expect value, better clinical and economic outcomes, and work
towards ultimate system sustainability. A few independent organisations lead
and promote quality by rewarding providers with higher re-imbursement for
outstanding quality services (pay-for-performance).
Governments, politicians and bureaucrats must demonstrate
their commitment to quality and lead by working with other stakeholders to
develop and manage sustainable re-imbursement models, to reward quality
providers and to invest in research and development on quality and safety
infrastructure. Government funding on system-based quality and safety R&D
is minuscule when compared to other industries with a similar budget. When
there is a significant change in the practice delivery model (e.g.
telemedicine), law makers must lead by providing the necessary regulatory or
legal framework to ensure that quality is not compromised and the delivery
model is in the consumers� best interest.
Other stakeholders as leaders
The consumers of medical imaging and interventional radiology
include patients and referring physicians. There is an increasing awareness of
and expectation for quality services by consumers. Consumers can lead the
quality push by: becoming better informed, providing feedback, acknowledging
the community�s limited resources, recognizing their social responsibilities
and requesting services appropriately.
Stakeholders� collaboration and quality systems
Cooperation and collaboration between the stakeholders are
synergistic and will add value in spearheading the push for quality.
Collaboration is strength! Collaboration is needed among all stakeholders (i.e.
consumers, providers, payers, etc.), professional organisations (i.e. local,
national, international, etc.), professional groups (i.e. radiologists, technologists,
physicists, etc.) and disciplines (i.e. radiologists, other clinical
disciplines, etc.). Collaboration will breakdown barriers, identify common
goals and pave the way towards better quality outcome for patients.
Radiologists are initiators, facilitators and participants.
Over a long time, radiologists have led, developed and successfully managed a
range of quality programs and processes, while addressing individuals�,
practices�, national and international needs. Quality systems are recognised as
effective risk control measures. It is important for radiologists and
professional organisations to lead, develop, maintain, manage and improve such
quality systems. Well-directed team work is equally, if not more, important
than individuals in delivering systematic improvement.
Quality systems for radiologists
There are jurisdictional and institutional requirements
addressing the quality standards for radiologists. These requirements include
the qualification and certification needed following the completion of a
training program covering theoretical knowledge and practical experience. There
is a progressive trend by authorities and professional organisations requiring
radiologists to demonstrate the on-going proof of practice competency by
re-certification or re-validation. This may be via examination or participation
in a Continuing Medical Education (CME) or Continuing Professional Development
(CPD) Program. Professional organisations usually provide and manage the
infrastructure or systems necessary to support these requirements.
Credentialing and privilege of practice is granted by institutions to
radiologists following confirmation of training, experience, insurance cover
and participation in on-going learning.
Quality systems for facilities
Quality efforts for radiology facilities range from
participation in facility-based quality improvement measures by applying
quality maps, measurable metrics, performance indicators and audits or formal
radiology-specific accreditation programs dealing with quality issues in a more
comprehensive and systematic way [10, 11]. Radiologists can lead and manage
facility-based quality infrastructure by instituting quality improvement
measures, developing metrics which are easily measurable, implementing changes
which are readily achievable and leading the facility�s participation in a
formal accreditation program. These collective efforts will minimize the
facility�s risks and benefit the consumers.
National radiology-specific accreditation programs for
facilities are available in Australia from the Royal Australian and New Zealand
College of Radiologists (RANZCR) and National Association of Testing
Authorities ; in Finland, from the Radiation and Nuclear Safety Authority;
in Korea, from the Korean Institute of Accreditation in Medical Imaging; in New
Zealand, from the International Accreditation New Zealand and in the United
States, from the American College of Radiology (ACR), American Institute of
Ultrasound in Medicine and the Inter-Societal Commission for the Accreditation
of Vascular Laboratories. Generic quality management accreditation is available
through the International Organization of Standardization (ISO) agencies.
National quality systems
As a demonstration of their leadership and commitment to
quality in medical imaging and interventional radiology, radiologists and
professional organisations around the world have led, collaborated, developed
and contributed to a range of measures aiming to secure a sustainable, quality
future within the finite resources. These include an education campaign for the
stakeholders to promote appropriate utilisation, e.g. the publications of
Appropriateness Criteria (ACR); Clinical Referral Guidelines (Hong Kong College
of Radiologists); Imaging Guidelines (RANZCR) and Making the Best Use of a Department of Clinical Radiology [Royal College of Radiologists (RCR) and European Association of Radiology (EAR)].
Other national system-wide quality improvement initiatives
include: the Continuous Improvement in Radiology Information System (CIRIS) in
the United Kingdom; the Medical Excellence in Diagnostic Imaging Campaign
(MEDIC) in the United States and the Quality Use of Diagnostic Imaging (QUDI)
Program in Australia.
CIRIS  was developed in partnership between the Royal College
of Radiologists (RCR) and the College of Radiographers, with financial support
and advice from the Department of Health and the Scottish Executive. It is
available to the NHS Trust to: bring the stakeholders together; provide online
service to assist with the compliance to standards, regulatory requirements,
governance and quality improvement; and ensure that patients receive the best
care possible. In addition to record keeping, compliance and quality
improvement, benchmarking is a useful feature. An individual department can
benchmark its waiting time or the age of a piece of equipment across the
country. Such information may support the business case for more resources or
MEDIC  was developed by the ACR to educate the public, media,
physicians and government officials that by establishing quality and safety
standards for medical imaging providers and facilities, Medicare and American
taxpayers can save billions of dollars while improving quality of care; provide
a repository of information, government reports and peer-reviewed studies
illustrating how inappropriate imaging lowers quality of care and how the cost
associated with unnecessary tests threatens the solvency of Medicare/Medicaid
and drains the healthcare system of billions of dollars annually; explain the
important role that radiologists have in providing quality patient care; and
how the public can help protect quality care for the nation�s seniors while
lowering healthcare costs.
The QUDI Program [15, 16] was initiated by RANZCR and funded
by the Commonwealth Department of Health and Ageing. It is a AUD$5 million
program over 5 years. The vision is a comprehensive, long-term strategic
approach to promote sustainable, evidence-based, appropriate and quality use of
medical imaging, focusing on and addressing the needs of the key stakeholders
including consumers, referring physicians, providers and payers. The integrated
projects are designed so that they will complement each other and add value to
each sub-program. A built-in program evaluation is a key feature of QUDI. It is
envisaged that when these projects are completed and the findings implemented,
it will lead to a significant improvement of medical imaging services in Australia.
There are common features associated with these national
quality initiatives. They are usually developed by the profession as it is
committed to the professionalism principles, aiming to deliver quality and
safety of care within finite resources and to work towards system
sustainability. This requires leadership, vision and dedication. These
initiatives aim to develop long-term, pro-active, system-based, multi-tiered,
and multi-dimensional plans; to inform, engage, collaborate and seek
stakeholders� support and to define roles and clarify responsibilities for all
The biggest challenge for such initiatives is failure to
deliver on what was intended due to a variety of reasons. Financial impact to
radiology facilities and political considerations might bring adverse effects
and threaten support. Individual workload and organisational resources might be
inadequate. Inevitable change of leadership and key personnel could be other
possible risks threatening these long-term plans.
International quality efforts
International efforts in promoting quality in radiology
include the works of the Asian Oceanian Society in Radiology, European
Association of Radiology, Inter-American College of Radiology, International Atomic Energy Agency, International
Commission on Radiological Protection, International Radiology Quality Network,
International Society of Radiographers and Radiation Technologists,
International Society of Radiology, Radiological Society of North America, the
World Health Organization, etc.
Each organisation�s quality focus depends on its objectives,
the needs of its members and the areas of interest. Given a diversified range
of quality efforts by these professional organisations and finite resources,
the profession�s aim should be to add value and not to re-invent the wheel.
This can be achieved by good communication and mutual sharing of information,
resources and feedback between projects or programs, and within and between
organisations. The profession should work towards collective and integrated
efforts at all levels and among all team members and organisations.
The International Radiology Quality Network (IRQN)
The IRQN was founded in 2002. It is a network of
organisations. The current members are the American College of Radiology (ACR),
Asian and Oceanian Society in Radiology (AOSR), European Association of Radiology
(EAR), now known as European Society of Radiology (ESR), Inter-American College
of Radiology (CIR), International Society of Radiographers and Radiological
Technologists (ISRRT), International Society of Radiology (ISR), Japan
Radiological Society (JRS), Radiological Society of North America (RSNA), Royal
College of Radiologists (RCR), Royal Australian and New Zealand College of
Radiologists (RANZCR) and Global Steering Group in Diagnostic Imaging and
Laboratory of the World Health Organization (WHO). The network�s objectives are
to promote quality in radiology through collaboration, experience sharing and
mutual assistance [17, 18].
The IRQN is poor in financial resources but rich in
professional leadership assets. It is supported by a wealth of experienced
people and organisations, which it can readily consult for expert opinion and
assistance. It regards itself as one of the leaders to champion, facilitate,
develop and manage an infrastructure towards a sustainable quality future, in
collaboration with other stakeholders at an international level. Its quality
Undertaking a quality awareness program by participating in quality
sessions in international conferences including the ACR, AOSR, ESR,
International Atomic Energy Agency (IAEA), ISR and RSNA;
Hosting a Quality Improvement in Radiology Conference in collaboration
with the RANZCR in 2003;
Publishing its quality activities in radiology journals;
Developing and harmonizing Principles for International Clinical
Implementing a �Quality Improvement in Practices� paper competition in
collaboration with the Journal of the American College of Radiology. The aim is
to promote awareness either by active research and manuscript contribution or
by passive learning through reading and applying the published quality
improvement techniques; and
Establishing a Performance Metrics/Quality Indicator Workgroup to
develop metrics benchmarking. This will commence with a pilot project by
initially developing and defining an indicator and piloting data collection.
These steps will help to identify the issues involved with a voluntary
multi-national, multi-facility undertaking prior to the development of a more
comprehensive benchmarking project internationally.
In advancing the quality agenda, there are potential
collaborations and synergies between the IRQN and other related organisations.
For example, other organisations may be informed of IRQN developments, be
supportive of the network�s principle, objectives and quality initiatives, and relay
this information to their members. Organisations can avoid duplication of
efforts by improving link and communication. Collectively, the network and
other organisations can share quality resources, provide networking
opportunities, co-sponsor quality segment in conferences and jointly approach
governments for the funding of quality initiatives.
The radiology working environment is rapidly changing due to
globalisation of healthcare, corporatisation of radiology facilities,
commercialisation of teleradiology and possible commoditisation. Such changes
will upset the existing equilibrium but may offer new opportunities. For
example, there are many pros and cons associated with international clinical
The increase in demand due to an aging population and the
skyrocketing of healthcare costs are becoming concerns in some countries, which
if uncurbed will be unsustainable. The payers are therefore keen to cap
healthcare expenditure. The outsourcing of healthcare including medical imaging
will grow, as a means of saving cost: the rate depends on implemented local
standards and guidelines . Such arrangements will challenge traditional
arrangements and will be controversial.
In this environment, radiologists and the profession should
not reject changes because they are upsetting the existing equilibrium but
transform these concerns into opportunities. However, these fundamental changes
in practice will require timely leadership and thoughtful development of new
ethical, legal and quality framework by the profession and regulators. With
awareness, commitment, leadership, collaboration, planning, good management and
appropriate utilisation, it may be possible to achieve both quality and
Radiologists and the profession must uphold their duty of
care and ensure that quality and safety are not compromised as a result of
change in practice and budgetary pressures. They will lead and collaborate with
other stakeholders to develop a long-term, integrated, proactive and system-based
framework rather than reacting to short-term issues. The profession must be the
prime movers, leaders and facilitators with collaboration and support from all
other stakeholders. The challenge for the leaders is to develop plans that will
bring better outcome to ALL stakeholders and be sustainable for the long term.
Quality leadership in medical imaging and interventional radiology is a
marathon and requires patience and perseverance.
Providers and payers when leading the quality agenda should
recognise the difference among quality control, quality assurance and quality
improvement . Using chest X-ray as an example, quality control is the
rejection and re-doing of a poorly exposed or positioned film to ensure that
the final view is diagnostic and meet the minimal referrer expectation. Quality
assurance requires a little more effort, i.e. well- documented procedure
manuals, exposure charts, processor quality control measures, staff training,
etc., to reduce the percentage of poorly exposed or positioned films. Quality
improvement is a proactive process, by analysing, developing and implementing
ongoing improvement measures for each and every step of the examination so that
the final film is better exposed, positioned and diagnostic with minimal radiation.
The importance and benefits of a system-based approach to
the promotion of quality should be emphasised. In an ideal world, it would be
good to have A systems supported by A teams. However, in reality and with
limited resources, it is far better to have A systems supporting B teams rather
than the reverse. Good systems will guide the facilities to do the job right
the first time and save time and cost.
A hurdle regularly faced by professional organisations in
managing long-term strategies is the turnover of key personnel and office
bearers, leading to inevitable loss of corporate memory and direction. However,
the profession is optimistic that as a result of the dedication of the
radiologists and the commitment of the professional organisations, it should be
possible to maintain ongoing interest, leadership and direction.
Quality efforts are expensive in the short- and medium-term,
especially if uncoordinated. However, they are inevitable and indispensable in
the long term as an integral part of professionalism and risk minimisation.
Professional leadership by radiologists and professional organisations via
informing the uninformed and converting the sceptics is the only sustainable
way forward. Closer collaboration between the profession, governments and other
stakeholders will be a major step forward towards achieving cost-effective and
appropriate use of medical imaging and interventional radiology, and better
delivery of care in the long term. The International Radiology Quality Network
can play a useful facilitating role in this worthwhile but challenging
endeavour at an international level.
Figure 1 (a) The Performance Bar - workload performance metrics, i.e. access/waiting time, workload, accuracy and turn around time are closely linked. Within the allocated resources, it is important to strike a balance between these metrics to ensure the quality and safety of care; (b) The Performance Bar under threat - within the allocated resources, the output is finite. Attempts to set unrealistic performance expectation in one or more areas (e.g. workload, turn around time, etc.) could adversely impact other areas (e.g. accuracy, safety, etc.). However, such objectives could be achieved by additional resources to ensure that the other metrics are not compromised.
|Received 8 May 2006; accepted 17 May 2007
Correspondence: Chairman, International Radiology Quality Network, 29 Monomeath Avenue, Canterbury, VIC 3126, Australia. Tel.: +61 3 9836 6215; Fax.: +61 3 9888 5749;
E-mail: firstname.lastname@example.org (Lawrence Lau).
Please cite as: Lau LS,
Leadership and management in quality radiology, Biomed Imaging Interv J 2007; 3(3):e21
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