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    Qi Meeting Agenda Template

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    The quarterly quality improvement meeting at Baptist Memorial Hospital – Desoto reviewed minutes from the previous meeting, quality standards including instrument maintenance, procedure volumes, continuing medical education for staff, and quality assurance measures such as appropriate use criteria, variability studies, report timeliness and completeness, and correlation with nuclear medicine studies. Interesting cases were also presented. The group discussed the facility's upcoming accreditation expiration and making changes to the echo protocol. Adding an evening shift and suggestions for improving turnaround times were proposed. No policy revisions or corrective actions were needed. The meeting concluded with an opportunity for staff to provide questions or feedback.

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    Qi Meeting Agenda Template

    Uploaded by

    api-338166933
    675 views4 pages
    The quarterly quality improvement meeting at Baptist Memorial Hospital – Desoto reviewed minutes from the previous meeting, quality standards including instrument maintenance, procedure volumes, continuing medical education for staff, and quality assurance measures such as appropriate use criteria, variability studies, report timeliness and completeness, and correlation with nuclear medicine studies. Interesting cases were also presented. The group discussed the facility's upcoming accreditation expiration and making changes to the echo protocol. Adding an evening shift and suggestions for improving turnaround times were proposed. No policy revisions or corrective actions were needed. The meeting concluded with an opportunity for staff to provide questions or feedback.

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    The quarterly quality improvement meeting at Baptist Memorial Hospital – Desoto reviewed minutes from the previous meeting, quality standards including instrument maintenance, procedure volumes, continuing medical education for staff, and quality assurance measures such as appropriate use criteria, variability studies, report timeliness and completeness, and correlation with nuclear medicine studies. Interesting cases were also presented. The group discussed the facility's upcoming accreditation expiration and making changes to the echo protocol. Adding an evening shift and suggestions for improving turnaround times were proposed. No policy revisions or corrective actions were needed. The meeting concluded with an opportunity for staff to provide questions or feedback.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    675 views4 pages

    Qi Meeting Agenda Template

    Uploaded by

    api-338166933
    The quarterly quality improvement meeting at Baptist Memorial Hospital – Desoto reviewed minutes from the previous meeting, quality standards including instrument maintenance, procedure volumes, continuing medical education for staff, and quality assurance measures such as appropriate use criteria, variability studies, report timeliness and completeness, and correlation with nuclear medicine studies. Interesting cases were also presented. The group discussed the facility's upcoming accreditation expiration and making changes to the echo protocol. Adding an evening shift and suggestions for improving turnaround times were proposed. No policy revisions or corrective actions were needed. The meeting concluded with an opportunity for staff to provide questions or feedback.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    The meeting agenda outlines the quality improvement measures and standards discussed at the Baptist Memorial Hospital quarterly echo meeting. Items addressed include instrumentation maintenance, procedure volumes, continuing education requirements, and quality assurance metrics.

    Quality measures discussed include appropriate use criteria, sonographer variability, physician interpretation variability, echo report timeliness, correlation with nuclear medicine studies, and interesting/notable cases. Metrics like LA size measurements and consistency between reports and exams are evaluated.

    Accreditation expires in August 2018, so beginning to acquire case studies for resubmission one year prior is discussed. The protocol, required images, physician and technician representation, and exclusion of valve replacements are reviewed. Any needed protocol changes would be made at this time.

    Baptist Memorial Hospital Desoto

    Meeting Agenda
    December XX, 2016
    7:00am
    Type of Meeting: Quarterly Echo Quality Improvement Meeting (July- December
    2016)
    Meeting Facilitator: Kim Edwards, RDCS
    Invitees: Medical Director, Technical Director, Cardiology Medical Staff, Echo
    Technical Staff, Facility Administrator
    1. Review Minutes
    2. Quality Standards
    a. Instrument Maintenance
    i. Suggestion of designating one day a week to deep cleaning echo
    rooms and machines- dusting, air filters, behind beds, desks,
    etc- tech feedback on this
    ii. New echo machine- Demo 6/17/16
    b. Procedure Volumes Facility, Medical, and Technical 2016 YTD
    c. CME Update Medical Staff and Technical Staff must have 15 CMEs
    every three years relative to echo
    1. All MDs are up to date with CMEs for 2016
    2. Technical staff- per IAC- hard copies on premises
    d. QA Meeting Attendance Medical Staff and Technical Staff
    i. Will send reminders of upcoming meetings. Do physicians have
    a preference on time frame/frequency of reminders?
    ii. For 2016- only two required meetings a year to cover two
    quarters worth of data- planning next one for December 2016
    1. Dont have to be physically present, must sign off on
    receipt of packet- packets contain pertinent information
    for all staff
    2. Still a 50% required attendance- since there will only be 2
    meetings during the year, please be mindful of your
    participation
    3. Can either call in OR pick up meeting packet- packets are
    left in your folders in the read room, please be sure to
    grab these

    4. Must still sign the sign in sheet at earliest availabilityit will be in the echo read room also- will send reminders
    of doing this
    5. Lunch and learns - Rhonda and Bill working with Scottie
    e. Required Quality Assurance Measures
    i. Appropriate Use Criteria
    1. Performed at beginning of year- 100% appropriate
    ii. Variability
    1. Sonographer Variability- Two random studies per tech per
    quarter
    a. Make sure to include all three labeled Pedoff
    Doppler views with every aortic stenosis
    b. Watch for aliasing on Dopplers and gain
    c. Be sure to include all required images listed in
    protocol
    d. If any image cant be obtained, must still be
    recorded and labeled to document that an attempt
    was made
    e. Any valvular insufficiency is to be evaluated in two
    planes with color Doppler- TR is to include multiple
    measurements with CW
    2. Physician interpretation variability- two random studies
    per quarter were chosen for a blind overread to assure
    consistency between physician interpretations
    a. Study 1 and 2 - No variabilities
    b. Study 3- Variability is present with LA size- original
    report states moderately dilated
    i. LA 2D measurement of on exam 3.1cm , but
    is 4.5cm in report
    ii. LA volume of 17.05 ml/m2 on exam
    c. Study 4- Variability is present with comment on LA
    size in report
    i. Original report states normal LA size
    ii. Overread states severely dilated LA
    1. On exam, LA size is 4.5cm

    2. LA volume is 70ml/m2
    d. A list of ASE approved criteria is posted within the
    read room-pinned to the bulletin board- copy
    included in packet
    e. Need to avoid internal consistencies- such as LA
    size on report vs what was measured in exam,
    aortic stenosis, etc. IAC will ding us for this
    iii. Echo Report Timeliness & Completeness Audit- Are our reports
    read within 24-48 hours and are all elements included in the
    report that are required by the IAC
    1. 10 random TTE and TEE studies were audited each
    quarter
    a. All were read within 24 hours
    b. Two were still missing a report summary and
    mention of the aorta
    c. One TEE reviewed was missing comment on ease of
    probe insertion and if any complications occurred
    d. If contrast or bubble studies are performed, this
    needs to be mentioned within the report by
    physician and changed by tech under the type of
    procedure
    e. One TTE was missing comment on mitral valveonly had E/E value under it. Need to include if
    valve is normal in structure and function.
    iv. Correlation- Two random studies per quarter were chosen to
    correlate with Nuclear Medicine studies for ejection fraction and
    wall motion abnormalities
    1. Study 1- Nuc showed a mild inferior wall hypokinesis,
    echo showed normal wall motion
    2. Studies 2 through 4- Positive correlation
    v. Annual Summary- brief summary of all quality measures taken
    during each quarter- as of 2016 this will not be a requirement
    anymore, but IAC still suggests doing so
    vi. QI standards are in the process of being changed again
    3. Interesting cases- Two TEE cases where MPA view helped to aid in diagnosis and
    patient care
    a. Case 1- Mass visualized on pulmonic valves left cusp- Dr. Szatkowski
    to speak on this study

    b. Case 2- RA mass and MPA thrombus- Dr. Szatkowski to speak on this


    study
    4. Facility Issues
    a. Accreditation expires 8/2018- will begin acquiring case studies for
    resubmission one year prior
    i. Can apply up to 6 months prior to expiration
    ii. 4 AS and 4 RWMA, each physician and each tech represented
    iii. No valve replacements
    iv. Must follow protocol- only required images and in order
    v. Need best studies only
    vi. If any changes need to be made to protocol, this will be the time
    to do it
    b. Lori to discuss the adding of an evening shift as part of the schedule
    i. Turnaround time for dedicated observation unit opening
    ii. Hospitalists satisfaction
    iii. Reduced overtime / call backs for echo techs
    iv. Suggestion of having a cut off time to roll studies over to next
    day reader or MD letting tech know when theyre leaving for the
    evening- same as Baptist Memphis
    5. Policy Review & Revisions- None at this time
    6. Corrective Action / Improvement Plan / Recommendations
    7. Any questions, suggestions, or concerns from staffing (technical or medical)

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