Quality means back to basics

Rinckside 1999; 10,1: 1-3.

 hen you go to a restaurant and find the tables dirty, the service slow and unfriendly, and the food tasteless, you describe the quality of this establishment as low. This kind of assessment is easy and can be done by anybody. In medicine, thus also radiology, the prevailing benchmarks for measuring quality are the opinions of the patient, the referring physicians and, last but not least, your own knowledge whether you perform to the best of your abilities.

Quality assessment becomes more difficult when patient care involves technology that is not transparent to the layman or even to the user. This holds for cars and aircraft, as well as for imaging equipment. So many things can go wrong with modern electronic imaging machines that it is quite amazing that scanners produce images of such high quality.

When people talk about quality assurance, they usually mean preservation of equipment performance. In Europe, there is no set process for a generally accepted quality control in radiology.

Cost and quality are the two most discussed aspects of patient care and getting the balance right is difficult. Everybody would like a decrease in costs and an increase in quality. Usually, however, costs increase, and many people believe that this goes hand-in-hand with an increase in quality; but this assumption is hard to prove.

   Deterioration of image quality is often a slow process. At the beginning, it goes mostly unnoticed. One then becomes accustomed to the way the images look and begins to believe that they are of good quality. When looking at your patient studies, colleagues realize that the quality of your images is not up to standard or actually poor. Commonly, they put the blame on the manufacturer, not on the owner of the machine. This is right legitimate in many instances because the manufacturer is also in charge of servicing the equipment. Hardly any radiologist who own or are in charge of a machine is able to service it or even reliably test its quality and performance. Even if they knew how, they would not have the time required to maintain its top performance.

This can result in two outcomes: first, poor image quality, which ultimately means poor patient care, and second, negative comments about manufacturers, such as: “The equipment of manufacturer X which you know is eight years old creates better images than a similar machine by manufacturer Y, which is only eighteen months old.” This contrast might be only due to differences in service and maintenance.

Recently, someone told me that his 0.2-Tesla MR machine makes better images than the neighbor’s 1-Tesla machine. The reason was not that the higher-field machine was worse per se, but that the owner had not “wasted money” in consistent service.

There is no doubt that manufacturers make a lot of money from service. Part of this money can be saved by performing daily quality checks and a weekly quality assurance program during the weekend. If the institute or department is large enough, an in-house engineer, physicist, or radiographer trained in quality assurance is a worthwhile investment to insure continuing image quality.

Supervision and affirmation that the nature of your medical service is optimal should never be forgotten. Always keep in mind that the best of your knowledge might not be good enough. Also remember that medicine is not an exact science. The technical aspect is only a part of it.

Quality control and quality assurance are expensive. They require time, money and the admission that you might not be perfect. There is not straight feedback or financial remuneration for quality control. Public recognition will follow, but it might take five or even ten years. With public recognition, the influx of patients will increase, because patients and referring physicians will trust you and your institute.

Plan ahead

Quality assurance and control programs require long-term planning, which can be tedious. People working with you have to accept their necessity and have to stay in the department or private practice for years. For staff just passing through to is more difficult to understand how quality assurance works. It is a way of life which cannot be picked up in a month or two.

The restaurant example can easily be translated into a familiar scenario: Patient may have a similar experience when visiting a radiologist. Quality is often assessed from the waiting room and the desk of the referring physician, both angles from which you commonly do not watch your work.

The following account is not a single case; you might have heard similar stories. I choose it because it does not involve a radiologist. Appearances can be deceptive, but sometimes they are true.

   Last winter, a friend of mine felt unwell. She made an appointment with a gynecologist. This gynecologist worked in a very fashionable neighborhood, but did not make a good impression on my friend. His rather small waiting room was crowded and did not have enough chairs. The wall of the waiting room were painted in a dirty-brownish hue. The well-thumbed magazines on the table were old and greasy from the fingers of many patients. Patients need something to distract them, to read, to look at – some easy reading, to get their thoughts off the ordeal which may await them – but here they didn’t want to touch the magazines.

The doctor finally appeared more than an hour after the set appointment. He also looked slightly dirty. His hair was too long and had not been washed for some days. He did not introduce himself but grumpily asked for my friend’s complaints.

While he listened to her description, he started without further explanation an ultrasound examination which was accompanied by: “Hmmh, hmmh ...” He then ordered some blood tests and prescribed a medicament against a disease he presumably had found in the ultrasound examination, again without further explanation. When asked the secretary what the diagnosis was, she answered: “What the doctor has told you.”

After buying the prescribed drug at the next pharmacy, my friend read its description which listed more side effects than wished for effects. She did not take it because she did not trust the doctor; she had neither faith in the diagnosis nor the treatment proposal and went to another doctor in a different city.

This second doctor was the complete opposite of the first; he, his technicians and his office were neat, and he explained everything he did to her in detail. When he repeated the ultrasound examination he found no pathology.

Admittedly, this story sounds like an invention to hammer home the point, but it is true. Of course, it could also be the other way around: The clean and talkative doctor might not know how to use the ultrasound equipment and how to interpret the images.

Smile, be friendly, try to explain the procedure to patients, and tell them when you expect the results.

Roots of the problem

An ancient Greek physician said something along the lines of: “Quality starts at home”. In other words, do not look at others or blame others, blame yourself first.

A friend-foe relationship sometimes develops between physicians (as well as nurses and technicians) and patients. Many hospitals – and departments of radiology – are run in a way that patients are considered a nuisance. This should not be the case but is part of human behavior.

Very few people have enough patience and permanent dedication to their sick, helpless and often querulous counterparts. Everybody has good or bad days. You may not feel well, you are tired, but the patient should not feel this, he will have the impression that your bad mood is connected to him and his disease. This is easier said than done, but quality assurance means self-discipline and includes politeness.

   Quality means simple things such as not showing a bored face, not receiving patients impolitely, introducing oneself and one’s position, and explaining the radiological procedure. This holds true in all countries, for nurses and technicians, and for residents and professors.

You can raise the quality of your radiological examination by numerous simple routines - from placing flowers in the reception area to providing clean gowns for the employees. Smile, be friendly, try to explain the procedure to the patients, tell them when the referring physician will receive the results.

Try to schedule patients in a way that they do not have to wait too long. If a wait is necessary, there should be distractions and patients should be reassured that they have not been forgotten. Try to resolve complaints from patients or from referring colleagues. Encourage them to put complaints in writing. This ensures that notorious trouble-makers among patients, doctors and administrators, and among your own radiological staff are kept at bay. It also allows to follow up problems easier.

Good medical quality also means that the department heads – as well as everybody else – are friendly and open towards the rest of the staff, supporting them and keeping them informed. Duties should be delegated and people made responsible for their tasks, without overloading them with work. This also means that bad apples have to be removed, even if it hurts. Ambitious and content staff working on defining improvements and seeing them through will be the best quality assurance possible. People will easier cooperate with one another and their manager under these circumstances.

Many things can, and often do, go wrong which can seriously degrade image quality – both the radiological image and the image of radiology.

Citation: Rinck PA. Quality means back to basics. Rinckside 1999; 10,1: 1-3.

A digest version of this column was published as:
Quality means back to basics.
Diagnostic Imaging Europe. 1999; 15,3: 23-24.