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QA and CQI: How?. Merri L. Bremer MEd, RN, RDCS, FASE. Disclosures. Relevant Relationship Member, ICAEL Board of Directors Off Label Usage None. Learning Objectives. Define QA Discuss ideas for development and implementation of Echo Lab QA. QA: What is it?. Many names (QA, QI, CQI)

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QA and CQI: How?

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QA and CQI:How?

Merri L. Bremer MEd, RN, RDCS, FASE


Relevant Relationship

Member, ICAEL Board of Directors

Off Label Usage


Learning Objectives

Define QA

Discuss ideas for development and implementation of Echo Lab QA

QA: What is it?

Many names (QA, QI, CQI)

Method of continuously examining processes and making them more effective

Focus is on the process, not the individual

Lesson Learned

QA: What is it not?







When you watch me, they want me to do it differently…


Develops and maintains quality in your practice

Ensures uniform, consistent standards for interpretation and reporting

Excellent continuingeducation tool

Standards and Guidelines

ICAEL Standards

ASE Guidelines and Standards

SDMS Position Statements

ASE Sonographer Minimum Standards

ICAEL QA Components

Written policy


Instrument maintenance

Procedure volumes


Peer review


Report Timeliness


Record keeping

Writing a QA Policy

Identify required elements (ICAEL Standards)

Figure out how YOUR TEAM can accomplish them and write them down

Sample policies on ICAEL website

Try them….revise and try again if necessary

Communicate! Frequently!


Lesson Learned

Appropriate Use Criteria (AUC)

  • Mandatory requirement for accreditation effective January 1, 2012

  • Appropriate use must be measured in a minimum of 30 consecutive TTE, 30 consecutive TEE and 30 consecutive Stress patients annually

  • ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography

  • Percentage of appropriate, inappropriate and uncertain indications for testing must be measured


Appropriate Use Criteria

  • A program for education and reporting must be developed and include:

    • Baseline rates of adherence

    • Patterns of adherence

    • Goals for improvement

    • Measurement of improvement

    • Confidential reports on patterns of adherence

      • Ordering physician

      • Ordering practice

      • Interpreting practice


Instrument Maintenance

Recording of method and frequency of maintenance

Establishment of and adherence to a policy regarding routine safety inspections and testing of all laboratory electrical equipment

Establishment of and adherence to an instrument cleaning schedule

Instrument Maintenance

Use institutional resources if you have them

If you don’t have them, create a policy using the manufacturer’s guidelines and follow it

Ask your equipment reps for help!

Maintenance Log

Procedure Volumes

Annual individual and laboratory stats

Records of individual procedure volumes should include volumes from all laboratories where staff perform/interpret echocardiograms

Methods of tracking


Procedure list


Lesson Learned

Sonographer Procedure Volume Log

MD Procedure Volume Log


Documentation of echocardiography-related continuing education for all medical and technical personnel must be maintained

Keep in central location; update annually


CD, journal, Internet, videotape materials

Departmental, local, regional and national conferences and courses


15 echo-related CME credits required for all staff (3 year period)

Category 1 AMA credit

Other approved non-category 1 credit (ASE, SDMS or ARRT) that have content specific to echocardiography



Peer Review

Feedback is essential for improvement!

Intermittent peer review of both performance and interpretation of studies should be performed

Optional QA measure, but very useful

Both physicians and sonographers should be involved

Peer Review

Differences in interpretation styles and performance should be reconciled

Individual vs group reviews


Document it!

Lesson Learned

MD Peer Review


EF, wall motion analysis and degree of regurgitation/stenosis must be assessed on a minimum of two cases per modality per quarter to be reviewed in quarterly conferences

Represent as many physicians as possible

Policy to address discrepancies


Variability Worksheet

Variability Summary


EF, wall motion analysis and degree of regurgitation/stenosis will be correlated on a minimum of two per modality per quarter with other imaging modalities in quarterly conferences

Represent as many physicians as possible

Policy to address discrepancies


Report Review

  • Minimum of 10 random reports per quarter

  • Time from performance of study to report sign-off

    • Inpatient: 24 hours

    • Outpatient: end of next business day

  • Report completeness (Standards)

  • Represent as many physicians as possible

  • Policy to address discrepancies


QA Conferences

Quarterly conferences must be held to review the results of variability, correlation and report timelines, to address discrepancies and to discuss difficult cases

Attendance by the medical and technical directors or their designees is required at all meetings

QA Conferences

All medical and technical staff are required to attend at least two of the fourmeetings

Minutes of the meetings and attendance must be recorded

Record Keeping

If you don’t document it, it didn’t happen

Keep data in a central location and back it up

Annual summary of information required

Lesson Learned

Lesson Learned


Requirements for Success


Accreditation/QA Resources

Merri’s Rulesfor QA

Keep it SIMPLE and practical

Involve lots of people and ideas

Steal shamelessly from others

Adapt what you’ve stolen

Be methodical


Share what you’ve found

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