XXX Nuclear Facility
Quality Improvement Plan
OBJECTIVES: A nuclear medicine facility must be able to document processes and quality measures taken to
assure that examination results are valid and reliable. IAC Nuclear/PET accreditation requires facilities to measure
quality from each of the following three areas annually: administrative, technical and physician performance
(interpretive). The quality improvement program must show evidence of improvement activities or, if an assessment
confirms acceptable quality of a measure, the facility must select new or additional areas for assessment. Measures
must be selected based on areas of potential improvement. The program must collect measureable data and have predefined indicators of quality and pre-defined thresholds.
A minimum of two quality improvement meetings must be held per year to review the findings of the quality
improvement measures and to determine actions for improvement or correction. All interpreting physicians and
technologists must participate in the meetings.
Administrative Quality Measures:
PURPOSE: To assess and improve the administrate quality of the facility’s operations. Areas that may be assessed
are as follows:
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Patient Satisfaction
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Referring Physician Satisfaction
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Patient satisfaction will be evaluated by random questionnaires given to patients upon completion of their
imaging study. A minimum of 30 patient’s responses will be analyzed. All negative responses and
complaints and any results falling below the predicted threshold will be discussed. Suggestions for
improvement will be discussed and put into operation.
Variables to be assessed: hours of operation, convenience of the facility location, cleanliness, waiting
time, comfort, explanation of the procedure, questions answered, friendliness of the staff, knowledge and
professionalism of the staff, respect for modesty, confidentiality, overall impression of visit, willingness
to return, likelihood of referring others.
Referring physician satisfaction will be evaluated by mailed satisfaction questionnaires to all external and
internal physicians referring patients for imaging to this practice. All negative responses and complaints
and any results falling below the predicted threshold will be discussed. Suggestions for improvement will
be discussed and put into operation.
Variables to be assessed: Transcription of reports, availability/timeliness of reports, procedure scheduling
process, phone hospitality, billing/insurance/pre-authorization instructions, quality of the images,
timeliness of scheduling, quality/accuracy of the reports, availability for consultation, interactions with
the patient, convenience for patient, staff courtesy, frequency of patient complaints, response to
complaints.
Completeness of Documentation
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Completeness of documentation in the final reports will evaluated by randomly accessing patient reports
and evaluating to make sure all required reporting elements are present. A minimum of 30 reports will be
evaluated. All results falling below the predicted threshold will be discussed. Suggestions for
improvement will be discussed and put into operation.
Variables to be assessed: Facility name, address, phone number; gender; age or date of birth; requesting
physician; interpreting physician; name of the procedure; date of the procedure and date of the report;
clinical indication; description of the procedure; radiopharmaceutical name, exact amount administered,
and route of administration; pharmaceutical name, exact amount administered and route of
administration; physician signature, report approved with 4 working days, pertinent positive and negative
findings; other findings, if applicable; succinct impression
Quality Improvement Plan (SAMPLE)
1
NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.
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Report turnaround time
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Report turnaround time will be evaluated by analyzing final reports and to determine the time from
completion of the study to the time the final report is faxed to the referring physician. A minimum of 30
final reports will be evaluated. All results falling below the predicted threshold will be discussed.
Suggestions for improvement will be discussed and put into operation.
Variables to be assessed: study completion date and time; date and time of dictation, date and time of
transcription, date and time the report is proof read by interpreting physician and signed as being
accurate; date and time the report is faxed to the referring physician.
Appropriateness of Care (Appropriate Use Criteria)
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Appropriateness of study will be evaluated for myocardial perfusion imaging using the
ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Radionuclide imaging.
Appropriate use will be measured in consecutive patients so that 5% of the annual volume of patients referred
for radionuclide imaging is evaluated (a minimum of 30 patients must be evaluated). The Astellas Appropriate
Use Criteria application will be used to determine the appropriateness of the indications and the results will be
tracked in a spreadsheet. All results falling below the predicted threshold will be discussed. Suggestions for
improvement will be discussed and put into operation. A program for the education of the referring physician
regarding appropriateness of procedures will be developed.
Variables to be assessed: percentage of appropriate, inappropriate and uncertain indications; referring
physician name and practice
Technical Quality Measures:
PURPOSE: To assess and improve the technical quality of the images and procedures being performed. Areas that
may be assessed are as follows:

Image quality
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Proper patient preparation
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Myocardial perfusion imaging technical quality will be assessed by randomly evaluating the raw cine
data for a minimum of 30 patients. All results falling below the predicted threshold will be discussed.
Suggestions for improvement will be discussed and put into operation.
Variables to be assessed: patient motion; breast attenuation; diaphragmatic attenuation; superimposed
bowel artifact, hot liver, low count study, gating error, overall quality, imaging technologist
Adequacy of patient preparation will be assessed by reviewing patient history and checklist form to
ensure that all patients undergoing myocardial perfusion imaging receive an accurate test. A minimum of
30 patient history forms will be evaluated. All results falling below the predicted threshold will be
discussed. Suggestions for improvement will be discussed and put into operation.
Variables to be assessed: patient NPO, caffeine withheld >18 hours, no theophylline containing products,
Beta blockers withheld, calcium channel blockers withheld, patient appropriately dressed.
Adequacy of exercise stress test
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All exercise stress tests performed in conjunction with myocardial perfusion should be symptom limited
unless indications for stopping the test early are achieved. Achievement of 85% of the maximum
predicted heart rate (MPHR) is not an indication for termination of the test. Patients unable to perform
maximal exercise and reach a heart rate greater than 85% of the maximum predicted heart rate should
undergo pharmacologic stress testing. Adequacy of exercise stress test performed in the facility will be
assessed by evaluating the stress results from the report. All results falling below the predicted threshold
will be discussed. Suggestions for improvement will be discussed and put into operation.
Variables to be assessed: patient age, maximum predicted heart rate, target heart rate (85% of the
MPHR), patient symptoms, METs achieved, test length, peak heart rate, peak blood pressure, reason for
test termination.
Quality Improvement Plan (SAMPLE)
2
NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.
Physician Performance (Interpretive) Measures:
PURPOSE: To assess and improve the performance of physicians regarding the quality of medical practice (report
accuracy, appropriateness of care, effectiveness of therapy) and physician behaviors (communication and
professionalism). Areas that may be assessed are as follows:

Interobserver variability
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Interobserver variability for myocardial perfusion imaging will be assessed by comparing the results of
one physician against the results of another physician. A minimum of 30 cases per physician must be
evaluated. Physicians may be compared against other independent physicians within the practice or
against a consensus interpretation. Upon completion of the study all results will be distributed to the
interpreting physician and each case will be displayed and discussed during the quality improvement
meeting. Any discordant findings will be analyzed and suggestions for improvement or education will be
performed.
Variables to be assessed: overall result; defect size, severity and type; defect location using a 17 segment
model; ejection fraction, regional wall motion abnormality; and artifact.
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Intraobserver variability
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Interobserver variability for myocardial perfusion imaging will be assessed by comparing the
interpretation for a physician against the interpretation of the same case studies following a period of
time. There must be a minimum of 6 weeks between each interpretation. A minimum of 30 cases per
physician must be evaluated. Upon completion of the study all results will be distributed to the
interpreting physician and the cases will be displayed and discussed during the quality improvement
meeting. Any discordant findings will be analyzed and suggestions for improvement or education will be
discussed.
Variables to be assessed: overall result; defect size, severity and type; defect location using a 17 segment
model; ejection fraction, regional wall motion abnormality; and artifact.
o
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Defect quantification
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Defect quantification reporting accuracy will be assessed by randomly evaluating the final report for
abnormal studies. A minimum of 30 reports per physician will be evaluated. All results falling below
the predicted threshold will be discussed. Suggestions for improvement will be discussed and put into
operation.
o
Variables to be assessed: Defect extent (small: 1 -2 segments, medium: 3 – 4 segments, or large: ≥ 5
segments); defect severity (mild, moderate or severe); defect location; and defect type (reversible,
persistent, mixed)
Correlation of interpretation with other diagnostic studies, pathology/surgical results and/or patient
outcomes (i.e., Cath Correlation)
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Myocardial perfusion imaging results will be compared to the results obtained by coronary
catheterization. All known patients undergoing a myocardial perfusion imaging and catheterization
will be tracked. The results will be evaluated during the quality improvement meeting. All results
falling below the predicted threshold will be discussed. Suggestions for improvement will be discussed
and put into operation. Specifically methods to reduce false positives and false negatives and means to
improve myocardial perfusion imaging technical quality and interpretation will be discussed.
Variables to be assessed: MPI results (normal or abnormal); MPI defect location (anterior, lateral,
inferior, septum, or apex); MPI defect type (ischemia or infarction); catheterization result (normal or
abnormal); catheterization vascular territory (left main, left anterior descending, left circumflex, right
coronary artery); catheterization stenosis (no lesion, stenosis < 50%, stenosis >50% and <70%,
stenosis >70% and <90%, stenosis >90%); correlation (true positive, true negative, false positive, false
negative).
Correlation parameters to be reported: sensitivity; specificity; false positive rate, false negative rate;
positive predictive value; negative predictive value; overall correlation (accuracy)
Quality Improvement Plan (SAMPLE)
3
NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.

Appropriateness of Care (Appropriate Use Criteria)
o
o
Appropriateness of study will be evaluated for myocardial perfusion imaging using the
ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Radionuclide
imaging. Appropriate use will be measured in consecutive patients so that 5% of the annual volume of
patients referred for radionuclide imaging is evaluated (a minimum of 30 patients must be evaluated).
The Astellas Appropriate Use Criteria application will be used to determine the appropriateness of the
indications and the results will be tracked in a spreadsheet. All results falling below the predicted
threshold will be discussed. Suggestions for improvement will be discussed and put into operation. A
program for the education of the referring physician regarding appropriateness of procedures will be
developed.
Variables to be assessed: percentage of appropriate, inappropriate and uncertain indications; referring
physician name and practice
2012 Quality Improvement Schedule
1st quarter:
Administrative quality – Patient Satisfaction Survey
Data collection period: February 1 - March 1, 2012
Technical quality – Image quality
Data collection period: March 1, 2012 - March 31, 2012
Meeting – 11 a.m. on June 10, 2012
Meeting location: Staff lounge
Required to attend: Dr. Jones, Dr. Smith, Dr. Johnson, Mary North and Diane West
3rd quarter:
Physician performance (Interpretive) quality – Interobserver variability
Data collection period: August 1, 2010 to August 31, 2010
Meeting – 11 a.m. on September 10, 2012
Meeting location – Staff lounge
Required to attend: Dr. Jones, Dr. Smith, Dr. Johnson, Mary North and Diane West
Written:
Revised:
Reviewed:
Reviewed:
Quality Improvement Plan (SAMPLE)
Date:
Date:
Date:
Date:
4
NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.
XXX Nuclear Facility
Meeting Minutes
Date of Staff Meeting:
Staff Attendance:
Date of Monitoring Period:
From: __________________________
To: _____________________________
Analysis of Data:
Discussion:
Corrective Action/
Improvement Plan:
Other Comments:
Re-evaluation Date:
Reported by:
Date:
Reviewed by:
Date:
Quality Improvement Plan (SAMPLE)
5
NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.