<INSERT FACILITY NAME HERE>
QI
Pediatric Quality Improvement (QI) Policy
Sample Template
GENERAL INSTRUCTIONS FOR CREATING A QI POLICY:
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Refer to the Sample Documents posted on the IAC Echo (www.intersocietal.org/echo) website.
Policies must be modified so that they are facility-specific. Tracking forms and spreadsheets may
be used as is or may be modified. Alternate or additional forms may be created.
Include sufficient detail so that each element of the IAC Standards for Echocardiography
Accreditation (Part C, Section 1C) is addressed.
Describe your policies with sufficient clarity so that anyone reading the QI policy would be able to
implement all aspects of the policy.
State who is responsible for each aspect of the QI process you describe.
Outline the specific method for accomplishing each goal/required element.
Address each testing section specifically in your policy.
Pediatric QI Policy (SAMPLE)
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<INSERT FACILITY NAME HERE>
QI
Quality Improvement Policy
Pediatric Echocardiography
PURPOSE: To establish guidelines for maintaining high-quality performance and providing high-quality
patient care, in compliance with IAC Standards for Echocardiography Accreditation, in all aspects of the
echocardiography facility. Specifically, our goals are to:
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Perform high-quality diagnostic echocardiograms
Prepare complete and accurate echocardiogram reports
Maintain our equipment for use at its full capability
Continue our education to learn new techniques
Ensure continuous compliance with IAC Standards for Echocardiography Accreditation
List additional QI goals your facility has set
POLICIES: To meet these goals, our Quality Improvement (QI) Policy will include:
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Policy for Reviewing Physician Interpretation Variability
Policy for Reviewing Sonographer Performance Variability
Policy for Correlation with other Modalities
Policy for Tracking Report Timeliness and Report Completeness
Quality Improvement Conferences Policy
Record-Keeping Policy
List other QI measures utilized in your facility, such as Patient Care Surveys, Special Projects, etc.
POLICY FOR STUDYING PHYSICIAN REPORT VARIABILITY
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Describe the method your facility will use to review physician interpretation variability of studies(blinded
over-reads). Outline the schedule and method for choosing cases and for examining results and the policy for
the Medical Director to address discrepancies among readers.
POLICY FOR STUDYING SONOGRAPHER PERFORMANCE VARIABILITY
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Describe the method your facility will use to review sonographer performance variability of studies. Outline
the schedule and method for choosing cases and for examining results and the policy for the Medical Director
to address discrepancies among readers.
POLICY FOR CORRELATION WITH OTHER IMAGING MODALITIES
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For each testing section, describe the method by which your facility will correlate echo reports with reports
of other imaging modalities. Include the modalities with which you will correlate, instructions for obtaining
reports from the other imaging modalities, the method by which cases are chosen for correlation, the number
of cases per quarter that will be correlated, the method for examining results, etc. Describe your process for
distributing correlation data to each interpreting physician and the policy for the Medical Director to address
discrepancies between echocardiogram examination results and results of other exams.
Pediatric QI Policy (SAMPLE)
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<INSERT FACILITY NAME HERE>
QI
POLICY FOR TRACKING REPORT TIMELINESS AND REPORT COMPLETENESS
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Describe the method you will use to ensure that reports are completed in a timely manner and that they
contain all required components (demographics, measurements, text comments). Outline the schedule and
method for choosing reports and for examining results, and the policy for the Medical Director to address
discrepancies
ECHOCARDIOGRAPY CONFERENCES POLICY
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Outline the schedule for the quarterly QI meetings in the facility, the minimum attendance requirements, and
the required discussion topics. Include other topics you choose to address. Require that minutes are kept,
including attendance.
RECORD-KEEPING POLICY
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Mandate that written records will be kept for all QI and that an annual summary (sample document available)
will be compiled for each QI measure. Describe (in this section or under each section above) how the results
of the various QI measures will be utilized to improve the quality of the cases/reports or otherwise maintain
compliance to IAC Standards for Echocardiography Accreditation.
Pediatric QI Policy (SAMPLE)
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