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Cochrane Report - Phase 1
Cochrane Report - Phase 1
MedicalImagingCredentialingandQualityAssurance
Phase1Report
DDCochraneMDFRCSC
Chair,BCPatientSafety&QualityCouncil
March9,2011
Introduction
Promptedbyconcernsregardingthequalityoftheinterpretationofradiologyimagesbythree individualsinBritishColumbia,onFebruary11,2011,theHonourableColinHansen,MinisterofHealth Servicesrequested,anindependentinvestigationintothecredentialingofradiologistsandmedical imagingqualityassuranceinBC.Thisinvestigation,tobeledbyDr.DouglasCochrane,Provincial PatientSafetyandQualityOfficerandChairoftheBCPatientSafety&QualityCouncil,wastoexamine allaspectsofthelicensingandcredentialingofradiologistsintwophases.Thefirstphaseistofocus onthecredentialsandexperienceofindividualprovidersandthesecondphasetofocusonthe processes: 1)relatedtophysiciancredentialingandprivilegespertainingtomedicalimagingwithin healthauthorities,includingtheroleplayedbytheBCCollegeofPhysiciansandSurgeons,2)related toqualityassuranceandpeerreviewofmedicalimagingreportsandtoreviewfullytheincidents wherephysicianslackedeithertheappropriatecredentialsorexperiencetointerpretimages, includinganalysisoftheresponsebyhealthauthoritieswhentheylearnedofproblems.
Background
InOctober2010,concernswereraisedtoVancouverCoastalHealth(VCH)administrationaboutthe qualityofaradiologistsinterpretationofCTscans. Thehealthauthorityinvestigatedtheseconcerns byconsultingtheCollegeofPhysiciansandSurgeons(theCollege)andreviewingthemedicalimaging reports. ThereviewbyVCHidentifiedthebreachofavoluntaryundertakingnottointerpretCTscans orobstetricalultrasoundsandthefailuretoreportpersonalskillupgradingdoneinCTandultrasound imagingtotheCollege.Asaresult,aformalreviewofthisindividualsCTinterpretationswas performedbyVCHinDecember2010.Significantdiscrepanciesbetweentheindividualsreportsand thereportsprovidedbypeerreviewersassessingthesameimageswerefound.
InDecemberof2010,FraserHealth(FHA)wasinformedbytheCollegeofconcernsregardingthe interpretationofCTscansbyalocumradiologist. Thisindividualhadprovidedlocumservicesin InteriorHealth(IHA)andhadbeenthesubjectofaqualityreviewpromptedbyphysicianconcern. IHA hadnotifiedtheCollege,andtheyinturninformedFraserHealthwhothenundertookareviewofthe CTinterpretationsreportedbythelocumduringthemonthhe/shepracticedintheregion. Theresults ofthisreviewwereconsistentwiththefindingsofInteriorHealth;theradiologistinquestionwas foundtohaveinsufficientknowledgeandskillstointerpretCTscans.
Mandate
Methodology
Theevaluationconsidereddataprovidedthehealthauthorities,theCollege,andtheDiagnostic AccreditationProgram(DAP). ThedataelementsarelistedinAppendicesBandC. Theevaluationof individualcredentialsandexperiencewasbasedonthedateofregistrationandlicenseissuedbythe College,theyearofRoyalCollegecertification,maintenanceofcompetenceshoursindiagnostic imagingasreportedtotheRoyalCollegein2010,andothercontinuingmedicaleducationactivities reportedtothehealthauthority.CurrentvolumesofstudiesinCT,MRandultrasoundwereusedto profileservicesprovidedtopatients.Informationreceivedfromthepublicwasconsideredinthe reviewwhereapplicable.
ResultsandAnalysis
RoyalCollegeCompetencies
The Royal College included competency in computed tomography of all body sites in 1981. Ultrasound competency was expected of certificants the same year. Magnetic resonance imaging competencywasexpectedin1990.
Practitioners
AsofFebruary2011,therewere287practitionerslicensedtoprovidediagnosticimagingservicesacross 66sitesinBC. TheseindividualsmeetthecriteriarequiredbytheCollegeforlicensure.Allare registeredandlicensedtopracticeinBC. Allindividualsareprovidingserviceswithinthescopedefined bytheirlicense. Fivepercentofprovidershaveeitheraprovisionalorconditionalpracticesetting registrationinBC;sixoftheseindividualshaveRoyalCollegeofPhysiciansandSurgeonsofCanada (RCPSC)certificationinDiagnosticImagingand9haveforeigntrainingatthelevelrequiredoftheRCPSC andarecommittedtoachievingRoyalCollegecertification.Noindividualisprovidingservicesthat extendbeyondthescopedefinedbytheirregistrationbasedontheinformationavailable.Thosewho workundersupervisionandwhoarelimitedastothelocationofpracticeareincompliancewiththese requirements.
HealthAuthorityQualityAssuranceandReviewProcessesforDiagnosticImaging
Since2006,DAPreviewsofimagingfacilitieshavebeenscheduledonathreeyearcycleandhave focusedonthetechnicalaspectsofthefacilities,policiesandproceduresandthesafetyofpatients 4
PatientClientInput
Duringthecourseofthephaseonereview,anumberofconcernswerereceivedfrompatients regardingspecificimagingservices.
Recommendations and Conclusion Diagnosticimagingisblessedandchallengedwiththeintroductionofnewtechnologiesonan ongoingbasis.Computedtomography,hasevolvedthrough(atleast)4generationssince1976and MRIisnowinitsthirdgeneration. Withineachgenerationandineachimagingmodality,the diagnostictoolshavebeenimprovedandnewtoolsintroducedashardwareandsoftwarechange; theresultisthatbetter,moreaccurateandcomprehensivediagnosescanbereachednoninvasively. Itisachallengeforresidencyandfellowshiptrainingprogramstokeepupwiththesechangeswhilst ensuringcompetencyoftheirgraduates,anditisagreaterchallengeforthepracticingradiologist.
Recommendations
Recommendation#1ProvincewideProspectiveConcurrentPeerReviewSystem
ItisrecommendedthattheMinistryofHealthServices,theCollegeofPhysiciansandSurgeonsand thehealthauthoritiescreateaprovincewideconcurrentpeerreviewsystemfordiagnosticimaging forqualityreviewandmonitoringofimageinterpretationandtechnicalimagequality. Itis envisionedthatsuchasystemwould: A)Defineaprocessthatrequiresaproportionofstudiesinitiallyreadbyeachradiologistin thehealthauthoritytoberereadbyanotherradiologist.Theimagereportswouldbe comparedandinconsistenciesclassified. Interpretivedifferenceswouldbereportedto theoriginalreportingradiologistandothersforthepurposeofimprovingreporting quality.Wherethereviewfounddifferencesofclinicalimportance;asupplementary reportwouldbeissuedandappropriateparties,includingthepatient,notified. B)Facilitatetheselectionofrandomimagesforpeerreviewanddistributionoftheimagesto
Implementation of a peer review system could be approached in two phases.The first phase wouldbeginMarch16,2011andpursueworkunderwaybytheCollegethroughitsDiagnosticImaging QualityAssurance Committee. Thisbody hasdraftedaprocess forpeerreviewwithinhealth 6
authoritiesthatwillrequireareviewofaproportionofstudiesinitiallyreadbyeachradiologistinthe healthauthoritytoberereadbyanotherradiologist.
Thesecondphasewouldinvolvetheimplementationanduseofanelectronicsystemandpractices thatenablesecondreadsofrandomlyselectedimages.Thissystemwouldallowtheworkofsecond readstobedistributedacrossthehealthsystemsothattheimpactonindividualradiologistsis minimizedwhilepreservingtheintegrityofthereviewprocess. VCHandVIHAhavealready embarkedonthisprocess,whichcanbeexpandedtoincludeallofthehealthauthorities.Thisprocess would: 1. Reviewvendorsofsuitablesystemsthataddresstheworkflow,statisticalvalidityofreview, andthequalityneedsoftheprovince.Thiswouldincludeassessmentsofcurrentprovincial resourcesincludingexistingPACsystems,theprovincialnetwork/gateway,theimagetransfer gridandotherfacilitiesastotheirsuitabilitytosupportthissystem. 2. Definetheworkprocessessothatconcurrentreviewcanbedistributedamongstpeersinall healthauthorities. Allradiologistswouldparticipateinthisactivityandwouldhavetheir workreviewedbypeers 3. Definereportingprocessestothediagnosticimagingdepartments,theradiologistsandtothe Boardsofthehealthauthorities.
Recommendation#2RetrospectiveScreeningPeerReviewstoSupportQuality
implemented.Theneedtocontinueretrospectivescreeningreviewsoffacilitieswillbeassessed whentheconcurrentpeerreviewsystem(Recommendation#1)isimplemented.
Recommendation#3 DiagnosticAccreditationProgramMedicalReviews
Recommendation#4 HealthAuthorityBoardResponsibility
As indicated in recommendation #1, the health authority Boards should receive and evaluate the reports generated by the peerreview systemand to take actions as necessarytorectifydeficiencies withrespecttoimagingmodalitiesorprovidersatsitesforwhichtheyareresponsible.
Conclusions
Geographyandaccesstospecialistproviderslimitstheopportunitiesforformalandinformalpeer review. Theimplementationofprovincewideimagereview,incorporatingallprovidersregardlessof whereinBCtheyareprovidingservices,willstrengthenthediagnosticimagingservicesprovidedby thehealthauthoritiesandwillbettersupportourproviders. Thesecondphaseofthisreviewistoprovide recommendationsto the Ministeronhow health authoritycredentialing andqualityassuranceprocessescanbeimproved.Itwillalsodescribe theindexincidents where physicianslackedeither the appropriatecredentialsorexperience to interpretimagesandwillincludeananalysisofthe responsesofhealth authoritieswhen they learned of problems.ThesecondphasereportwillbedeliveredtotheMinisteronorbefore August31,2011.
APPENDIX A
Dr. Doug Cochrane Investigation into Medical Imaging Credentialing and Quality Assurance Terms of Reference
Phase 1
Objective:
The objective of Phase 1of the investigation is to ensure that radiologists currently practicing in BC are appropriately credentialed and experienced to interpret images generated by medical imaging modalities.
Scope:
Radiologists that read and interpret images from all medical imaging modalities are within scope of Phase 1,but the focus of Phase 1will be on: Ultrasound, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and lnterventional Radiology procedures.
The scope includes images generated by health authority owned and operated sites,as well as images that may have been produced elsewhere and referred to a health authority for diagnostic interpretation. Radiologists that work solely in Community Imaging Clinics and do not provide publicly-funded medical imaging services are not within scope.
Process:
Dr. Cochrane will gather information from each health authority, the BC College of Physicians and Surgeons,and other sources as required,about the individual radiologists including their appointment history,educational background,medical credentials/privileges, and license status.
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Phase 2
Objective:
The objective of Phase 2 of the investigation is to provide recommendations to the Minister of Health Services on how the credentialing and quality assurance processes within health authorities can be improved.
Scope:
The following is within scope of Phase 2: A full description of the incidents where physicians lacked either the appropriate credentials or experience to interpret images,including analysis of the response by health authorities when they learned of problems,the relationship between the BC College of Physicians and Surgeons and health authorities,and the relationship between the BC College of Physicians and Surgeons and other professional and regulatory bodies in BC and other provinces. A review of all processes related to physician credentialing and privileges within health authorities,including the role played by the BC College of Physicians and Surgeons.
A review of all processes related to quality assurance and peer review of medical imaging reports.
Further issues that arise during the course of the review.
Process:
Dr. Cochrane will gather information for fact finding and analysis by working with representatives from each health authority,the BC College of Physicians and Surgeons,the BC Radiological Society,the Ministry of Health Services and other organizations as required.
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APPENDIX B
650 West 41st Avenue Suite 610, North Tower Vancouver, BC, V5Z 2M9 T 604.668.8210 F 604.668.8220 www.bcpsqc.ca
As you are aware, arising from concerns regarding the quality of professional practice, I have been asked to undertake a review of the credentials of members of your medical staff who have been granted privileges in diagnostic imaging (radiology) by your Health Authority Board. This is the first phase of a comprehensive investigation of radiology medical staff credentialing and clinical quality assurance processes in the health authorities. In order to complete the first phase review which is focused on diagnostic imaging, as defined by Minister Hansen, I request the following information, provided in a readable electronic format. Regarding your medical staff appointment and re-appointment process, 1. 2. 3. Copies of your current Medical staff Bylaws and Rules. A copy of your medical staff application form and reappointment form. An outline of your process for credentialing, appointment and re-appointment, including the process used for verification of medical licence and any associated restrictions in B.C. or other jurisdictions, reference checks and document verification, the administrative officers and Medical Advisory Committee(s) responsible.
Regarding the diagnostic imaging (Radiology) health authority structure, 1. A description of diagnostic imaging organization in the Health Authority and its facilities (hospitals and other facilities). As the relationships between the medical staff and the facility may differ, please describe the models in place in your Health Authority. For example, is there a Health Authority-wide department or is diagnostic imaging organized locally in a hospital or a programme. The description should include answers to the following questions: a. b. c. What is the administrative structure responsible for quality and safety in the department/programme? How does this structure interface with the members of the medical staff? Is peer review done in the hospital or the Health Authority, and if so, describe how, when reviews are undertaken and by whom?
2.
Documentation of the most recent DAP review including: a. b. Date of last review of diagnostic imaging. Summary of recommendations. Contd./2
-2Regarding individual medical staff members holding privileges in diagnostic imaging, Using the appended template, please provide the following information for each individual currently interpreting ultrasound, CT and MR images of any body system and those providing interventional radiology services in your Health Authority. Please include individuals interpreting images generated by your Health Authority facilities and images that may have been produced elsewhere and have been sent/referred to your Health Authority for diagnostic interpretation. Also include radiologists who are working in the community for your Health Authority and medical staff members in Radiology who have departed your Health Authority in the past five years. The appended template includes the following data fields: Anonymous identifier Appointment to the Medical Staff Date of appointment Date of last reappointment Facility where the individual practices Administrative officer (Department Head or other) responsible for interpretive quality DI specialty credentials Specialty credentials (Y/N) Specialty Credentials/privileges in: CT specify body systems 2010 number of reports specify body systems MR specify body systems 2010 number of reports specify body systems Ultrasound Paediatric 2010 number of reports Obstetrical 2010 number of reports General 2010 number of reports Specialty systems 2010 number of reports Interventional (body system) 2010 number of interventional procedures specify body system Date CT scanning interpretation started Date MRI interpretation Started Qualifications of the medical staff member Undergraduate education School Degree granted Date of graduation Postgraduate education University RCPSC certification Date of certification Re-certification if applicable Date of re-certification Maintenance of competence programme Date of last submission Append copy of 2010 submission to the MOCERT Certification by other professional colleges Subspecialty qualification Programme Date completed Contd./3
-3B.C. College of Physicians and Surgeons licence Type of licence Date of licensure Restrictions or limitations on licence applicable to diagnostic imaging (voluntary or College) College required remediation with respect to diagnostic imaging Date of remediation order Date restriction removed by College or individual Departmental Reviews Date of last review of this individual by Department Head or equivalent Non-technical (for example Physician Achievement Review or equivalent) Date of last review Areas for improvement Diagnostic interpretive review Date of last review Areas for improvement
Please forward this information to Andrew Wray (awray@bcpsqc.ca) at the B.C. Patient Safety & Quality Council by Wednesday, February 23, 2011. Please confirm the contact person to whom the review team may address questions should they arise. I thank you and your staff for your assistance in providing this information. Please do not hesitate to contact Mr. Wray or myself if you have questions or concerns.
Yours sincerely,
D. Douglas Cochrane, M.D., FRCSC, FAAP Provincial Patient Safety & Quality Officer and Chair, B.C. Patient Safety & Quality Council DDC/ec
A APPENDIX C
Revie ewMethodo ology
Theevaluationcon nsidereddata aprovidedby thehealthau uthorities,the eCollege,and dthe nosticAccreditationProgra am(DAP). He ealthauthorit ydataforind dividualswas Diagn anony ymizedpriort tosubmission ntothereviewer: A.Theeducation,certificat tionandlicen nsureofphysiiciansprovidingdiagnostic cimaging
se ervicesinBC:
yalCollegeof Physiciansan ndSurgeonsc certificationin 2. dateofRoy diagnostici imaging, dicallicensurebestowedb bytheCollege eofPhysician nsand 3. typeofmed
4. 2010RoyalCollegeofPh hysicianandS SurgeonsofC Canada ceofcompet tence(MOCER RT)hoursand d, maintenanc 5. dateofapp pointmentandlastreappo ointmentbyt thehealth authority,t thelocationo ofservice,and danylimitatio onsimposedupon thatappoin ntment. B.Thecurrent tscopeofpra acticeinCT,M MR,ultrasoun ndandinterve ention,forea ach providerb baseduponth henumberof servicesprov videdin2010 0; C. Themostr recentDiagno osticAccredit tationProgram mreviewsofdiagnosticim maging
facilities;a and
D.Currentlice ensinginform mationforindi ividualradiolo ogistsprovidi ingdiagnostic c imagingse ervicesinthehealthauthoritysectorin BC(provided dbytheCollegeof Physicians andSurgeon ns).
Thep practitionersw weregrouped dforreviewas fo ollows:A.BCregistrationt toprovide diagnosticimaging; Full,provisi ional,conditio onal
B.CertificationinDiagnosticImaging;
h hours Ev vidence of co ontinuing medical educatiion relevant to CT, MRI, ultrasound o or int terventioninparticularforthoseindiviidualswhowerecertifiedpriortoeithe er 19 982(CT,ultras sound)or199 90(MRI)
Follow wing review of the anony o ymized data for each prov f vider, the he ealth authorit VP Medicine ty was asked for clarification of fact, for missing information if available and oth f n her mmendations. recom