Echocardiographers and cardiac sonographers can certainly agree that evaluating and improving the quality of echocardiography laboratories is a topic of high interest and importance. As professionals, we always strive to provide the best services possible to our patients. We know that every member of the echocardiographic “team”, including the cardiac sonographers, nurses, physicians, and laboratory support personnel, has an important role in producing our final work pro-duct—diagnostic evaluations that answer clinical questions, address important findings, and help requesting caregivers to provide high quality care to their patients. We realize that when patients come to us for an echocardiogram, in some ways they also become “our” patients; while we may not be responsible for the details of their day-to-day care, we want to do our best to facilitate what ultimately is best for them. Toward that end, we understand that high quality echocardiography depends upon proper training and skills for all members of the team, and proper operation of the environment in which echocardiography is performed, regardless of where the services are provided. The American Society of Echocardiography (ASE) has for years emphasized the importance of physician training and expertise, sonographer training and professional credentialing including professional licensure (where applicable), and accreditation of the laboratories in which services are provided.
In this issue of the Journal of the American Society of Echocardiography , an important ASE Guideline article by Picard et al . describes a framework for evaluating and improving the provision of echocardiographic services. Written by a distinguished group of leaders in our field, this document describes how echocardiography laboratories ought to be structured (including the space, personnel, and equipment needed to provide echocardiographic services), discusses the process of acquiring and interpreting images, and makes recommendations about how to evaluate and improve operational quality. We believe that this is an important document, and urge all echocardiography professionals to read it carefully. While we certainly endorse the importance of assessing quality, identifying areas in need of improvement, and instituting methods for quality improvement, we also believe that several specific points deserve emphasis.
What Is Quality?
While everybody agrees with the concept that “quality is important”, it is also important to recognize that the word “quality” can have different meanings. One can use this term to describe an attribute; for example, a person can have an “outgoing” or a “standoffish” personality, while an object can have a certain mass. The same term may also be used to describe the inter-action of melody, harmony, and rhythm in a musical composition, which determine its quality of sound. In the business world, “quality” is often used to describe conformance to pre-specified requirements, or to expectations. Experts agree that this term is rather subjective. As applied to the performance of diagnostic echocardiography studies, “quality” is used to describe “adherence to established guidelines”. The meaning of “quality” then depends upon what guidelines are considered, and what levels of performance are expected.
Perhaps a baseball analogy might help. For the sake of discussion, let’s say that Babe Ruth was the greatest baseball player ever. Some might disagree, and perhaps argue that Willie Mays, Hank Aaron, Joe DiMaggio, and Ted Williams played at an equivalently high level. Most baseball fans would concur that these players had extraordinary skills and performed at the highest level. At the other end of the spectrum, many children enjoy playing Little League baseball, and it is easy to see that their level of skill and performance is not up to major league standards. In baseball, the quality of play ranges widely, from the weekend athlete who enjoys the game but does not play it very well, to the perennial “All Star” player whose skills and accomplishments are listed in record books. In addition, it is important to note that some players’ skills improve considerably over time. Every year, baseball fans see a young player who has worked his way up through the minor leagues and, by virtue of long hours of practice, hones his skills to a level that justifies his being promoted to the “big league” club. It is also fair to observe that if only “All Star” players were allowed to play professionally, the number of teams would be very small, and many fans would be deprived of games to watch. In many cities and towns throughout our country, baseball fans get great joy out of attending accessible, affordable, competitive minor league games where the level of play is not at major league level, but is nonetheless entertaining and most enjoyable. In other words, the level of performance that is deemed “acceptable” depends on one’s expectations. No team is comprised exclusively of “all stars”, and teams whose players are only “good”, but who play well together, can achieve considerable success.
Applied to echocardiography laboratories, quality also might refer to several different levels of performance. One could promote the very highest level of performance as the standard to be met—in effect, analogous to the All Star level. We might term this “optimal practice”, and have seen others use the term “best practice” to describe this high level of performance. It is worth re-emphasizing that while optimal practice is a valid and important goal, not everyone will be able to achieve this level of performance (as Picard et al . acknowledge), just as few baseball players can be expected to be able to play at a level of excellence approaching “The Babe”. This does not mean that “optimal performance” is an inappropriate level of quality to promote, but it does mean that this performance level ought not to be used to determine who should be allowed to play. Again, a realistic level of expectations is important, so that a patient whose care depends on the results of an echocardiographic evaluation will have access to this evaluation when it is needed.
In this regard it is of critical importance to emphasize that recommendations discussed in the article by Picard et al . are intended to serve as “minimum quality standards” and deemed to be “realistic goals for the average practitioner”. To apply the baseball analogy, this might be considered equivalent to achieving a level of performance that is appropriate to play professionally. Some laboratories will perform at a “minor league” level, some will perform at the “major league” level, and a small number will develop the skill and expertise to be considered “All Stars”. While these different gradations of “quality” may be notable, it is important to remember that all of these quality levels are considered “good enough to play professionally”. Equally important, of course, is to remember that (as in baseball) laboratories in which quality improvements are needed can work hard to elevate their level of performance in order to achieve or surpass minimum standards. We recognize and support the benefits of performing careful and thorough examinations, but would suggest that some flexibility is needed in judging how complete a “complete” study needs to be. For example, in a patient with symptoms of heart failure and no clinical reason to be concerned about an aortic coarctation or dissection, one might legitimately argue that it would be more important to spend some extra time evaluating left ventricular systolic and diastolic function carefully, rather than to spend the same energy recording views of the aorta from the suprasternal notch. Ultimately, “minimum quality standards” in echocardiography must achieve a balance between the desire, on the one hand, to protect patients from services of substandard quality, and the need, on the other hand, to assure that patients whose care requires echocardiographic evaluation will have access to those services when they are needed. We believe that the recommendations by Picard et al . do a good job of considering that balance, and agree with their observation that the recommendations in their document are “only advisory”. We believe that the spirit of this document would be best served if the recommended elements were used to evaluate and make improvements in quality, and not to penalize those who do not quite measure up.
Continuous Quality Improvement
As discussed above, one can identify different levels of “quality” performance, and it is certainly possible for practitioners and echocardiography laboratories to improve their performance and thereby provide services of higher quality. A brief review of the process of “continuous quality improvement” (CQI), seems in order. CQI is in essence a management philosophy that focuses on the expectations of “customers” and that is based on the concept that most products can be improved. Importantly, CQI focuses on processes rather than individuals; when a product does not meet customers’ expectations, blame is not assigned to the individuals involved in producing the product, but instead attention is focused on those processes that need improvement. Improvements are made through a series of steps, including reviewing and measuring performance at the various steps in the creation of the product, identifying problems or areas needing attention, analyzing the cause(s) of the problem, developing methods for making improvements, implementing these approaches, reviewing and measuring performance after process improvements have been made, and the repeating the process, focusing on other problems that have been identified.
Let’s consider how this applies to echocardiography. What is the product? While it seems logical to think that the product is an “echocardiogram”, from a broader perspective we would argue that the product is a diagnostic evaluation utilizing cardiovascular ultrasound, the result of which is used to improve the care of the patient. Who are the customers? The requesting caregiver (often termed the “referring physician”, although echocardiographic services also can be requested by mid-level providers) is certainly a “customer” who has certain expectations about the “product”; he or she wishes to obtain a timely examination that is pertinent to the clinical concerns, performed accurately, and interpreted and reported promptly in a manner that facilitates good patient care. Of course, the patient is also a “customer” whose expectations may overlap considerably with those of the caregiver, but who may expect in addition to be treated kindly, gently, and personally, and who may also have considerable anxiety about the procedure and its results, requiring a certain amount of empathy and explanation. The institution providing echocardiography services, such as a hospital or office-based echo laboratory, is in some ways the provider of the service, but also a “customer” in the sense that the institution will expect the laboratory to meet certain performance measures, likely including number of studies performed per employee, number of studies needing to be repeated because of incomplete or questionable results, patient satisfaction measures, and financial concerns. Depending on the setting, third party payers could also be considered as “customers” with expectations of their own, although increasingly reimbursement models seem to be turning toward reimbursing “episodes of care” based on average costs, and not based on individual services such as echocardiography. This list may be incomplete, but it does emphasize that echo laboratories produce products and need to be aware of the expectations and needs of their various customers.
With that background, let us now consider a hypothetical laboratory, located in a hospital with a large oncology unit. The laboratory has for years been evaluating left ventricular (LV) function qualitatively, describing it in terms such as “normal”, or “mildly”, “moderately”, or “severely” reduced. The oncologic caregivers, however, believe that they need a quantitative expression of LV function so that they might choose and adjust chemotherapy regimens in an appropriate manner. To meet this need, they order radionuclide angiography to measure LV ejection fraction (LVEF), and echocardiography to evaluate overall cardiac function as well as valvular performance, and to assess for pericardial disease. In evaluating laboratory performance profiles, a manager might discover that nearly all oncology patients who are sent for an echocardiogram are also sent for an EF determination by radionuclide angiography. This might then lead to the realization that by using quantitative methods used to determine echocardiographic LVEF (for example, by measuring and reporting ejection fraction as “45%” rather than as “mildly reduced”), the echo lab might provide more useful results to the requesting caregivers, which might in turn help them to tailor therapy more efficiently, to the patients’ benefit. The hospital would expend fewer resources but be able to provide the same quality of care, more quickly. The sonographers or physicians who had been performing qualitative studies would not be criticized for doing things badly, but rather would become part of the solution and derive the satisfaction of knowing that by modifying their procedures, they were able to provide a better product and to meet their customers’ expectations. Note that this scenario all starts with a careful evaluation of laboratory performance, identification of a problem, development of a proposed solution, implementation of that approach, and assessment of the results, in what is in effect a continuous loop focused on improving quality.