March 07, 2023

The Power of Collaborative Learning and Quality Improvement to Enhance Patient Care

In this issue, Ben C. Wandtke, MD, MS, discusses real-world approaches that can help radiology practices solve today’s complex healthcare challenges and deliver better patient care. He highlights how participating in the ACR® Learning Network and attending the 2023 Quality and Safety + Informatics Conference can lead to an action plan for quality improvement.

What is the ACR Learning Network and how does it contribute to quality improvement?

The ACR Learning Network is an initiative to improve diagnostic imaging care through a learning health systems approach. A radiologist expert leads each of four improvement collaboratives that are focused on improving lung cancer screening, mammography positioning, prostate MR image quality and recommendations follow-up (RFU). The collaboratives are comprised of teams from four to six sites per cohort working together to solve the same problem, at the same pace and time, within their respective healthcare settings.

Each collaborative develops and refines one or more performance measures to support the progress of the individual site projects and the progress of the entire collaborative. Learning together helps identify common methods to build a culture of performance measurement in these four important areas of cancer diagnoses.

The Learning Network focuses on improvement-driven metric design, which is the real-world application of performance metrics that directly impact the outcomes of patients involved in these programs. Instead of a group of experts getting together and determining the right way to measure success, our teams work collaboratively to suggest ways to gather data and measure program success that work in the real world.

What is the status of the first cohort of improvement collaborative participants and what new opportunities lie ahead as you move into the second and third cohorts?

The first cohort graduated at the end of 2022, and those organizations are now transitioning into the ongoing phase of collaborative participants where they will continue to share their data with the collaborative. The cohort 1 sites have laid important foundational work, such as problem definition, refining quality improvement measures and developing process maps, that will support subsequent cohorts in getting off to an accelerated start. Participants will share measures, common issues and solutions to improve performance, so we're going to continue to get stronger as a learning network as we grow with each cohort. This common support infrastructure will also address multiple problems and sustain the learning network over time.

The second cohort is now getting underway, and we are accepting rolling applications for cohort 3, so we invite any sites who are interested in participating in the ACR Learning Network to join us.

As the physician lead for the RFU collaborative, what are your goals for the upcoming cohorts?

The RFU collaborative addresses the problem of incidentally detected lung nodules. Lung nodules are incredibly common, identified in millions of patients each year in the United States. While only a small minority of lung nodules represent lung cancer, the huge number of lung nodules identified results in an opportunity to identify many more early-stage lung cancers. Despite their prevalence, management of lung nodules is highly variable and many are simply ignored.

The RFU collaborative is attempting to identify the most worrisome lung nodules and standardize follow-up care, essentially creating programs of opportunistic screening. We've worked hard in the first cohort to identify ways to standardize the recommendations being made to assure that all appropriate nodules of significant size have a recommendation for follow up.

In addition, we worked to measure and improve follow-up compliance with our recommendations. Our goals for the next cohort include identifying metrics for success in incidental nodule tracking that can be readily applied and potentially used for value-based payment programs in the future.

When it comes to lung nodules, why is standardizing recommendations and creating real-world measures for follow-up care so important?

About half of potentially malignant lung nodules are not followed up currently at most sites around the country, despite radiology recommendations to do so, which places many patients at risk for delayed diagnosis of lung cancer. With five-year survival rates for early-stage lung cancer being relatively high (over 60%), there is a significant benefit to identifying more early-stage lung cancers.

Tracking programs for incidental findings work very well in conjunction with lung cancer screening programs to increase the percentage of lung cancers diagnosed at an early, more treatable stage. In our experience, about three quarters of lung cancers identified through tracking programs are caught at an early stage, which potentially represents many lives saved.

We believe that every patient deserves their best chance for a cure, and early-stage diagnosis is the best way to guarantee that.

How does the RFU learning collaborative contribute to real-world solutions?

Tracking incidental lung nodules is a complex problem. Complex problems often require teams and significant iteration on early ideas to solve them. This lends itself well to performance improvement tools that the collaboratives are using.

As part of the process, participants measure the performance of their programs and look in depth at the root causes for failure in their programs when things aren't working well. This leads to the identification of key drivers for success and the development of focused interventions to improve performance. We measure that performance over time, and we share the results transparently with other collaborative participants.

When one site identifies a breakthrough, it is shared with all of the other collaborative participants, who can attempt to replicate that improvement effort and determine if it works in their environment as well. That's the power of collaborative learning.

What types of practices should join the RFU collaborative in the new cohorts?

Essentially any practice with an existing lung nodule tracking program is encouraged to apply to the RFU collaborative. Your program does not need to be particularly mature, but the organization needs to be willing to measure its effectiveness, share that measurement transparently with other collaborative participants and be open to making changes to their programs as they learn.

What are you most excited about for the future of the RFU collaborative?

We are still at the cutting edge of quality improvement in recommendations follow-up. Right now, only a minority of organizations are actively participating with incidental findings tracking programs, so there is not a great deal of literature on the topic or a clear best practice for how often and what message to communicate to patients and providers. We simply don't know the best way to tackle this problem yet.

We believe the fastest way to identify best practice is to have multiple organizations attempting to tackle this problem with many different approaches and sharing their successes and failures openly. The learning network approach should help the radiology community reach a best practice state much faster than is possible with individual organizations working in a vacuum.

Switching gears a bit, let’s talk about the Quality and Safety + Informatics Conference and why people should attend in 2023.

The Quality and Safety + Informatics Conference is the largest dedicated gathering of quality and safety experts in radiology each year. If you could pick just one conference to attend to learn from the leaders in quality and safety, this is it. There's just no other conference that that provides this level of focused attention on quality and safety.

There are a few big changes happening in 2023. The first is that the conference will be moving to the West Coast for the first time in a number of years. It will be held Oct. 24–26 at the Sheraton San Diego Hotel in California. The meeting is scheduled midweek, to allow for travel time while avoiding conflicts with family obligations and weekend call duties.

We are also working with the ACR Informatics Summit planning committee to more closely integrate the two meetings with a full day of overlapped content as part of a three-day conference. The overlap among operations, informatics and quality improvement — especially in areas like lung cancer screening, incidental findings and artificial intelligence — creates synergies and significant opportunities to enhance patient care.

Why should people come to the conference this year?

The planning committee has made a conscientious effort to broaden the scope of content to ensure the meeting is relevant not just to experts in quality and safety, but to anyone with a leadership role in clinical operations and informatics. Whether you are a physician, radiologist or a staff leader, we'll have content for everyone.

Beyond the ability to access outstanding content from national quality and safety experts, you're going to be in an environment where you can make contacts and network with people who are dealing with the same operational and safety problems you face at your organization. You will hear from people who have solutions to address these challenging and complicated operational and quality improvement problems.

One of the goals of the planning committee is that everybody should leave the meeting having a concrete first step towards solving the problems we discuss. You're going to walk away with an action plan for how to get started building a team and obtaining the resources needed. You will know who the right contacts are to get you started, whether it's a vendor to implement an IT solution or a connection to someone from another organization who has solved that particular problem and can shed insight that will save you time and wasted effort.

Last question: Do you have one or two actionable steps your colleagues should take on the quality improvement journey?

First, I would say, whether you're a radiologist, trainee, technologist, nurse or administrator, that optimizing the performance of your clinical operations simply can't be done without accepting a mindset of continuous quality improvement. Everything we do in radiology (and in healthcare in general) can be improved.

In my experience, your ability to impact the performance of your organization will be significantly increased if you have knowledge and skills in quality improvement — addressing concerns and problems with a strategic and standardized approach. Quality improvement is not just for the vice chairs of quality and safety; it is a general skillset for everyone who aspires to be a leader in radiology and in healthcare.

A great first step on the journey to quality improvement would be to join us at the ACR Quality and Safety meeting in 2023. And a second step is to join one of the four collaboratives in the ACR Learning Network.

In the Spotlight

Ben C. Wandtke, MD, MS

Ben C. Wandtke, MD, MS, is an Associate Professor and Vice Chair of Quality and Safety in the Department of Imaging Sciences at the University of Rochester (UR) Medical Center. He is Chief of Radiology at FF Thompson Hospital and Director of the UR Medicine CT Lung Screening Program. In 2015, he developed and implemented the Backstop Program, one of the nation’s first incidental findings tracking systems. He is active in leadership having served on the board of directors for the University of Rochester Medical Center and Thompson Health.

Dr. Wandtke also serves on the ACR Quality and Safety and Informatics Commissions, helping to facilitate adoption of incidental findings tracking solutions. He serves as Chair of the Quality and Safety + Informatics Conference planning committee and has chaired Data Science Institute Committees on Non-Interpretive Artificial Intelligence. Dr. Wandtke is the physician leader for the ACR Learning Network recommendations follow-up collaborative, which is focused on improving the management of lung nodules.

He is actively involved in ACR efforts to develop quality and equity metrics for incidental findings management.

He has worked closely with medical informatics companies to develop commercial solutions to facilitate incidental findings tracking.