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LCSR Performance Improvement Overview

Purpose

This series of articles describes how radiologists, other clinicians, and administrators can use Lung Cancer Screening Registry (LCSR) performance reports to plan and implement a performance improvement (PI) project at their institutions.


The LCSR is a data registry that helps clinicians monitor and demonstrate the quality of a CT lung cancer screening (LCS) program through the submission of LCS data and review of periodic feedback reports that include peer and registry benchmarks. These objective comparisons are used to advance lung cancer screening practice, target specific areas for improvement, implement performance improvement programs, and improve patient care.


LCSR participating facilities choose a performance measure on which to base improvement interventions. The impact of the intervention is measured by comparing the facility’s target measure calculated during the baseline period to the same measure calculated during the post-intervention period.


Background

The ACR's LCSR Committee established a subcommittee to focus on offering registry participants PI and educational opportunities. The subcommittee members identified three measures they anticipate having the most impact on and being the most feasible for implementing PI initiatives. The Radiation Exposure - Mean Volumetrics CT Dose Index (CTDIvol) measure has been included in the LCSR since its inception. Two recently developed LCSR measures include Adherence to Annual Screening and Non-Smoking Rate.


The subcommittee developed a Plan-Do-Study-Act (PDSA) Worksheet tailored for the LCSR PI projects and accompanying instructional articles as tools for implementing and documenting PI efforts based on the three measures. The PDSA cycle is shorthand for testing a change in practice by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). Used in the Institute for Healthcare Improvement’s (IHI) "Methods and Tools for Breakthrough Improvement" course, the PDSA format has been used by hundreds of healthcare organizations.


Note: Read the article Beginners Guide to Practice Quality Improvement Using the Model for Improvement to learn more about the IHI's model including a case study that illustrates how the IHI's improvement model can be used in the radiology setting.


Watch the PDSA Methodology video below for an overview on the PDSA model and why the ABR recommends it as an effective model for medical continuous quality improvement. The video walks through each of the 4 stages and what to consider as you progress. (PDSA Methodology video reused from Practice Quality Improvement with the JACR with permission from Otto Schoeck and the JACR.) 


PDSA Availability Timeline

An Achieving Appropriate Radiation Dose PDSA Worksheet and accompanying instructional articles are now available. PI materials for the Improving Adherence to Annual Screening and Increasing Smoking Cessation Rates projects will be available in early 2023. 


Directions

1. Plan

Start by looking at your LCSR radiation dose data. Talk with your colleagues to obtain buy-in and assemble a project team. Measure your baseline data. Identify a problem area and interventions for improvement. 

2. Do

Involve all necessary staff and departments and implement improvement interventions.

3. Study

Measure your post-intervention data and compare to baseline data. Draw conclusions on the interventions’ effectiveness.

4. Act

Plan how to sustain or spread successful improvements or modify/identify different interventions to try in the next project cycle.


Follow the PI Project Walkthrough which will guide you through each step of the process. Use the PDSA Worksheet to help your team document your progress. The Walkthrough explains how to complete each section of the worksheet. 


Download the PDSA Worksheet Attachment (docx)


Articles Outline

The series of articles below is designed to support and guide you in using your LCSR data for PI. We encourage you to reference them frequently as you plan and work through the stages of your project.


Performance Improvement Project Walkthrough

This article presents how to complete each stage of a PDSA PI project and document your progress using the PDSA Worksheet.


Performance Improvement Resources

This article contains a continually updated collection of performance improvement reference material including publications, videos, web articles, and templates. 


Achieving Appropriate Radiation Dose - Rationale

Introduction explaining the reasons this LCSR measure is important in clinical practice and how improvement is necessary to patient care. 


Achieving Appropriate Radiation Dose - Data Review

This article explains how to analyze your data and identify areas that can be targeted for interventions.


Achieving Appropriate Radiation Dose - Interventions

Suggested interventions to improve each measure and supportive resources on what has worked for others.


Performance Improvement (PI) Continuing Medical Education (CME) Credits

LCSR participants starting and completing a PI project using the PDSA Worksheet within the specified 3-year period will qualify for PI-CME AMA PRA Category 1 Credit™. Click here for details.

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