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LCSR Performance Improvement Project Walkthrough


This article presents how to complete each stage of a Plan-Do-Study-Act (PDSA) performance improvement (PI) project.

Available Projects 

The LCSR PI project topics Achieving Appropriate Radiation Dose and Increasing Adherence to Annual Screening, and Improving Smoking Cessation Rates are available to help facilities assess their performance.

PDSA Worksheet

The PDSA Worksheet allows you to easily document your PI project. A project may have multiple cycles for testing a variety of improvement interventions to meet your performance goal. A new worksheet should be completed for each cycle of improvement.

PDSA Worksheet

In each of the following blue sections, the related portion of the PDSA Worksheet will be explained as well as how to use your LCSR data to fill in each section to document project progress.

PDSA Steps


Access Your Reports  

1. Log in to the NRDR Portal with your user credentials. If you do not have NRDR login credentials, contact your Corporate Account Administrator or Facility Administrator to assign you a user profile or submit a ticket to NRDR Support for help. 

2. Under the section Quality Improvement Registries in the portal's left menu, select LCSR. Then, under the Interactive Reports section, select Facility Comparisons.

Review Your Data

Reviewing the LCSR Facility Comparison Report is a good place to start to help determine if a PI project would be feasible and worth pursuing for your facility. The Knowledge Base article LCSR Facility Comparisons Report provides an overview of the report's features and how to compare your facility's performance with national performance. 

Four brief videos provide details about the report's peer comparisons, annual trends, measure rates, and peer rankings. (ACR is updating these videos to visually align with the current report version. Functionally, the content discussed still applies and can be used to better understand the Facility Comparisons Report.)

Two tabs within the Facility Comparisons Report are available specifically to support participants completing a PI project: 

  • PI Analysis tab helps you to dive deeper into your performance data to look for root causes and analyze outliers.

  • PI Assessment tab is used for baseline and post-intervention performance data and can be used as a control chart.

Review the Data Review article for each measure for more information about the new reports’ purpose and functionality.

Select a Measure

Upon reviewing your LCSR performance data (described in the Data Review articles) determine which measure would be best for an improvement project at your facility. Consider criteria such as the extent of the opportunity for improvement, potential buy-in from leadership, available team members, impact on patient care, and other relevant factors. If you choose radiation dose, you will also need to select a BMI category to focus on.

PDSA Worksheet

Project Selection and Team

QI Project Title: Select a measure for your project.

BMI Category: For the Achieving Appropriate Radiation Dose project, select a weight category that will be the target of your interventions.

Determine the Participants

Including the right people on a PI team is critical to a successful project. Teams vary in size and composition. Each organization builds teams to suit its own needs.

First, review the measure and your goal for improvement. Second, consider the system related to that goal: What system will be affected by the improvement efforts? Third, be sure the team includes members familiar with all the components of the process — managers and administrators as well as those who work in the process, including physicians, physicists, nurses, and front-line workers. Fourth, if you are a multi-facility organization, which facilities should be involved? Finally, each team needs an executive sponsor who assumes responsibility for the success of the project.

PDSA Worksheet

Project Selection and Team

Corporate Account and Facilities Included in the PDSA Cycle

Corporate Account: Enter the name and ID of your LCSR corporate account.

Associated Facility(ies): Enter the names and IDs of all facilities within the corporate account participating in the project.

The Project Team

Project Lead: Enter the name, role, and email of the project leader or main point of contact. This person is responsible for the project and is involved in all stages.

Project Team: Enter the name, role, and email of all individuals contributing to the project. This should include those familiar with all the components of the process and may include persons outside the radiology department or practice — managers and administrators as well as those who work in the process, including physicians, physicists, nurses, and front-line workers. Participants must be named here to claim CME for the project.

Set a Project Timeline

Determine the start and end dates of your project. Start by deciding the period you will use for your baseline data and how long you want to spend implementing your improvement interventions. You will need to allow some time for the interventions to take effect before collecting post-intervention data, and the amount of time and exams used for post-intervention data should match the baseline, so results are comparable.

PDSA Worksheet

Project Selection and Team

Cycle Start Date: Record the date of the start of the PDSA cycle. This can be when the project is approved by your facility when you start documenting baseline data, or at any time point you consider the official start.

Cycle End Date: Record the date of the end of the PDSA cycle. This is the date when you have completed the Act part of the cycle. Setting a clear end date for your project increases the likelihood of successful completion.

Document Baseline Data

Use the PI Analysis tab of the Facility Comparisons Report (example below) to review your performance data at the Corporate Account or Facility level. This report can help you define your PI project, for example, if you will focus your efforts on the overall Corporate Account or only select facilities across all BMI categories or a specific BMI category. You can also determine what length of baseline period would be meaningful for determining improvement after an intervention.

Enter your baseline start and end dates into the PI Assessment tab (example below) to review your baseline data. After allowing time for the intervention to take effect, you will enter your post-intervention data timeframe into this report for comparison. This report is further described in the Study section of this walkthrough.

PDSA Worksheet

Document Baseline Data

Baseline Timeframe Selected: Enter the start and end dates for your baseline data. 

Baseline Measure Performance: Record the baseline measure performance (mGy value) for all or several facilities within your corporate account (listed individually or combined) or for a single facility.

Baseline Registry Median: Record the baseline registry median. 

Set a Goal and Analyze Baseline Performance Results

Consider clinical guidelines, peer-reviewed publications, and LCSR registry statistics to determine a performance goal for the measure. Determine where you would like to be in 6 months to a year. The goal should be time-specific and measurable; it should also define the specific population of patients that will be affected. Instead of your goal being a specific value, use a mean value (e.g., a mean of 5%) as reaching this goal is much more likely indicative of a true change due to your interventions and not the result of typical random variation.

PDSA Worksheet

Determine the Performance Gap

Performance Goal: Establish a desired goal for the measure. What does the group want the measure value to be to achieve an appropriate standard of performance and/or patient care? Provide a statement about what you intend to achieve by implementing an improvement cycle to include an estimate of the amount of improvement—for one or multiple facilities. For example: After 6 months, the average CTDIvol dose index for healthy weight patients will be reduced by a mean of 5%.

Scope: Briefly describe the parameters or specific considerations for the cycle that may affect results. Will you focus only on certain facilities or modalities? What departments will be involved?

Analyze Baseline Performance Results

Performance Gap: Describe the root causes of the gap in performance. Include the methods you used to come to this conclusion, e.g., cause/effect diagram, Pareto chart or process maps.


Design an Intervention Plan

Discuss and adopt interventions to address contributing factors and root causes preventing you from reaching your performance goal. Review the Interventions article for the relevant measure and select interventions appropriate for your team and facility. The interventions described in the article are provided as examples that have been used successfully, but you may design your own.

Construct an Intervention Plan based on these findings and a process by which to implement the plan. The plan should provide guidance to the facility on who will participate, how often the group will meet, and what the goals and key activities will be. In addition, the plan should lay out the process that will be used to drive improvement in the facility, such as PDSA cycles, how these are to be documented, and the way current and ongoing status is going to be monitored using data.

Determine an appropriate time interval after plan implementation to allow for the plan to have its desired effect. Then proceed with re-measurement to assess improvement in the Study stage of the project.

PDSA Worksheet

Plan Interventions

Intervention Timeframe Selected: Enter the start and ends dates of the planned intervention.


Planned Intervention(s): Describe the planned intervention(s) your team will implement to improve performance.

Intervention Measurement: Describe how you will determine if the intervention is working. How frequently will you evaluate changes, e.g., weekly or monthly?


Measure Post-Intervention Results

During and after conducting your interventions, you need to know if they are making a difference and how close you are to achieving your performance goal. A run chart displays performance over time, but it can be hard to know if changes in values are due to a true change or typical random variation. Statistical process control helps discern this. A control chart is a run chart with 3 additional lines: a line in the middle called the centerline which is the performance median and lines above and below the data called the upper and lower control limits (defined as +/-  3 standard deviations from the mean). See the example below.

View the Statistical Process Control video below to learn more about the use of control charts in performance improvement projects. (This video was repurposed from the ACR Learning Network’s ImPower Program. Please disregard the reference to an improvement coach which is specific to that program.)

The PI Assessment tab of the Facility Comparisons Report enables you to view a control chart of your baseline and post-intervention performance data. There are 2 basic rules for reading a control chart: 

  1. If there are 7 consecutive points above or below the median, you can assume the underlying performance level has shifted.

  2. Only points outside the control limits indicate something out of ordinary happened and should be investigated.

You can continue to monitor your performance using the PI Assessment tab even after your project is over to see if improvement is being sustained over time. 

Using the PI Assessment tab, you can also view a baseline vs post-intervention “snapshot” of your PDSA cycle results.

Read the Data Review article for the relevant measure to learn more about the PI Analysis and PI Assessment reports.

PDSA Worksheet

Document Post-Intervention Data

Post-Intervention Timeframe Selected: Enter the start and end dates for post-intervention data. The amount of time should be approximately the same as the baseline.

Post-Intervention Measure Performance: Record the post-intervention measure performance (mGy value) for all or several facilities within your corporate account (listed individually or combined) or for a single facility.

Post-Intervention Registry Median: Record the post-intervention registry median. 


Post-Intervention Results: Describe post-intervention results as compared to your performance goal. 


Create a Sustain Plan

Determine whether the PI project has met its performance goal. If results met or exceeded the target, adopt the improved practice process as a standard and expand implementation if appropriate.

If results did not meet the target, re-evaluate the Intervention Plan by determining any problems with the plan design or implementation, including issues preventing root causes from being addressed effectively. Has the performance goal been set too high? Is an adjustment in order? Is the measure the correct one? Are modifications to the Intervention Plan warranted?

Proceed with additional PDSA cycle(s) as needed to adjust the Intervention Plan or the performance goal. Continue the existing project either until the performance goal is met or an endpoint is otherwise determined. (Any improvement identified through this process may be an indication of success and in some cases, the magnitude of improvement in the measure achieved may be all that can be reasonably expected.)

PDSA Worksheet

Plan for What's Next

Interventions to Sustain: What did you learn, benefits, challenges, etc. and how will you sustain improvements?

Interventions That Need Continued Work: Which interventions need further testing or refinement? Which will you test next, if any?

Claim CME

20 Performance Improvement (PI)-CME credits are offered for the completion of a PDSA cycle. For more information, please see the Requirements for PI-CME article.

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