Baptist Memorial Hospital Desoto

Meeting Agenda
December XX, 2016
7:00am
Type of Meeting: Quarterly Echo Quality Improvement Meeting (July- December
2016)
Meeting Facilitator: Kim Edwards, RDCS
Invitees: Medical Director, Technical Director, Cardiology Medical Staff, Echo
Technical Staff, Facility Administrator
1. Review Minutes
2. Quality Standards
a. Instrument Maintenance
i. Suggestion of designating one day a week to deep cleaning echo
rooms and machines- dusting, air filters, behind beds, desks,
etc- tech feedback on this
ii. New echo machine- Demo 6/17/16
b. Procedure Volumes Facility, Medical, and Technical 2016 YTD
c. CME Update Medical Staff and Technical Staff must have 15 CMEs
every three years relative to echo
1. All MDs are up to date with CMEs for 2016
2. Technical staff- per IAC- hard copies on premises
d. QA Meeting Attendance Medical Staff and Technical Staff
i. Will send reminders of upcoming meetings. Do physicians have
a preference on time frame/frequency of reminders?
ii. For 2016- only two required meetings a year to cover two
quarters worth of data- planning next one for December 2016
1. Dont have to be physically present, must sign off on
receipt of packet- packets contain pertinent information
for all staff
2. Still a 50% required attendance- since there will only be 2
meetings during the year, please be mindful of your
participation
3. Can either call in OR pick up meeting packet- packets are
left in your folders in the read room, please be sure to
grab these

4. Must still sign the sign in sheet at earliest availabilityit will be in the echo read room also- will send reminders
of doing this
5. Lunch and learns - Rhonda and Bill working with Scottie
e. Required Quality Assurance Measures
i. Appropriate Use Criteria
1. Performed at beginning of year- 100% appropriate
ii. Variability
1. Sonographer Variability- Two random studies per tech per
quarter
a. Make sure to include all three labeled Pedoff
Doppler views with every aortic stenosis
b. Watch for aliasing on Dopplers and gain
c. Be sure to include all required images listed in
protocol
d. If any image cant be obtained, must still be
recorded and labeled to document that an attempt
was made
e. Any valvular insufficiency is to be evaluated in two
planes with color Doppler- TR is to include multiple
measurements with CW
2. Physician interpretation variability- two random studies
per quarter were chosen for a blind overread to assure
consistency between physician interpretations
a. Study 1 and 2 - No variabilities
b. Study 3- Variability is present with LA size- original
report states moderately dilated
i. LA 2D measurement of on exam 3.1cm , but
is 4.5cm in report
ii. LA volume of 17.05 ml/m2 on exam
c. Study 4- Variability is present with comment on LA
size in report
i. Original report states normal LA size
ii. Overread states severely dilated LA
1. On exam, LA size is 4.5cm

2. LA volume is 70ml/m2
d. A list of ASE approved criteria is posted within the
read room-pinned to the bulletin board- copy
included in packet
e. Need to avoid internal consistencies- such as LA
size on report vs what was measured in exam,
aortic stenosis, etc. IAC will ding us for this
iii. Echo Report Timeliness & Completeness Audit- Are our reports
read within 24-48 hours and are all elements included in the
report that are required by the IAC
1. 10 random TTE and TEE studies were audited each
quarter
a. All were read within 24 hours
b. Two were still missing a report summary and
mention of the aorta
c. One TEE reviewed was missing comment on ease of
probe insertion and if any complications occurred
d. If contrast or bubble studies are performed, this
needs to be mentioned within the report by
physician and changed by tech under the type of
procedure
e. One TTE was missing comment on mitral valveonly had E/E value under it. Need to include if
valve is normal in structure and function.
iv. Correlation- Two random studies per quarter were chosen to
correlate with Nuclear Medicine studies for ejection fraction and
wall motion abnormalities
1. Study 1- Nuc showed a mild inferior wall hypokinesis,
echo showed normal wall motion
2. Studies 2 through 4- Positive correlation
v. Annual Summary- brief summary of all quality measures taken
during each quarter- as of 2016 this will not be a requirement
anymore, but IAC still suggests doing so
vi. QI standards are in the process of being changed again
3. Interesting cases- Two TEE cases where MPA view helped to aid in diagnosis and
patient care
a. Case 1- Mass visualized on pulmonic valves left cusp- Dr. Szatkowski
to speak on this study

b. Case 2- RA mass and MPA thrombus- Dr. Szatkowski to speak on this

study
4. Facility Issues
a. Accreditation expires 8/2018- will begin acquiring case studies for
resubmission one year prior
i. Can apply up to 6 months prior to expiration
ii. 4 AS and 4 RWMA, each physician and each tech represented
iii. No valve replacements
iv. Must follow protocol- only required images and in order
v. Need best studies only
vi. If any changes need to be made to protocol, this will be the time
to do it
b. Lori to discuss the adding of an evening shift as part of the schedule
i. Turnaround time for dedicated observation unit opening
ii. Hospitalists satisfaction
iii. Reduced overtime / call backs for echo techs
iv. Suggestion of having a cut off time to roll studies over to next
day reader or MD letting tech know when theyre leaving for the
evening- same as Baptist Memphis
5. Policy Review & Revisions- None at this time
6. Corrective Action / Improvement Plan / Recommendations
7. Any questions, suggestions, or concerns from staffing (technical or medical)