Guidelines for establishing a quality assurance program in vascular and interventional radiology.

ENSURING quality care in vascular and interventional radiology is the primary goal of the SIR Standards of Practice Committee. To achieve this goal, the Committee has previously defined the qualifications of physicians performing the procedures and the facilities that are required for safe diagnostic and interventional procedures. The next focus is on the assessment of quality care; this is done by identifying important aspects of care, defining acceptable standards for each of these areas, and designing a system to monitor and evaluate the care given. Such a program is mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO medical staff regulations 3.11 requires that “. . . there is a mechanism to assure the same level of quality of patient care by all individuals with delineated privileges in a given medical institution.” Within a diagnostic radiology department, JCAHO requirements DR.4.2.1.2.1.1 further states “. . . These criteria are used by the diagnostic radiology department/service or by the hospital’s quality assurance program in the monitoring and evaluation of patient care services . . .” Thus, the program must be based on objective criteria that can define quality care and these criteria must be applied to all individuals with the defined privileges within an institution. The JCAHO has published guidelines on how to establish and maintain a Quality Assurance program to monitor and evaluate the quality and appropriateness of care. We will briefly review the essential elements of such a program and then show how these elements may be applied in interventional radiology.