Download Date Submitted Case Reviews

Cardiac Care Network of Ontario
Echocardiography Quality Improvement Program
Self-Assessment Tool
Site: __________________________________
Date Registered: __________________________________
Date Submitted Documents: __________________________________
Date Submitted Case Reviews: __________________________________
Date of Site Visit: __________________________________
Site Reviewer(s): __________________________________
Instructions:
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This Self-Assessment document is provided for sites to utilize during a self-review of policies and practices, as part of the EQI process, prior to the site review.
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This document can be printed and/or filled out on-line. Please also refer to the “Standards for Provision of Echocardiography in Ontario” and the
“Echocardiography Policy and Procedure Manual” for further information. These are both available on the EQI Website under “Helpful Resources”.
Pertinent questions that help to determine status of achievement for each standard are listed under “Questions to Consider” in the middle column.
Links to the “Templates” are available in the “Echocardiography Policy and Procedure Manual”.
Required Documents for Submission to CCN prior to the site visit, are listed below and highlighted in grey. For easy reference the far right hand column is
highlighted in grey in sections where there are required documents. This column can be checked-off once the required document has been prepared for submission
to CCN.
Criteria
Content
Meeting the
Standard
Self-Assessment Tools, Templates, and “Questions to Consider”:
Required Documents and Processes
Document
Process
Document
on Site
in Place
Submitted
Section 1: Standards regarding the Echocardiographic Examination
Standard E1
Echocardiographic facilities will
have established protocols
that describe the components
of the comprehensive
examination.
Are there protocols in place regarding the acquisition of images for every
modality? Are they available to be reviewed and have they been accepted
by all sonographers and physicians involved?

Template: Guidelines for ordering Echocardiography Exams
Template: Adult Transthoracic Study Protocol

Protocol for Performing Complete Transthoracic Echocardiograms (TTE)
Standard E2
Standard E3
Standard E4
The comprehensive echo
exam. Every case study will
contain the full complement of
views including Doppler
tracings and measurements.
Does every comprehensive echo contain all of the imaging components
mentioned in Standard E2? Please review Section 1 of the Standards for
complete views, measurements and Doppler.
The comprehensive echo exam
with a Doppler assessment
component. Specific
comments on the study quality
relating to any technical
deficiencies and or inadequate
alignment will be included.
Does every echo contain all of the Doppler components listed in Standard
E3?
The comprehensive
examination will contain
standard measurements.
Standard measurements will be
obtained and recorded by
either M-mode of 2D for all
studies, based on their
situational strengths and
limitations.
Please refer to this template to ensure standard measurements are being
utilized for all comprehensive examinations.








Template: Echocardiography Imaging Protocols and Measurements
Template: Protocols for Measuring Doppler
Standard E5
Provision of additional
information.
Provided according to the
established procedures of the
facility, where clinical indication
warrants.
Does your facility have Protocols in place for specific cardiac disease states?
Are exams meeting the needs of the patient?




Template: TTE Additional Imaging Views for Pathology
Section 2: Standards Regarding Echocardiography Facilities, Equipment and Procedures

Standard F1
Examining rooms.
Echocardiographic examining
rooms must provide patient
comfort, quality and safety, as
well as the appropriate
ergonomic environment for the
sonographer.
Are the exam rooms large enough to provide adequate room for all of the
equipment, staff and the patient? Are workplace ergonomics, safety and
infection control protocols assessed regularly?
Provide a diagram of TTE echocardiography floor plan(s)
2.2 Echocardiography Imaging Systems
Standard F2
Standard F3
Imaging systems.
Ultrasound diagnostic
instruments must include
hardware, and software
required for proper
performance of M-Mode and 2D imaging.
Does the facility have the necessary hardware and software in order to
provide/produce good quality studies?
Equipment maintenance.
Equipment must be maintained
in good operating condition and
be routinely inspected for
safety by trained individuals.
Are there records maintained and available pertaining to the following:
Template: Echocardiography Equipment List
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Policy and records of safety inspections and testing of electrical
equipment.
Records of preventative maintenance and required repairs.
Infection prevention and control related policy and cleaning schedules
including sterile processing policy and processes.


2.3 Operating Procedures
Standard F4
Requisitions.
Echocardiographic procedures
orders/requisitions will include
the study type, indications, and
name of ordering physician.
Does all staff at the facility understand the importance of including study
type, indications and ordering physician information on all echo
requisitions?










Standard F5
Sufficient time must be allotted
for each examination.
Generally, 30 to 45 minutes
should be allotted to complete a
transthoracic image
examination, including Doppler
assessment. An additional 10 15 minutes is required for
analysis, reporting, preparation
for the next examination.
Are patients scheduled into the facility allotted the appropriate time for
their test according to Standard F5? Will a review of the clinics
appointment schedule confirm this?
Standard F6
Echocardiographic reports.
Echocardiographic reports must
be provided to the referring
physician within specific
timeframes:

Inpatients and urgent
outpatients; by the end of
the next working day.

All other outpatients;
within 5 working days.

High risk findings should be
communicated
immediately.
When are the reports provided to the referring physician for inpatients and
urgent/non-urgent outpatients? Are high risk findings communicated
immediately?
Data storage. Echocardiographic
data and final reports must be
formatted to allow for the ready
retrieval of recorded, stored and
archived information and ensure
patient confidentiality.
What system does the facility have in place to ensure easy retrieval of
recorded, stored and archived studies? How does this system provide
patient confidentiality?
Standard F7
Standard F8
Standard F9
Record retention. A permanent
record of the echocardiographic
images and interpretation must
be made and retained in
accordance with provincial
guidelines for medical records.
What is this facility’ policy and practice regarding permanent record
retention? Please submit a copy of the clinics’ specific process regarding
record retention.
Unexpected high risk findings.
Protocols will be in place
whereby unexpected high risk
findings can be communicated
immediately by the interpreting
physician to the referring
physician.
How is high risk findings communicated? What is the time frame and who is
responsible to provide follow up care for the patient? Please submit your
policy.


Site Process for Record Retention (regarding retaining echocardiography
imaging as a permanent record ensuring patient confidentiality)

Site Policy for Communication of High Risk Findings
2.4 Additional considerations for transesophageal echocardiography (TEE)
Standard FT1
Staff training. The facility is
required to have appropriately
trained and qualified personnel
for the provision of patient
sedation and monitoring
throughout the procedure and
recovery period.
Physicians with adequate training perform TEE’s. Who is providing
sedation and monitoring throughout the exam and recovery?

Standard FT2
Informed consent. All
transesophageal procedures
must be explained to the patient
and/or the guardian of those
unable to give informed
consent.
How is informed consent documented? Who obtains it and at what step in
the process is it obtained?

Transesophageal transducers.
Transesophageal transducers
must be readily available and
meet the specific standards.
All transesophageal transducers provide multiplane imaging. 3D capabilities
are available.
Standard FT3



Facility Protocol for Performing Transesophageal Examinations (TEE)
Protocol for Performing Transesophageal Examinations (TEE)



Standard FT4


Adequate room size to perform
transesophageal
echocardiography.
Larger rooms, in which to
perform transesophageal
echocardiography, must be
provided. The recommended
room size is 150 to 200 square
feet which can accommodate
extra equipment, personnel and
potential resuscitation
procedures.
What are the dimensions of the transesophageal echo exam room? Does
the layout accommodate all of the required equipment, personnel and
potential resuscitation procedures? Please document any challenges that
may have presented in meeting this standard. Please provide a diagram of
the floor plan in the TEE procedure room.
Standard FT5
Examination room content.
Laboratories providing
transesophageal
echocardiography require the
following features: Blood
pressure monitoring, suction,
oxygen, pulse oximetry,
resuscitation, medications and
equipment, intravenous
equipment, lockable cabinets, a
means of rapidly calling for help
with an unstable patient and a
large sink.
Where is the emergency cart located in conjunction with the TEE exam
room? Is it easily accessed? Does the TEE procedure room have a large sink
for the purpose of rinsing scopes? How are medications, including sedatives
and analgesics, managed?


Standard FT6
Cleaning and disinfection. The
echocardiography laboratory
must follow proper cleaning,
disinfection, and maintenance
procedures.
What is the process in following infection prevention & control standards?
Where does the cleaning of probes occur? Is there a log kept?


Provide a diagram of the floor plan in the TEE procedure room
Infection prevention and control related policies and processes regarding
cleaning schedules and sterile processing is dependent on the
echocardiography system. Please refer to the following link for Infection
Prevention guidelines:
http://www.publichealthontario.ca/en/eRepository/IPAC_Clinical_Office_P
ractice_2013.pdf
Standard FT7
Observation rooms. Facilities
and procedures must be
available for
observation/recovery of
patients by trained and qualified
personnel.
Is there a dedicated recovery space for patients, where they are monitored
by qualified personnel? If not, what impact does this have on the
operations of the clinic?
Qualified personnel available to
conduct stress
echocardiography.
Appropriately trained and
qualified personnel are required
to monitor the patient, operate
the treadmill or supine bicycle,
record the electrocardiogram
and/or, administer medication
specific to the type of
examination.
What are the qualifications of the personnel monitoring the patient;
operating the treadmill or supine bicycle; administering medication; and
carrying out the examination?


2.5 Stress Echo

Standard
FS1
Standard
FS2
Informed consent.
Stress echocardiography
procedures must be explained
to the patient and/or the
guardian of those unable to give
informed consent.
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If applicable please submit:
Protocol for Performing Stress Echocardiography Examinations
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Template: Protocol for the addition of Contrast to Echocardiography Studies
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Template: Treadmill Exercise Stress Echo Procedure
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Template: Bicycle Stress Echocardiography Protocol
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Template: Agitated Saline Echocardiography Study Protocol
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Template: Comprehensive Dobutamine Stress Echo Procedure
How is informed consent documented for stress echo? Who’s responsibility
is it and at what step in the process is it obtained?





Standard
FS3
Adequate room size to perform
stress echocardiography.
Larger rooms must be provided
to perform stress
echocardiography with the
purpose of accommodating
extra equipment, personnel and
potential resuscitation
procedures.
Observation rooms. Facilities
and procedures must be in place
for the observation and recovery
of patients, and staffed by
trained and qualified personnel.
Does the size of the stress echo exam room accommodate all of the
required extra equipment, personnel and potential resuscitation
procedures? Please provide a floor plan including equipment configuration
of the stress echocardiography procedure room.
Standard
FS5
Echocardiographic imaging
equipment requirements.
Additional echocardiography
equipment with reasonable
memory and dual imaging must
be present to allow for the
“triggered image acquisition and
side-by-side image display,
utilized in stress
echocardiography studies.
Is the sites’ stress echo imaging system able to perform the required
processes according to the standard?
Standard
FS6
Additional facilities required for
stress echocardiography.
Provision of additional facilities
are required to perform stress
echo procedures which include a
treadmill, ECG monitor, blood
pressure, oxygen, resuscitation
equipment, medications,
available IV and emergency call
access.
Does the stress procedure room contain all of the necessary equipment
and space that allows for safe patient care? Is the clinic a comfortable and
safe work environment that is ergonomically sound?
Standard
FS4


Provide a diagram of Stress echocardiography floor plan(s)








Is there a dedicated recovery space for patients, where they are monitored
by qualified personnel? If not, what impact does this have on the
operations of the clinic?
Section 3: Standards for Reporting of Echocardiography Examinations
Standard R1



Are required targeted imaging and hemodynamic assessments specifically
indicated on the standard report form?



Is there a specific area to document data acquisition limitations on the
standard report form? If not, how is this documented?



Echo report. Echocardiographic
reports should be standardized
and in accordance to Appendix A
outlined in the Standards for
Provision of Echocardiography in
Ontario (2012), to include
specific information (1) patient
demographics, (2)
echocardiographic findings, and
(3) a summary/interpretation,
provided in a clinically relevant,
useful manner.
Are the echo reports standardized to include all of the required
components mentioned in Standard R1? Does the document flow according
to the study review process so that priorities are specified in predominant
areas of the report? For example the summary of the study should be
located at the beginning of the report.
Standard R2
Specific evaluations. Specific
indications or pathologies
require further targeted imaging
and/or hemodynamic
assessment in addition to the
standard outlined in Appendix A.
Standard R3
Assessment and limitation of
study quality. It is recognized
that a full set of interpretable
echocardiography data may not
be possible for all patients due
to technologic limitations. Data
acquisition limitations must be
clearly stated within the report,
in order to avoid the assumption
of normality by the referring
physician.
Template: Standardized Report for Adult Transthoracic Echo
Standard R4
Amendments to reports.
Amended reports must be
identified as such, including the
date and time of the change, as
well as the specific changes from
the original report.
How are amendments to the reports identified? Are the amendments
dated?



Standard R5
Final reports.
Final reports should be
completed only after full review
of all acquired data and must
include the following:

Summary of interpretations
of positive and negative
findings, as it relates to the
presenting issue
assessment,

Summary of other
significant pathological
findings,

Relevant comparisons to
prior studies or reports,

Study limitations and

Recommendations
regarding alternative or
additional investigations.
When are the final reports completed? Do they include all of the
requirements mentioned in Standard R5? Does the document flow
according to the needs of the reviewer?



Mechanism in communication
of urgent findings.
How are urgent findings communicated? Is this communication included in
the documentation for auditing purposes?



Standard R6
Site Policy for Validation by Study Comparison
Section 4: Standards Regarding Personnel Involved in Echocardiography Examinations
Standard P1
Standard P2
Standard P3
Qualifications of the facility
Medical Director.
Laboratories will have a
designated Medical Director,
who must be a licensed
physician and hold one of the
following qualifications:
1) Level 3 training in
echocardiography
2) Level 2 training and
continuing
echocardiography practice
including interpretation of a
minimum of a minimum of
1800 echo/Doppler
examinations over the
previous 3 years.
Submit a completed attestation form for Medical Director.
Have role profile and CME record available on site.


Template: Reporting responsibilities
Submit a copy of the Staff Organizational Chart
Roles and responsibilities of the
Medical Director.
The Medical Director is
responsible for:
1) clinical services, quality of
medical care,
2) Medical and technical staff
compliance to facility standards,
3) Participation in the
interpretation of studies
performed in the laboratory.
Continuing maintenance of
competence of the Medical
Director.
The Medical Director will
maintain medical competence






by attending 24 hours of
accredited CME relevant
echocardiography activities over
a 2 year period and interpreting
a minimum of 400 transthoracic
echo studies. For laboratories
performing transesophageal
echocardiography, the Medical
Director must perform and
interpret a minimum of 25
examinations per year. For
laboratories providing stress
echocardiography, the Medical
Director must interpret at least
75 stress echocardiograms per
year.
4.2 Standards Regarding the Technical Director
Standard P4
Qualifications of the facility
Technical Director.
Laboratories must have a
designated Technical Director
who has credentialing from the
American Registry of Diagnostic
Medical Sonography (ARDMS) or
equivalent credential, and
experience as assessed and
approved by the Medical
Director. In laboratories without
appropriately qualified
sonographers, a physician
assumes the role of Technical
Director and must have at Level
2 or 3 training.
Submit a copy of Credentials/Registration for the Technical Director.
Please have a copy of role profile and CME record available on site.


Standard P5
Roles and responsibilities of the
Technical Director.
Technical Director has oversight
for the following:
1) Performance of
echocardiography
examinations.
2) Supervision of technical and
support staff.
3) Delegation of
responsibilities to technical
staff.
4) Daily laboratory
administration.
5) Operation and maintenance
of laboratory equipment.
6) Compliance of technical
staff to standards.
7) Maintenance of quality of
patient care.
8) Training of technical staff.


Standard P6
Continuing medical education
(CME) for the Technical
Director.
Technical director must
document a minimum of 30
hours of echocardiography
related continuing medical
education credits (CME) over a 3
years period.



4.3 Standards Regarding Medical Staff


Standard P7
Qualifications of medical staff.
Members of the Medical Staff
must be licensed physicians and
have formal training in adult
echocardiography level II/III, and
interpretation of 400
Echo/Doppler exams per year.
Standard P8
Roles and responsibilities of the
Medical Staff.
Members of the medical staff
are responsible for interpreting
exams, reporting,
supervising/triaging emergency
cases, performing transthoracic
echocardiography,
transesophageal and/or
supervising stress
echocardiography.



Continuing education (CME) for
Medical staff. Members of the
Medical Staff must undertake
and document continuing
maintenance of competence as
described in Section P3.



Standard P9
Submit completed attestation forms for Medical Staff.
Have role profiles and CME records available on site.
4.4 Standards Regarding Technical Staff
Standard
P10
Qualifications the Technical
Staff.
Technical staff performing
echocardiographic exams must
meet one of the following
criteria:

Credentialing from ARDMS
Submit a copy of Credentials/Registration for all technical staff.
Have a role profile and CME record available on site for all technical staff.




Standard
P11
or equivalent agency, as
approved by the Medical
and Technical Directors.
Completion of an
accredited
echocardiography program.
Completion of one year of
full time clinical
echocardiographic
examinations and a two
year program in another
allied health profession.
Roles and responsibilities of the
Technical Staff.
Under the direction of the
Technical Director,
responsibilities of technical staff
include:

Ensuring the patient’s
identity, information
documentation, comfort
and safety.

Acquisition and recording of
all echocardiographic
images and data.

Alerting supervising
physicians as to any
technical acquisition
deficiencies, urgent
conditions, significant
symptoms or patient
distress identified in the
course of the examination,
or while in the
echocardiography
laboratory.


Standard
P12



Continuing medical education
(CME) for the Technical Staff.
The Technical Staff must
document a minimum of 30
hours of related
echocardiography CME every 3
years.
Section 5: Indications for Echocardiography Examination
Standard I1
Indications for
echocardiography examination.
What is the mechanism used to ensure that all referrals have a primary
indication code?



Standard I2
Referrals without a standard
indication.
What is the process in place to clarify the reason for the referral when an
indication code is not documented on the referral? Is staff aware of this
mechanism? Are echo’s done without a primary indication?



Site Policy for requisitions without indication codes
Standard I3
Echocardiographic laboratories
must ensure policies for
indications for
echocardiograms. Mechanisms
are required to be in place to:

Track indications of
completed studies, ensuring
that at least 95% of studies
meet standard indications
(as per Appendix B in the
What is the method used to track indications of completed studies in order
to ensure that a minimum of 95% of completed studies include standard
indications?
Do you have a standard approach to educating referring physicians
regarding appropriate study indications? Is this documented?
Template: Indications for Echo



Standards).
Provide education to
referring physicians
regarding appropriate study
indications.
Section 6: Continuing Quality Assurance in the Echocardiography Laboratory
Please submit:
The following past year statistics are to be submitted with all other “required documents” prior to site review:
All Echocardiography Statistics are done on an annual basis with monthly subtotals for the following: TTE inpatient/outpatient/emergency; TEE inpatient/outpatient/emergency; DSE
inpatient/outpatient/emergency; ESE inpatient/outpatient/emergency
Standard Q1
Regular review of study
acquisition. Regular review of
the study acquisitions by the
Medical Director to assess image
quality and accuracy of
measurements by sonographers.




Is it regular practice for the Medical Director of this site to assess image
quality and accuracy by the sonographers? How many random studies are
reviewed and how frequently is this done?
Is a pre-defined scoring system with pre-set standards of accuracy utilized
in order to provide feedback?
What is this facilities’ process for Regular Review of Study Acquisition?
Standard Q2
Review of study interpretation.
Regular random report reviews,
over Director to assess accuracy,
completeness and timeliness of
the reports.
How often does the Medical Director (or designate) review random reports
for accuracy, completeness and timeliness of each interpreting physician?
Site Policy for Review of Study Interpretation and Report turnaround times
Standard Q3
Staff meetings.
Conduct routine staff meetings
to review and discuss the results
of the QA process and introduce
changes or improvements.
Are regularly scheduled staff meetings held in order to review this sites
quality assurance processes and for the purpose of introducing
improvement measures? How frequently do they occur and are minutes
recorded and distributed?



Standard Q4
External review.
Processes for external reviews
that allow for constructive
feedback and review of any
discordant findings.
What is the process for external review?



Standard Q5
Validation against other
diagnostic modalities.
Processes for validating test
findings by the correlation with
other diagnostic procedures,
intraoperative findings and
pathologies.
How are test findings validated against other diagnostic modalities?


Standard Q6
Case review.
Conduct rounds or case reviews,
focusing on relevant
instructional content of
interesting cases or specific
disease entities.
Please describe the educational opportunities offered to staff, such as
attending clinical rounds/reviews or conferences, in order to maintain
competencies and advance skills.