I was told early in my career from a respected colleague: “When quality competes with quantity, quantity always wins.” If you'd prefer a baseball analogy (widely credited to S. Jobs, although I could not confirm its origin): “Quality is more important than quantity. One home run is better than two doubles.” Another valuable concept when considering what quality is (widely credited to H. Ford, although I could not confirm its origin): “Quality means doing it right when no one is looking.”
This month's editorial is dedicated to the readers who take quality to heart. In a healthcare environment that too easily rewards for growth, productivity and similar metrics dedicated to quantity, but is too reticent to similarly reward (or even define) quality metrics, holding onto this value has never been more important.
I don't think a week goes by without my being asked about growth strategies; yet it remains exceedingly uncommon that anyone in a leadership position asks about quality strategies. I am often heard emphasizing my opinion that ‘right-sizing’ is much more important than ‘up-sizing’. I appreciate that most business models, including the healthcare industry, are built upon a vision of success that centers on increased productivity as its primary marker of success. However, I believe it is more important today than ever before, that each of us raise our collective voices and demand quality over quantity.
Instead of ‘more echocardiograms’ annually performed as a marker of success, how about we seek new measures that reward quality, such as patient and operator satisfaction? Echocardiography is really difficult and requires an expert to obtain the appropriate views. This individual must know when to inject an ultrasound enhancing agent, acquire non-conventional images, and use non-conventional probes. Each patient is different and until you begin your examination, you simply don't know how complex the findings are or how difficult the study will be. Fitting this exam into a pre-defined 30-minute appointment (hopefully, you never do that, but someone may) seems feasible for administrators looking only at quantity, but is a recipe for low quality.
I would like to report that every echo I am asked to interpret is obtained with the same degree of dedication. Quality is a sign of commitment. We are fortunate that patients allow us to care for them; this may be the highest honor of trust that anyone can give to someone. But with that trust comes their request that we respect them enough to use our skills and expertise to the fullest. Dr. Anthony N. DeMaria (past president of ASE, past Division Chief at University of Kentucky, and my current Endowed Chair) and his successor Dr. Mikel D. Smith (ASE Richard Popp Award recipient, past University of Kentucky Echo lab medical director) used to tell the sonographers: “Acquire every echo image as if you want to publish it.” That is my request to everyone who reads this editorial. I wish every sonographer on the planet lived by that simple tenet!
CASE expects the highest quality images to be submitted with each case report. We commonly receive great pathology and wonderfully instructive reports with images that are over-gained, incomplete, or improperly scaled. Although we work with authors to address these deficiencies, it is a reminder that there remains work to be done to improve our efforts toward consistent quality acquisitions. In my opinion quality requires “constant vigilance” (Alastor Moody, in Harry Potter and the Goblet of Fire; 2000). It is incumbent upon each of us to always remain on our guard toward poor quality and strive to collect data that we would be proud to submit to CASE.
Here are some additional quotes (with my thoughts to follow) to help you as you progress along your quality journey:
“A bad workman blames his tools.” (ancient proverb) I use this to remind trainees and students to never blame the patient for poor quality images, but to strive to improve quality using all the tools available (change transducer, use contrast, modify body position, make breathing adjustments, or perform TEE).
“If a thing's worth doing, it's worth doing well.” (Chinese proverb) I use this to remind everyone they should not cut corners. I know there is another patient waiting to be studied, but choosing to skip an extra step in image acquisition, necessary for image optimization, defeats the purpose of acquiring any images at all.
“Quality is not an act. It is a habit.” (Will Durant paraphrasing Aristotle) This is such an important concept in echocardiography. Developing habits that are based on maximizing image quality will serve you well throughout your career and will help to distinguish you as a sonographer as opposed to a technician.
“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” (John Ruskin). I don't believe this quote warrants anything further than asking everyone who reads this editorial, to read that quote a second time.
In this month's issue of CASE, you will find many examples of how your sonographer peers and author colleagues from across the globe address quality in scientific reporting. Taverna et al. describe a patient with a mitral arcade and demonstrate the complementary value and correlation of echocardiography and cardiac CT. It is a wonderful example of high-quality images of the mitral and aortic valves and subvalvular apparatus. Harmouch et al. similarly use CASE to show-off their high-quality echo images to inform readers about their patient with infective endocarditis involving a PFO closure-device. In their cleverly titled manuscript, these authors remind us of this potential complication, review the published literature on this topic, and discuss the possible role that cardiac CT may offer to assess risk by monitoring neo-endothelization of these devices. In the important Hemodynamic Corner section of CASE, Carnazzo et al. describe the importance of using alternative approaches with Doppler spectral analysis to detect mitral regurgitation in patients with acoustic shadowing from prosthetic valves. This report reminds us that quality imaging is not the same as obtaining pretty pictures, but more importantly, quality means high intention, sincere effort, intelligent direction, and skillful execution. In a similar report, Mishra describes the unique mitral and tricuspid spectral Doppler inflow patterns in a patient with a non-sinus rhythm to educate and inform readers on a method to identify rhythm disorders and prevent misdiagnoses. Each month, CASE receives submissions from authors who want to enlighten readers after they experienced a poor patient outcome. Case reports are an important method to offer readers an opportunity to learn from those devastating clinical events. This month is no exception and Sahar et al., in the Rare But Deadly Findings category, use high-quality 2D and 3D echocardiographic images to educate readers about something they may have never seen: left atrial dissection. By reviewing these images carefully, you will be better prepared should your patient experience a similar complication after mitral valve surgery.
Lastly, in recognition of our quality-driven, engaged community, Kasouridis wrote a letter to the Editor regarding Condos et al. which I felt raised many important points that needed to be published. The Author Reply letter helps to provide additional insights readers may have had and clearly reiterates their driving motivation to adhere to quality.
So, in the end, I imagine that all of us want to join the quality team in this quality vs quantity competition. But, like me, you are probably struggling with what you can do. It is clear to me that quality takes time and therefore, if not carefully addressed at a system operations level, quality reduces quantity. For example, if the lab environment is unable to allow you to quickly inject an ultrasound enhancing agent and this causes great delays to your study completion, it essentially makes you less efficient. If your hospital or clinic is driven toward efficiency–at all costs–it may see quality as an enemy.
What are the other measures of a successful lab if it's not quantity and productivity? There are many and it is our job to voice these at all opportunities. Our patients' and providers' satisfaction reflect quality more than quantity. These stakeholders are more likely to be satisfied when the echo delivers: (1) an accurate diagnosis that allows treatment to be employed that results in clinical improvements; (2) an optimal image that does not require additional downstream/repeat testing; and (3) a report (read by the patient) that avoids using words like “suboptimal; was not seen; poorly visualized; suboptimal quality; not obtained; etc.”
Additional non-productivity business models that are used include: (1) social enterprise models (focusing on social or environmental issues over revenue generation); (2) boutique or niche models (focusing more on brand reputation and customer loyalty over market growth); and (3) lifestyle models (emphasizing work-life balance over scale). Can these be employed for healthcare and our echo labs? Absolutely. If a ‘high-volume’, quantity-based lab does not influence clinical outcomes in an important manner, then change should be sought. If, however, the only metric you obtain or are held accountable to is quantity, then you will never know if change is warranted. It is for this reason I believe that right-sizing is more meaningful than up-sizing.
I would ask that you adhere to the words of DeMaria, Smith and others: “Acquire every echo image as if you want to publish it”; “constant vigilance”; “Quality is not an act. It is a habit; ” and “Quality means doing it right when no one is looking.”
Remember, every echo you see today has a teaching point; and every teaching point is a potential new CASE report!