EQUIP: The Verdict Is In!

EQUIP Year 1. There were 8,486 annual MQSA inspections between January 1, 2017 and December 31, 2017 new results reveal 43% of those inspections had one or more EQUIP deficiencies!  The educational year for the EQUIP Initiative ended on March 2, 2018.  Now inspections performed at MQSA facilities with EQUIP deficiencies are being issued Level 2 violations.  There still seems to be more questions than answers on “how to” implement and document the process outlined by the EQUIP Questions.

The highest number of deficient inspections was noted for sub-questions 2(a) and 2(b) which cover the periodic clinical image review. Thirty three percent of the total inspections identified deficiencies for question 2(a). The question states “there is no mechanism in place for regular reviews of image quality attributes of a sample of mammograms performed by each active RT and a sample of mammograms accepted for interpretation by each active IP”. In part (2b) the question states “there is no documentation of review since the last inspection” and 30% of facilities inspected were deficient in regard to this sub question. The results reveal there is still a lot of work to be done to implement and document processes that will answer these questions

MQSA Insights comments indicate facilities do have mechanisms in place to provide ongoing image quality feedback from IP to technologist. However, they are missing the opportunity to take a facility wide look at image quality and the quality of actual mammograms performed or interpreted by facility personnel. These results are similar to what occurred in the medical outcomes audit implementation.  Facilities struggled with how to implement, document and engage everyone in the process. However, the questions for EQUIP go far beyond a simple answer of “do you have a medical outcomes audit in your facility yes or no”. EQUIP  not only wants to know if you have a process in place,  but requires demonstration of an active ongoing process engaging all mammography technologist and IP in a results driven process.

In my experience with mammography and mammography compliance, the best place to start is by using basic Quality Assurance concepts.  By utilizing continuous quality cycles you collect the data from your process, analyze the data in reference to your goal, design a process or program that is consistent for the logistics of your mammography program, measure the outcomes of the process and identify areas for improvement. The programs and processes for facilities might look very different based on individual practices. But, if a consistent process is employed for development of your program the outcomes will meet the criteria for EQUIP.

There is obviously a need for further guidance based on the first year statistics. A forum for sharing of information on how different facilities have achieved compliance would be helpful. This has to be a team effort and supported by the IP’s and LIP for a successful program.  Following are links to FAQ’S from MQSA and the State of Texas Mammography Accreditation Program.

Feel free to share your ideas and insights, it may be beneficial to your colleagues!

https://www.dshs.texas.gov/radiation/mammography/equipfaqs.shtm

https://www.fda.gov/downloads/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/FacilityCertificationandInspection/UCM526239.pdf

 

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