Quality Improvement in Urology

The QuEST (Quality, Efficiency, Satisfaction and Training) initiative is a continuous quality improvement project aimed at answering three questions across all areas of our practice:

  1. Are we doing things right? (Process)
  2. Are we doing the right things? (Outcomes)
  3. How do we know we are doing the right things every time? (Structure)

Goals of QuEST initiative

Our goals include improving:


  • Provide effective, high-quality care
  • Establish “best practices” for the field of pediatric urology
  • Ensure optimal treatment outcomes


  • Standardize practices across providers to facilitate research
  • Maximize time spent in office visit for patients and providers
  • Improve ability of electronic medical record (EMR) to work with research needs
  • Balance costs and reimbursements


  • Improve patient and family satisfaction
  • Maximize physician and non-physician provider satisfaction to retain high-quality staff


  • Improve training for residents, fellows and non-physician providers, especially around common diagnoses
  • Improve the quality of education provided to families

Reducing variation in care

Clinical pathways

Our first project focuses on developing and implementing evidence-based guidelines to support clinical decisions and reduce variability in care. In the past two years, we have implemented four clinical management pathways and are developing several others. The First to be implemented and measured was the treatment of adolescent varicoceles. The literature is inconsistent as to the treatment of varicoceles, and management varies considerably throughout the nation and within our own practice.

A workgroup of providers developed the pathway based on literature and feedback from their peers. Its goal is to set a standard for follow-up imaging, semen analysis and surgery. We agreed that patients with a testicular volume differential of less than 15 percent should have a scrotal ultrasound every two years; those with a discrepancy of more than 15 percent would be seen annually; persistent discrepancy on three studies warranted surgery; and all patients should submit a semen analysis at age 18.


Each quarter, we review adherence to the pathway and patient outcomes. Since inception, variations in practice have been reduced and compliance to the pathway is 90 percent. The algorithm has led to an effective, low-cost means of following this patient population. We believe that prospective data collection will allow us to assess the relationship between total testicular volume and semen analysis parameters; data that will guide care.

Planning for the future

We are extending the pathway program to include problems like daytime and nighttime wetting, stone disease, spina bifida and antenatally detected hydronephrosis. We will also be routinely measuring patient and provider satisfaction and the cost of care. However, the most important focus of this work will be on patient outcomes: Is the care we are providing resulting in the best outcomes for our patients? We will continually monitor our clinical data to help ensure we are providing the right care to the right patient at the right time — every time.

Next Steps
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