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Introduction: Family-centred rounds benefit families and clinicians and improve outcomes in general paediatrics, but are understudied in subspecialty settings. We sought to improve family presence and participation in rounds in a paediatric acute care cardiology unit. Methods: We created operational definitions for family presence, our process measure, and participation, our outcome measure, and gathered baseline data over 4 months of 2021. Our SMART aim was to increase mean family presence from 43 to 75% and mean family participation from 81 to 90% by 30 May, 2022. We tested interventions with iterative plan-do-study-act cycles between 6 January, 2022 and 20 May, 2022, including provider education, calling families not at bedside, and adjustment to rounding presentations. We visualised change over time relative to interventions with statistical control charts. We conducted a high census days subanalysis. Length of stay and time of transfer from the ICU served as balancing measures. Results: Mean presence increased from 43 to 83%, demonstrating special cause variation twice. Mean participation increased from 81 to 96%, demonstrating special cause variation once. Mean presence and participation were lower during high census (61 and 93% at project end) but improved with special cause variation. Length of stay and time of transfer remained stable. Conclusions: Through our interventions, family presence and participation in rounds improved without apparent unintended consequences. Family presence and participation may improve family and staff experience and outcomes; future research is warranted to evaluate this. Development of high level of reliability interventions may further improve family presence and participation, particularly on high census days.

BACKGROUND: Nearly every child undergoing congenital heart surgery has chest tubes (CT) placed intraoperatively. Center variation in removal practices and impact on outcomes has not been studied previously. We evaluated variation in CT management practices and outcomes across centers. METHODS: We included patients undergoing any of 10 benchmark operations from June 2017-May 2018 at participating Pediatric Acute Care Cardiology Collaborative (PAC(3))- Pediatric Cardiac Critical Care Consortium (PC(4)) centers. Clinical data from PC(4) were merged with CT data from PAC(3). Practices and outcomes were compared across centers in univariate and multivariable analysis. RESULTS: The cohort included 1029 patients (N=9 centers). Median CT duration varied significantly across centers for 9/10 benchmark operations (all p≤ 0.03) with a “model” center noted to have the shortest duration for 9/10 operations (range of 27.9–87.4% shorter duration vs. other centers across operations). This effect persisted in multivariable analysis (p

Objectives To assess clinically asymptomatic infants with single-ventricle physiology (SVP) for sleep-disordered breathing (SDB) in the supine and car seat positions using polysomnography. Polysomnography results also were compared with results of a standard Car Seat Challenge to measure the dependability of the standard Car Seat Challenge. Study design This was an observational study of 15 infants with SVP. Polysomnography data included Obstructive Index, Central Index, Arousal Index, Apnea Hypopnea Index, and sleep efficiency. Polysomnography heart rate and oxygen saturation data were used to compare polysomnography with the standard Car Seat Challenge. Results Polysomnography demonstrated that all 15 infants had SDB and 14 had obstructive sleep apnea (Obstructive Index ≥1/hour) in both the supine and car seat positions. Infants with SVP had a statistically significant greater median Obstructive Index in the car seat compared with supine position (6.3 vs 4.2; P = .03), and median spontaneous Arousal Index was greater in the supine position compared with the car seat (20.4 vs 15.2; P = .01). Comparison of polysomnography to standard Car Seat Challenge results demonstrated 5 of 15 (33%) of infants with SVP with abnormal Obstructive Index by polysomnography would have passed a standard Car Seat Challenge. Conclusions Infants with SVP without clinical symptoms of SDB may be at high risk for SDB that appears worse in the car seat position. The standard Car Seat Challenge is not dependable in the identification of infants with SVP and SDB. Further studies are warranted to further delineate its potential impact of SDB on the clinical outcomes of infants with SVP.

Background Interactive data visualization and dashboards can be an effective way to explore meaningful patterns in large clinical data sets and to inform quality improvement initiatives. However, these interactive dashboards may have usability issues that undermine their effectiveness. These usability issues can be attributed to mismatched mental models between the designers and the users. Unfortunately, very few evaluation studies in visual analytics have specifically examined such mismatches between these two groups. Objectives We aimed to evaluate the usability of an interactive surgical dashboard and to seek opportunities for improvement. We also aimed to provide empirical evidence to demonstrate the mismatched mental models between the designers and the users of the dashboard. Methods An interactive dashboard was developed in a large congenital heart center. This dashboard provides real-time, interactive access to clinical outcomes data for the surgical program. A mixed-method, two-phase study was conducted to collect user feedback. A group of designers (N = 3) and a purposeful sample of users (N = 12) were recruited. The qualitative data were analyzed thematically. The dashboards were compared using the System Usability Scale (SUS) and qualitative data. Results The participating users gave an average SUS score of 82.9 on the new dashboard and 63.5 on the existing dashboard (p = 0.006). The participants achieved high task accuracy when using the new dashboard. The qualitative analysis revealed three opportunities for improvement. The data analysis and triangulation provided empirical evidence to the mismatched mental models. Conclusion We conducted a mixed-method usability study on an interactive surgical dashboard and identified areas of improvements. Our study design can be an effective and efficient way to evaluate visual analytics systems in health care. We encourage researchers and practitioners to conduct user-centered evaluation and implement education plans to mitigate potential usability challenges and increase user satisfaction and adoption.

Objectives:To examine the strengths and opportunities for improvement of current home care education practices to inform the development of the Home Care for Heart Health intervention, and to develop a web-based intervention for parents and clinicians with complimentary print materials that could provide the right education at the right time to foster a safer transition from hospital to home.Methods:An inter-professional focus group of parents, clinicians, and designers was formed to co-create a home care education intervention for parents of children with congenital heart disease (CHD) and their care team. We used the Integrated New Product Development process model created by Jonathon Cagan and Craig Vogel at Carnegie Mellon University to develop the intervention. This process model is a way of thinking that combines horizontal and inter-disciplinary teams, stakeholder-centric focus, and a system of qualitative discovery and development evolving towards quantitative methods of refinement.Results:Our team developed the Home Care for Heart Health intervention. The evidenced-based intervention includes a quick reference guide for parents of children with CHD, an accompanying app, family-friendly pathways, and clinician education.Conclusion:Using an inter-professional approach, our team of clinicians, parents, and design experts were able to co-create a clinician–parent home care education intervention with broad application and lifelong relevance to the Congenital Heart Disease Community.Practice Implications:Our intervention has the potential to be used as a model for other home care education interventions for parents of children with chronic illnesses.

BACKGROUND Hospital discharge delays can negatively affect patient flow and hospital charges. Our primary aim was to increase the percentage of acute care cardiology patients discharged within 2 hours of meeting standardized medically ready (MedR) discharge criteria. Secondary aims were to reduce length of stay (LOS) and lower hospital charges. METHODS A multidisciplinary team used quality improvement methods to implement and study MedR discharge criteria in our hospital electronic health record. The criteria were ordered on admission and modified on daily rounds. Bedside nurses documented the time when all MedR discharge criteria were met. A statistical process control chart measured interventions over time. Discharge before noon and 30-day readmissions were also tracked. Average LOS was examined, comparing the first 6 months of the intervention period to the last 6 months. Inpatient charges were reviewed for patients with >2 hours MedR discharge delay. RESULTS The mean percentage of patients discharged within 2 hours of meeting MedR discharge criteria increased from 20% to 78% over 22 months, with more patients discharged before noon (19%–32%). Median LOS decreased from 11 days (interquartile range: 6–21) to 10 days (interquartile range: 5–19) (P = .047), whereas 30-day readmission remained stable at 16.3%. A total of 265 delayed MedR discharges beyond 2 hours occurred. The sum of inpatient charges from care provided after meeting MedR criteria was $332 038 (average $1253 per delayed discharge). CONCLUSIONS Discharge timeliness in pediatric acute care cardiology patients can be improved by standardizing medical discharge criteria, which may shorten LOS and decrease medical charges.

Background The routine use of angiotensin‐converting enzyme inhibitors (ACEI) during palliation of hypoplastic left heart syndrome is controversial. We sought to describe ACEI prescription in the interstage between stage 1 palliation (stage I Norwood procedure) discharge and stage 2 palliation (stage II superior cavopulmonary anastomosis procedure) admission using the NPC‐QIC (National Pediatric Cardiology Quality Improvement Collaborative) registry. Methods and Results Analysis of all patients (n=2180) enrolled in NPC‐QIC from 2008 to 2016 included preoperative anatomy, risk factors, and echocardiographic data. ACEI were prescribed at stage I Norwood procedure discharge in 38% of patients. ACEI prescription declined from 2011 to 2016 compared with pre‐2010 (36.8% versus 45%; P =0.005) with significant variation across centers (range 7–100%; P P =0.004). There was no difference in interstage mortality ( P =0.662), change in atrioventricular valve regurgitation ( P =0.101), or change in ventricular dysfunction ( P =0.134) between groups. In multivariable analysis of all patients, atrioventricular septal defect (odds ratio [OR], 1.84; 95% CI, 1.28–2.65) or double outlet right ventricle (OR, 1.47; CI, 1.02–2.11), and preoperative mechanical ventilation (OR, 1.37; 95% CI, 1.12–1.68) were associated with increased ACEI prescription. In multivariable analysis of patients with complete echocardiographic data (n=812), ACEI prescription was more common with at least moderate atrioventricular valve regurgitation (OR, 1.88; 95% CI, 1.22–2.31). Conclusions ACEI prescription remains common in the interstage despite limited evidence of benefit. ACEI prescription is associated with preoperative mechanical ventilation, double outlet right ventricle, and atrioventricular valve regurgitation with marked inter‐center variation. ACEI prescription is not associated with reduction in mortality, ventricular dysfunction, or atrioventricular valve regurgitation during the interstage.

This study examined Morbidity and Mortality (M&M) review practices and perspectives of physicians and parents regarding parent participation in M&M review. Surveys were distributed to parents of children with a prior hospitalization for congenital heart disease (CHD) and physicians caring for pediatric CHD patients. Response distributions and Fisher’s exact tests were performed to compare parent and physician responses. Qualitative survey data were thematically analyzed. Ninety-two parent and 36 physician surveys were analyzed. Physicians reported parent input or participation was rarely sought in M&M review. Parents with direct experience of adverse events or death of their child reported providers discussed events with them in a timely manner and answered their questions; however, nearly half wished their healthcare team had done something differently during the disclosure. There was no statistical difference between groups regarding transparency ( P = .37, .79); however, there was a significant difference in perspectives regarding parental involvement in the M&M review ( P

Background Reported long-term outcome measures vary greatly between studies in Fontan patients making comprehensive appraisal of mortality hazard challenging. We sought to create a clinical risk score to assist monitoring of Fontan patients in the outpatient setting. Methods A systematic review was conducted to evaluate risk factors for long-term (beyond the first postoperative year) mortality in Fontan patients. Studies were eligible for inclusion if ≥90 patients were included or ≥20 long-term mortalities we reported. Risk factors for long-term mortality were determined. The pooled hazard ratios were used to create components of a clinical score for long-term mortality using meta-analysis techniques. Results Twenty-eight studies were included. The total number of patients was 6707 with an average follow-up of 8.23 ± 5.42 years. There were 1000 deaths. Thirty-five risk factors for late mortality were identified and classified into 9 categories and their relative hazards were used to derive the initial components of a weighted, practical and clinically based Fontan risk score (ranging from 0 to 100). The final score included 8 risk factors: anatomic risk factors, elevated preoperative pulmonary artery pressure, atriopulmonary Fontan, heart failure symptoms, arrhythmia, moderate/severe ventricular dysfunction or atrioventricular valve regurgitation, protein losing enteropathy, and end organ disease (cirrhosis or renal insufficiency). Conclusion In patients with Fontan circulation, the influence of readily available risk factors can be quantified in an integer score to predict long-term mortality. Prospective validation and refinement of this risk score will be undertaken.

We all have a role in advocating for our most vulnerable. A systematic and coordinated approach to advocating for safe sleep will result in a significant reduction in preventable sleep-related infant deaths. Using a foundation of the psychology of risk with targeted messaging and methods will result in sustained improvement. This advocacy should be routed in an understanding of established beliefs, norms, and structures. Through effective advocacy across the infant life course, we will change the culture of infant sleep. Thousands of infant deaths can be prevented if we choose to advocate and act.

Background: The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) formed to improve outcomes in infants with hypoplastic left heart syndrome. The collaborative sought to (1) decrease mortality, (2) reduce growth failure, and (3) reduce hospital readmissions due to major medical problems during the interstage period between discharge following stage 1 palliation (S1P) and admission for stage 2 palliation (S2P). Methods: The NPC-QIC is a learning network, coproduced by parents and clinicians, of 65 pediatric cardiology centers that contribute clinical data on care processes and outcomes to a shared registry. The adapted Breakthrough Series Model structure brings teams together regularly to review data, share lessons, and plan improvements. Outcomes are monitored using statistical process control methods. Results: Between 2008 and 2016, interstage mortality decreased by >40%, from 9.5% to 5.3%. Identification and use of a nutrition bundle led to improved infant growth, with a 28% reduction in interstage growth failure. The rate of serious hospital readmissions was low and did not significantly change. Importantly, a formed partnership with the parent group Sisters by Heart fostered the coproduction of tools and strategies and an emphasis on data transparency and outcomes. Conclusions: The NPC-QIC’s initial efforts led to improvements in interstage growth and mortality. The NPC-QIC has modeled the use of data for improvement and research, the value of coproduction with parents, and the concept “all teach, all learn,” demonstrating the power of the learning network model.

Enhancing Patient and Family Experience (PFE) is vital to the delivery of quality healthcare services. Sociodemographic differences affect health outcomes and experiences, but research is limited on biases in PFE survey methodology. We sought to assess survey participation rates across sociodemographic characteristics. This retrospective study analyzed a health system’s ambulatory PFE survey data, collected January 1 – July 31, 2019. Outcomes of interest were rates of survey response, completion, and comments. Predictors included respondent-reported race, ethnicity, language, and measure of social deprivation attached to a respondent’s home address. Addresses were geocoded to census tracts. The tract’s degree of socioeconomic deprivation was defined using the Deprivation Index (DPI). Associations between outcomes and predictors were assessed using the Chi square test. 77,627 unique patient encounters were analyzed. Patients were predominantly White (76%); 5% were Hispanic; and 1% were Spanish-speaking. The overall response, completion, and comment rates were 20.1%, 17.6%, and 4.1%, respectively. There were significant differences across assessed sociodemographic characteristics in response, completion, and comment rates. White patients were most likely to respond, complete, and leave a comment. Spanish-speaking respondents and those living in the most deprived areas were more likely to respond and complete the survey, but less likely to comment than English-speaking respondents and those living in less deprived areas, respectively. PFE survey participation differs across a range of sociodemographic characteristics, potentially introducing noteworthy biases. Health systems should minimize differences in how they collect feedback and account for potential biases when responding to experience data. Experience Framework This article is associated with the Policy & Measurement lens of The Beryl Institute Experience Framework. (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens.

Background Achieving excellent outcomes for patients with congenital heart disease requires coordinated effort and resources, and a need has developed for a structure that facilitates improvement and measures cardiac centers' progress toward optimal patient care. Methods The Heart Institute (HI) at Cincinnati Children's Hospital developed a Safety, Quality and Value (SQV) program to formalize the use of quality improvement (QI) methods with the goal of optimizing patient outcomes, experience, and value. The SQV program adopted a conceptual framework that considers aspects of structure, process, outcome, and value in defining quality metrics, and the program used the Model for Improvement to guide design and implementation of QI interventions. Results In the first four years since its inception, the SQV program facilitated important improvements in clinical outcomes, cost reductions, and safety. In addition to achieving measurable improvements, the creation of a formal SQV program fostered a culture of transparency and accountability, providing a new structure for how the HI shares clinical data among clinicians, hospital leadership, and the public. Conclusion The creation of an infrastructure to strategically design, implement, and support QI efforts in a clinically busy pediatric acquired and congenital heart institute was successful in meeting its initial aims and is a promising approach and model for other programs.

Collaborative quality improvement and learning networks have amended healthcare quality and value across specialities. Motivated by these successes, the Pediatric Acute Care Cardiology Collaborative (PAC3) was founded in late 2014 with an emphasis on improving outcomes of paediatric cardiology patients within cardiac acute care units; acute care encompasses all hospital-based inpatient non-intensive care. PAC3aims to deliver higher quality and greater value care by facilitating the sharing of ideas and building alignment among its member institutions. These aims are intentionally aligned with the work of other national clinical collaborations, registries, and parent advocacy organisations. The mission and early work of PAC3is exemplified by the formal partnership with the Pediatric Cardiac Critical Care Consortium (PC4), as well as the creation of a clinical registry, which links with the PC4registry to track practices and outcomes across the entire inpatient encounter from admission to discharge. Capturing the full inpatient experience allows detection of outcome differences related to variation in care delivered outside the cardiac ICU and development of benchmarks for cardiac acute care. We aspire to improve patient outcomes such as morbidity, hospital length of stay, and re-admission rates, while working to advance patient and family satisfaction. We will use quality improvement methodologies consistent with the Model for Improvement to achieve these aims. Membership currently includes 36 centres across North America, out of which 26 are also members of PC4. In this report, we describe the development of PAC3, including the philosophical, organisational, and infrastructural elements that will enable a paediatric acute care cardiology learning network.

In the 2000 report, Crossing the Quality Chasm, the Institute of Medicine broadly outlined the changes needed to reinvent the delivery of health care in the United States. This report highlighted the limitations of traditional scientific discovery methods to translate knowledge into consistent, high-quality medical care. Since the release of this report, the health care industry has seen an increased application of quality improvement methods developed by Dr. Walter Shewhart and implemented with great success by W. Edwards Deming in the manufacturing industries. This systems-based approach is predicated on the concept of learning from sequential changes and establishing objective measures to assess if those changes result in improvement (Langley, 2009).

The Infants Single Ventricle trial published in 2010 demonstrated no benefit of angiotensin converting enzyme inhibitor (ACEi) over placebo. The effects of this study on prescribing patterns are unclear. We sought to describe ACEi prescription in the interstage between stage 1 palliation (S1P)

Reported long-term outcome measures vary greatly between studies in Fontan patients making comprehensive appraisal of mortality hazard challenging. We sought to create a clinical risk score to assist monitoring of Fontan patients in the outpatient setting.A systematic review was conducted to evaluate risk factors for long-term (beyond the first postoperative year) mortality in Fontan patients. Studies were eligible for inclusion if ≥90 patients were included or ≥20 long-term mortalities we reported. Risk factors for long-term mortality were determined. The pooled hazard ratios were used to create components of a clinical score for long-term mortality using meta-analysis techniques.Twenty-eight studies were included. The total number of patients was 6707 with an average follow-up of 8.23 ± 5.42 years. There were 1000 deaths. Thirty-five risk factors for late mortality were identified and classified into 9 categories and their relative hazards were used to derive the initial components of a weighted, practical and clinically based Fontan risk score (ranging from 0 to 100). The final score included 8 risk factors: anatomic risk factors, elevated preoperative pulmonary artery pressure, atriopulmonary Fontan, heart failure symptoms, arrhythmia, moderate/severe ventricular dysfunction or atrioventricular valve regurgitation, protein losing enteropathy, and end organ disease (cirrhosis or renal insufficiency).In patients with Fontan circulation, the influence of readily available risk factors can be quantified in an integer score to predict long-term mortality. Prospective validation and refinement of this risk score will be undertaken.

Barth syndrome (BTHS) is associated with myocardial disease, frequently left ventricular noncompaction cardiomyopathy, which may necessitate cardiac transplantation or lead to death in some patients. We report a child with BTHS who had an "undulating cardiac phenotype" and ultimately developed decompensated heart failure requiring mechanical circulatory support with a ventricular assist device as a bridge to transplantation. His course was complicated by acute lung injury requiring placement of an in-line oxygenator to maintain end-organ function. Not only was his course complicated by cardiac and respiratory failure but his BTHS associated comorbidities complicated the management of his therapy using mechanical assist device support. He was successfully supported and subsequently was transplanted. Here we discuss the management of a child with BTHS using mechanical circulatory support and describe the use of an in-line oxygenator, Quadrox, with the Berlin Excor device.

Background Interstage mortality ( IM ) remains significant after stage 1 palliation (S1P) for single‐ventricle heart disease ( SVD ), with many deaths sudden and unexpected. We sought to determine whether digoxin use post‐S1P is associated with reduced IM , utilizing the multicenter database of the National Pediatric Cardiology Quality Improvement Collaborative ( NPCQIC ). Methods and Results From June 2008 to July 2013, 816 infants discharged after S1P from 50 surgical sites completed the interstage to stage II palliation, transplant, or IM . Arrhythmia during S1P hospitalization or discharge on antiarrhythmic medications were exclusions (n=270); 2 patients were lost to follow‐up. Two analyses were performed: (1) propensity‐score adjusted logistic regression with IM as outcome and (2) retrospective cohort analysis for patients discharged on digoxin versus not, matched for surgical site and other established IM risk factors. Of 544 study patients, 119 (21.9%) were discharged on digoxin. Logistic regression analysis with propensity score, site‐size group, and digoxin use as predictor variables showed an increased risk of IM in those not discharged on digoxin (odds ratio, 8.6; lower confidence limit, 1.9; upper confidence limit, 38.3; P ECMO use, genetic syndrome, discharge feeding route, ventricular function, tricuspid regurgitation, and aortic arch gradient) showed 0% IM in the digoxin at discharge group and an estimated IM difference between the 2 groups of 9% ( P =0.04). Conclusions Among SVD infants in the NPCQIC database discharged post‐S1P with no history of arrhythmia, use of digoxin at discharge was associated with reduced IM .

There are multiple cardiac etiologies for wheezing and respiratory distress which require a high degree of suspicion for the pediatrician to diagnose. We present a case of a patient with a history of long-standing mild persistent asthma with minimal improvement on controller and bronchodilator therapies who presented to the emergency room with acute respiratory distress. When he demonstrated a lack of improvement with traditional respiratory therapies, additional etiologies of respiratory distress were considered. Ultimately an echocardiogram was performed, which revealed the diagnosis of cor triatriatum. He underwent surgical resection of his accessory membrane and has had no additional symptoms of asthma since repair.

Background: Prior improvement work integrating standardized medical discharge criteria in general pediatric inpatients led to improved discharge timeliness and reduced length of stay (LOS). Our aim was to develop standardized medical discharge criteria on a quaternary pediatric cardiology unit in an effort to improve the timeliness of discharge. We hypothesized that timely discharge would lead to cost savings and a reduced LOS. Methods and Results: Over 18 months (Jan. 2014 - June 2015), a multi-disciplinary team worked toward the quality improvement aim of increasing the percentage of pediatric cardiology inpatients discharged within 2 hours of achieving medical discharge criteria. We established preset ‘medically ready’ discharge criteria in our hospital EMR, initiated upon admission for all inpatients and modified daily as needed. We organized criteria into 7 categories (congenital heart disease (CHD) medical, CHD post-operative, heart failure/transplant medical, transplant post-operative, electrophysiology (EP) medical, EP post-procedure, and catheterization post-procedure). The median percentage of patients discharged within 2 hours of meeting criteria increased steadily from 35% to 78% over the project period. Concurrently, the median number of patients discharged before noon increased from 18% to 31%. Physician and nursing compliance with necessary process measures was 87% and 89%, respectively. LOS decreased by 8% (3.6 to 3.3 days) from the first 6 months of work to the last 6 months. All-cause readmission remained stable at 15% over the improvement time frame. Review of inpatient charges between Oct. 2014 and June 2015 demonstrated 169 patients (190 discharges) who experienced a delayed discharge based on the set criteria. The sum of charges from care provided after meeting criteria was $231,201 (average of $1,217 per delayed discharge). Conclusions: Discharge timeliness in pediatric cardiology patients can be improved by standardizing medical discharge criteria. We demonstrate that this can be achieved across all subcategories of pediatric cardiology without increasing the rate of readmission. Improved discharge timeliness not only reduces LOS; it provides an opportunity to substantially decrease medical charges.

Background: Variability in medical practice is associated with higher cost without improved outcome. Our aim was to standardize the evaluation and treatment of dizziness/syncope and track resultant cost savings. Methods: A multidisciplinary team developed a care algorithm using best evidence and

Background According to the American Society of Echocardiography, coronary artery (CA) imaging is recommended in pediatric examinations to identify CA anomalies. A review of the authors' center's echocardiographic studies revealed that CA images were often nondiagnostic. The aim of this study was to utilize quality improvement methodology to increase the percentage of first-time pediatric studies with definitive CA identification from a baseline of 45% to a goal of at least 75% in 9 months. Methods A scoring system was developed to characterize the completeness of CA imaging. One point was scored for demonstration of each of the following: right CA origin by two-dimensional imaging, right CA origin by color flow Doppler imaging, left CA origin by two-dimensional imaging, and left CA origin by color flow Doppler imaging. A score of 4 was considered to represent definitive imaging. A baseline was obtained on 100 first-time echocardiograms with normal findings. During the intervention, 10 randomly selected first-time studies with normal findings were scored weekly for assessment of CA imaging. Interventions were focused on the following domains: excellence in image quality, shared ownership, transparency, and effective communication. Key interventions included labeling CA images, requiring two-dimensional and color Doppler images, optimization of settings, and elimination of macros for CA reporting. Results The percentage of definitive CA identification increased from 45% to 82.5% over 4 months and was sustained for 7 months. Accurate reporting of incomplete CA imaging increased from 17% to 77.5%. Conclusions Improved pediatric CA imaging and reporting were achieved through the implementation of key interventions.