Quality Improvement Methods Research Articles

Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: Aquality improvement project.

Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia. We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram-guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations. The project key drivers were education, equipment, and electronic health record modifications. Plan-Do-Study-Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram-guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case-based knowledge; (3) adding age-based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram-guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart. After the four Plan-Do-Study-Act cycles, electroencephalogram-guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram-guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001). Quality improvement methods may be deployed to adopt electroencephalogram-guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.

Initiation of Palliative Care Referral from the Intensive Care Unit for Advanced Stage Metastatic Cancer Patients: A Quality Improvement Process from a Tertiary Referral Cancer Institute from South India.

Critically ill cancer patients in the intensive care unit (ICU) did not have any palliative care (PC) intervention as there was no PC referral from the ICU. The project aimed to initiate PC referral for at least 50% of progressive palliative intent cancer patients in intensive care to enhance communication with patients and caregivers. We included PC physicians, oncologists, and psychologists in the team for this project. We used the A3 problem-solving method of quality improvement (QI) and also used the Plan Do Check Act process. The first baseline assessment over 6 months of ICU deaths of patients who could have benefited from PC referral was collected; this made us realise that PC could have been initiated for some patients. Process maps of patient admission into the ICU and the process of their discharge were constructed. Analysis of root causes that were barriers to referral was examined. We made a PC trigger tool after team consultations and consensus and started using it to initiate PC referrals. PC discharge protocol was also initiated. Educational discussions were held with residents and nurses to ensure the continued use of the trigger tool. PC referral from intensive care slowly went up from 0% to beyond 50% by November 2019 and reached over 70% by March 2020; patients getting discharged had details of PC centres near their homes. Structured QI process and introducing the PC trigger tool led to the outcome of 50% PC referral for critically ill patients in ICU.

Multidisciplinary Initiative to Increase Guideline-concordant Antibiotic Prescription at Discharge for Hospitalized Children with Uncomplicated Community-acquired Pneumonia

Background: Clinical practice guidelines recommend using narrow-spectrum antibiotics to treat uncomplicated pneumonia in children. This quality improvement (QI) project aimed to evaluate if QI methods could improve guideline-concordant antibiotic prescribing at hospital discharge for children with uncomplicated pneumonia. Methods: For this single-center QI project, we implemented QI interventions in serial plan-do-study-act cycles, focusing on the key drivers targeting general pediatric inpatient resident teams. Interventions included: (1)Small bimonthly group didactic sessions, (2)Visual job aids posted in resident work areas, and (3) A noon conference session. Balancing measures included postdischarge emergency room visits, readmission and adverse drug reactions. Results: To establish a baseline rate, we conducted a chart review of 112 children diagnosed with uncomplicated community-acquired pneumonia during hospitalization from July 2017 through January 2019. The average monthly percentage of children discharged with guideline-concordant antibiotics was 67%. The intervention period was from February 2019 through February 2020, with 118 children meeting the criteria after a review of 262 charts. After our interventions, the average monthly percentage of children discharged with guideline-concordant antibiotics increased to 87%, with the increase persisting for at least 12 months. There were no significant differences in balancing measures pre- and post-interventions. Conclusions: Our QI initiative sustained increased rates of uncomplicated community-acquired pneumonia guideline-concordant antibiotic prescribing at discharge over 12 months without an increase in balancing measures. The enduring changes in prescribing behavior suggest a lasting impact of our interventions.

Factoring patients' beliefs and values into decisions around anticoagulation: a community-led multi-cycle quality improvement project

Low-molecular-weight heparin (LMWH), prescribed for prophylaxis of venous thromboembolism, is derived from porcine animal products. An audit in our Trust showed that most healthcare professionals (95%, n=58/61) did not consider religious or dietary preferences when prescribing LMWH. Focus groups with local stakeholders helped develop project aims. Quality improvement methods were used to develop, test and optimise interventions over two cycles in our medical unit. Interventions included written and audiovisual information for patients, a staff eLearning module, a policy to guide switching from LMWH to a synthetic alternative and a written prompt reminding doctors to consent patients before prescribing LMWH. The proportion of patients being appropriately consented for LMWH prescriptions increased following our interventions (from <5% at baseline to >80%). Patient and staff feedback was positive, with high demand for a non-animal-derived alternative to LMWH. Simple measures, increasing awareness and knowledge among staff and patients, can improve the number of patients being appropriately consented for LMWH prescriptions.

The quality improvement method of vibroseis records

Vibroseis seismic acquisition technology is a method of acquiring seismic data utilizing correlation technology. Specifically, the seismic single shot record is obtained through correlation between the reference signal and the mother record. Specifically, the seismic single shot record is obtained through correlation between the reference signal and the mother record. Specifically, the seismic single shot record is obtained through correlation between the reference signal and the mother record. In line with pertinent technical regulations, greater correlation between the two signals equates to superior correlation outcomes. The reference signal is transmitted to the surface via the vibration of the vibrating plate. This is achieved using the vibroseis machine. However, due to the coupling relationship between the vibrating plate and the surface, the vibration signal output by the former is not equivalent to the vibration signal received by the latter. Consequently, the correlation between the reference signal and parent record fails to procure the best correlation result. In this paper, a technique is presented for establishing a correlation between the surface vibration signals captured by the geophone in proximity to the vibroseis and the reference record. This approach improves the quality of the correlated single shot, and holds significant potential for broad dissemination.

Using Theories, Models, and Frameworks to Inform Implementation Cycles of Computerized Clinical Decision Support Systems in Tertiary Health Care Settings: Scoping Review.

Computerized clinical decision support systems (CDSSs) are essential components of modern health system service delivery, particularly within acute care settings such as hospitals. Theories, models, and frameworks may assist in facilitating the implementation processes associated with CDSS innovation and its use within these care settings. These processes include context assessments to identify key determinants, implementation plans for adoption, promoting ongoing uptake, adherence, and long-term evaluation. However, there has been no prior review synthesizing the literature regarding the theories, models, and frameworks that have informed the implementation and adoption of CDSSs within hospitals. This scoping review aims to identify the theory, model, and framework approaches that have been used to facilitate the implementation and adoption of CDSSs in tertiary health care settings, including hospitals. The rationales reported for selecting these approaches, including the limitations and strengths, are described. A total of 5 electronic databases were searched (CINAHL via EBSCOhost, PubMed, Scopus, PsycINFO, and Embase) to identify studies that implemented or adopted a CDSS in a tertiary health care setting using an implementation theory, model, or framework. No date or language limits were applied. A narrative synthesis was conducted using full-text publications and abstracts. Implementation phases were classified according to the "Active Implementation Framework stages": exploration (feasibility and organizational readiness), installation (organizational preparation), initial implementation (initiating implementation, ie, training), full implementation (sustainment), and nontranslational effectiveness studies. A total of 81 records (42 full text and 39 abstracts) were included. Full-text studies and abstracts are reported separately. For full-text studies, models (18/42, 43%), followed by determinants frameworks (14/42,33%), were most frequently used to guide adoption and evaluation strategies. Most studies (36/42, 86%) did not list the limitations associated with applying a specific theory, model, or framework. Models and related quality improvement methods were most frequently used to inform CDSS adoption. Models were not typically combined with each other or with theory to inform full-cycle implementation strategies. The findings highlight a gap in the application of implementation methods including theories, models, and frameworks to facilitate full-cycle implementation strategies for hospital CDSSs.

Investigating the Effect of the 7S Technique on Performance Management and Productivity of Operating Room Staff: An Interventional Study

Background: One of the most important issues in a health care system is the performance management and productivity of employees. Sigma technique is a quality improvement method, which has proved effective in many organizations and has recently been used in the health care system, especially in the operating room. The aim of this study was to investigate the effect of the Seven Sigma technique (7S) on performance management and productivity of operating room staff in selected educational and medical centers of Iran University of Medical Sciences. Methods: In this interventional research, the study population consisted of 45 operating room staff including technicians, technologists, and surgeons. Before the intervention, a WhatsApp channel was created to gather group members. Then, over the course of three weeks, the principles of the Seven Sigma technique were gradually sent to the research population, and participants were asked to carefully review the materials. Every three days, after posting a question in the channel to ensure understanding of the previous topic, the next section was also posted in the channel. Then, after three weeks, a productivity questionnaire was sent to the research population, and using a researcher-made checklist, the performance of the employees was evaluated. Standard statistical methods were used to analyze the data in SPSS version 22.0. Results: From a total of 45 staff, 62% were women and 38% were men. The majority of subjects (36%) were between 24 and 28 years old. The majority of personnel (89%) had a university degree in operating room, and most of them (84%) had a bachelor’s degree. Most of the staff (91%) worked rotating shifts during the month. There was a significant difference between the pre-test and post-test mean scores of performance management (P&lt;0.001). There was also a significant difference between the pre-test and post-test mean scores of productivity (P&lt;0.001). Conclusion: The findings indicated the effectiveness of the 7S technique in performance management and productivity of the staff. Therefore, the relevant authorities are requested to increase performance management using the 7S technique to reduce defects and problems limiting the efficiency of personnel in the operating room. This method can also be practical and useful for other wards of hospitals.

Implementation of a Children's Hospital Acute Care Behavior Response Team.

Pediatric patients with behavioral needs are frequently admitted to the hospital for medical care; when behavioral crises occur, patients and staff are at risk for injury. Our aim was to implement a behavior response team (BRT) to increase the days between employee injury due to aggressive patient interactions on the inpatient medical units from 99 to 150 over 1 year. A multidisciplinary team used quality improvement methods to design and implement the BRT system that includes 2 options: huddle to proactively plan for patients exhibiting early signs of escalation and STAT for immediate help for patients with imminent risk of harm to self or others. Using run and statistical process control charts, we tracked events per month, days between Occupational Safety & Health Administration-recordable events, and violent restraint use over time for 1 year after implementation. Staff pre and postimplementation surveys were compared to assess staff perception of safety and support provided by the BRT intervention. The BRT was implemented across the inpatient system in July 2020, with an average number of 13 events per month. Days between Occupational Safety & Health Administration-recordable events remained stable with a maximum of 134 days. Restraint use remained stable at 0.74 per 1000 patient days. The perception of behavioral support available to staff increased significantly pre to postsurvey. The implementation of a BRT can improve staff perception of support and confidence in safely caring for patients with behavior needs on the inpatient medical unit, although additional provider- and system-level improvements are needed to prevent employee injuries.

An Image Quality Improvement Method in Side-Scan Sonar Based on Deconvolution

Side-scan sonar (SSS) is an important underwater imaging method that has high resolutions and is convenient to use. However, due to the restriction of conventional pulse compression technology, the side-scan sonar beam sidelobe in the range direction is relatively high, which affects the definition and contrast of images. When working in a shallow-water environment, image quality is especially influenced by strong bottom reverberation or other targets on the seabed. To solve this problem, a method for image-quality improvement based on deconvolution is proposed herein. In this method, to increase the range resolution and lower the sidelobe, a deconvolution algorithm is employed to improve the conventional pulse compression. In our simulation, the tolerance of the algorithm to different signal-to-noise ratios (SNRs) and the resolution ability of multi-target conditions were analyzed. Furthermore, the proposed method was applied to actual underwater data. The experimental results showed that the quality of underwater acoustic imaging could be effectively improved. The ratios of improvement for the SNR and contrast ratio (CR) were 32 and 12.5%, respectively. The target segmentation results based on this method are also shown. The accuracy of segmentation was effectively improved.

Characterization and experimental verification of the rotating synthetic aperture optical imaging system

The rotating synthetic aperture (RSA) optical imaging system employs a rectangular primary mirror for detection. During the imaging process, the primary mirror rotates around the center to achieve the aperture equivalent to the long side of the rectangle at different rotation angles. As a result, the system’s point spread function changes over time, causing periodic time-varying characteristics in the acquired images’ resolution. Moreover, due to the rectangular primary mirror, the images obtained by the RSA system are spatially asymmetric, with a lower resolution in the short side’s direction than in the long side’s direction. Hence, image processing techniques are necessary to enhance the image quality. To provide reference for the study of image quality improvement methods, we first characterize the imaging quality degradation mechanism of the RSA system and the time–space evolution law of the imaging process. We then establish an imaging experiment platform to simulate the dynamic imaging process of the RSA system. We quantify the RSA system’s impact on image degradation using objective indexes. Subsequently, by comparing the imaging experiment results with theoretical analysis, we verify the spatially asymmetric and temporally periodic imaging characteristics of the RSA system. Lastly, we introduce image super-resolution experiments to assess the limitations of directly applying generic deep learning-based single image super-resolution methods to the images captured by the RSA system, thereby revealing the challenges involved in improving image quality for the RSA system.

Building lean improvement skills at scale: an evaluation of a massive open online course in the English NHS

BackgroundInternationally, healthcare systems face challenges from population demographics and rising care costs. Systematic methods of quality improvement (QI) are considered key to delivering needed transformation and change. Large-scale training in...

704 Use of process-focused quality improvement methods identified nonprocess-oriented opportunities for growth

704 Use of process-focused quality improvement methods identified nonprocess-oriented opportunities for growth

DMAIC Analysis of Educational Institutes in Pakistan

Pakistan is growing interest in implementing DMAIC in educational institutions to promote both quality and effectiveness. To teach learners about Six Sigma, the education sector is extremely important. Educational institutes don't want to adopt new technologies teaching methods or assessment strategies and fear of the unknown can make people resistant to trying something new or different they did not use proper training for the students and teachers thus, they didn't have any idea regarding the Six Sigma project, hence management wind up the training. Six Sigma and the education sector now have gaps in innovative learning styles, quality management, novel classroom learning methods, and effective teacher behaviour. A popular method of quality improvement Six Sigma is to be applied in a study using the DMAIC (define, measure, analyze, implement and control) criteria.

Pancreas Cancer Learning Health Network Established to Share Best Practice Across 14 Centers and Improve Patient Outcomes

Pancreas cancer (PC) survival is among the lowest of all malignancies. Clinical trials have failed to significantly improve outcomes. Individual and institutional biases in care result in significant variation in practice, further hindering progress. Learning health networks (LHNs) prospectively collect real world data across centers and test improvements that can rapidly be expanded across centers if deemed successful. Herein, we report preliminary progress from the Pancreas Cancer Canopy Cancer Collective (PC-CCC), the first oncology LHN, established to improve duration and quality of survival in PC. In 2019, we established the PC-CCC with six care centers who engaged in a collaborative design process to create a set of improvement aims, change ideas, and outcome measures. Center team members receive training and coaching in collaborative quality improvement methods, applied to local improvement efforts. Eight more centers joined in 2021, and a shared Canopy outcomes database was built and implemented to inform center-specific and network-wide improvement efforts and allow the LHN to undertake research using real-world data. Current improvement efforts are focused on proactively screening new PC patients for: (1) Clinical trials, (2) pancreas enzymes, (3) palliative care needs, and (4) goals of care conversations. Currently, 14 care centers are active participants in the PC-CCC LHN. Data on a total of 2,002 PC patients are available to date. At presentation to the care center, most patients are female (51%) and have biopsy proven PC (83.9%). Average age is 68 years, and presenting disease status is metastatic (14.5%), resectable (11.4%), locally advanced (10.9%), borderline resectable (8.1%), or not yet staged (40%). For those who received radiation, 75.8% received stereotactic body radiation therapy. Among patients whose chemotherapy regimen was documented, most received 5-fluorouracilbased treatment (52%). Descriptive follow up data (including treatment and outcomes) are being actively updated, to be reported at time of presentation. Creation of a cancer LHN for PC is feasible and has set the stage for improving patient and provider outcomes through iterative community-building, continuous improvement, and sharing of data and multidisciplinary best practices. Additionally, the data obtained from the CCC database can rapidly inform the network how variation in clinical practice across centers can influence outcomes.

Reducing Patient Care Delays in Radiation Oncology via Optimization of Insurance Pre-Authorization

Difficulties and delays in insurance pre-authorization (pre-auth) can negatively impact patient care, resulting in postponing, modifying, or even cancelling radiation therapy for patients. Unfortunately, pre-auth delays are not uncommon. The purpose of our project was to perform a root cause analysis of reasons for pre-auth delays, and implement solutions to optimize our workflow to better serve our patients. Our primary objectives were to decrease the mean time for clinical treatment plan (CTP) completion, and for number of cases delayed/denied, by 50% each. We performed a root cause analysis of reasons for pre-auth delays and used the PDSA & A3 quality improvement methods. We sampled ∼2 cases per disease site (total 19 cases from July - Aug 2022) to determine the "current state," pre-interventions. Countermeasures included: 1) customizing our CTP templates for each disease site to contain the specific clinical information required by each insurer, 2) formalizing earlier completion of CTPs through task automation at time of scheduling CT simulation in our Care Path, and 3) continuously refining our countermeasures based on monthly status updates and department meetings. We tracked various physician, authorization, and outcome-metrics between October 2022 and January 2023, including mean time for CTP completion, % usage of our Care Path, % usage of revised CTP templates, mean time until pre-auth initiated & completed, % of cases requiring peer-to-peer phone calls, and % of cases denied/delayed. There were 417 patients from a variety of disease sites who had a CT simulation at our institution between October 1, 2022, and January 31, 2023. Mean time for CTP completion (from the time of CT simulation request) improved from 16 days at baseline to 7 days by the end of the project. In the beginning, only 5% of CTPs were completed within 2 days of scheduling the CT simulation, and this improved to 42-56% during the project period. Percent usage of the Care Path improved dramatically from 16% to 91%, as did % usage of our revised CTP templates, from 0% to 96%. Despite initial lag in pre-authorization team workflow changes, the % of pre-authorizations initiated by day 3 from CT request improved from 32% at baseline to 48% by month 4. Mean time to complete insurance pre-authorizations improved from 16 days at baseline to 10 days. The percent of cases requiring peer to peer or were denied was reduced significantly from 32% at baseline to 4-11%. Improvingtimeliness and details of CTP documentation by using our Care Path and revising CTP templates improved efficiency of insurance pre-auth completion, and reduced the number of cases delayed/denied.

Increasing Mental Health Screening inPediatric Subspecialty Clinics: An Improvement Project at Brooke Army Medical Center.

Mental health screening allows for the early identification of patients at risk of mental health disorders such as anxiety and depression. The Defense Health Administration Procedures Manual 6025.01 established that patients older than 12 years of age should receive annual mental health screening assessing suicidality risk with a standardized screening tool. To improve rates of mental health screening in this at-risk population, an A3 Lean approach to quality improvement was undertaken in the Pediatric Subspecialty Clinics at Brooke Army Medical Center. Baseline data of Patient Health Questionnaire-9 or General Anxiety Disorder-7 screening from pediatric pulmonology and cardiology clinics were 6.3%. Plan-Do-Study-Act quality improvement methods evaluated possible interventions to improve screening. A standard operating procedure (SOP) outlining scoring and interpretation recommendations was distributed in pediatric pulmonology and cardiology clinics. Using the Armed Forces Health Longitudinal Technology Application, a post-implementation chart review was conducted for 8 weeks. With the initiation of Military Health System Genesis, the SOP was adjusted and a root cause analysis was performed. The pediatric gastroenterology clinic cares for patients presenting with functional abdominal pain; therefore, the clinic was added to the second iteration to determine if anxiety or depression may play a role. Providers were educated on documentation and coding. A second post-implementation chart review was conducted for 8 weeks. Over two iterations, mental health screening of new adolescent patients in pediatric subspecialty clinics increased by 794% from baseline. Our providers screened 50% of the adolescent patients. With increased surveillance of an at-risk population, more adolescents will receive the standard of care. With refinement of the SOP and expansion to other subspecialties, this project has the potential to expand within Brooke Army Medical Center and other clinics in the Defense Health Administration.

Screening for sleep disordered breathing among children hospitalized for asthma exacerbation.

Sleep disordered breathing (SDB) may exacerbate asthma and is a treatable comorbidity. To design and implement a screening process for SDB in patients hospitalized for asthma exacerbation using quality improvement (QI) methods. We sought to improve screening for SDB from zero to 60% from July 2019 to December 2020. A multidisciplinary team used QI methods to screen for SDB using the Michigan pediatric sleep questionnaire (PSQ) in patients 2-18 years hospitalized for asthma exacerbation. Key interventions included: pairing the PSQ screen with another element of routine care (the asthma risk factor screen), educating staff and physicians, engaging respiratory therapists to complete the PSQ and document scores, and modifying the electronic medical record (asthma order set and flowsheet for PSQ score documentation). A run chart tracked progress and descriptive statistics were generated. There were 2067 patients admitted for asthma exacerbation during this project. The PSQ was completed for 1531 patients (74%) overall. Of screened patients, 360 (24%) had a positive PSQ; the mean age was 8.6 years. Approximately 14 months after the project began, ~90% of children admitted for asthma were being screened; subsequently, >80% of patients were being screened until May 2022. Screening with the PSQ occurred approximately 90% of the time when routine asthma risk screens were completed. A screening process for SDB was successfully implemented and appeared feasible and sustainable. The high proportion of positive screens reinforces the importance of evaluating for SDB in the high-risk population of children requiring hospitalization for asthma exacerbation.

Application of novel methods for quality improvement in explosion puffing drying of apple snacks

In this study, vacuum drying (VD), microwave drying (MW) and freeze-drying (FD) alternatives to air drying (AD) were applied to apple samples before explosion puffing drying (EPD). The volumes of AD+EPD samples were determined 20% higher than the volume of AD samples. The porosity value and the average pore radius value were obtained by examining the SEM images with the MATLAB program. Porosity values were found between 0.41-0.82 for all drying processes applied. The lowest porosity was found at 180MW, and the highest porosity was found in the FD samples. It is seen that the porosity ratio increases as the microwave power per product increases. Rehydration rates of 180, 360 and 600MW samples were determined as 308, 320 and 336%, respectively. It contributed to the increase in rehydration due to the increase in the porosity of the product with the increase in power density per product in MW drying. There was an increase in the amount of TPC with the combined use of the EPD process. The highest ABTS and DPPH were determined in the FD, FD+EPD and 600MW+EPD samples, respectively. The pre-drying methods and parameters described in the study significantly affected the quality of apples in terms of their physical and chemical properties.

A real-time quality improvement method based on an adaptive dynamic screened Poisson equation for surveillance video in sand-dust weather

A real-time quality improvement method based on an adaptive dynamic screened Poisson equation for surveillance video in sand-dust weather

A quantitative CBCT pipeline based on 2D antiscatter grid and grid-based scatter sampling for image-guided radiation therapy.

Quantitative accuracy is critical for expanding the role of cone beam CT (CBCT) imaging from target localization to quantitative treatment monitoring and plan adaptations in radiation therapy. Despite advances in CBCT image quality improvement methods, quantitative accuracy gap between CBCT and multi-detector CT (MDCT) remains. In this work, a physics-driven approach was investigated that combined robust scatter rejection, raw data correction and iterative image reconstruction to further improve CBCT image quality and quantitative accuracy, referred to as quantitative CBCT (qCBCT). QCBCT approach includes tungsten 2D antiscatter grid hardware, residual scatter correction with grid-based scatter sampling, image lag, and beam hardening correction for offset detector geometry linac-mounted CBCT. Images were reconstructed with iterative image reconstruction to reduce image noise. qCBCT was evaluated using a variety of phantoms to investigate the effect of object size and its composition on image quality, and image quality was benchmarked against clinical CBCT and gold standard MDCT images used for treatment planning. QCBCT provided statistically significant improvement in CT number accuracy and reduced image artifacts when compared to clinical CBCT images. When compared to gold standard MDCT, mean HU errors in qCBCT and clinical CBCT were 17±9 and 38±29 HU, respectively. Magnitude of phantom size dependent HU variations were comparable between MDCT and qCBCT images. With iterative reconstruction, contrast-to-noise ratio improved by 25% when compared to clinical CBCT protocols. Combination of novel scatter suppression techniques and other data correction methods in qCBCT provided CT number accuracy comparable to gold standard MDCT used for treatment planning. This approach may potentially improve CBCT's promise in fulfilling the tasks that demand high quantitative accuracy, such as online dose calculations and treatment response assessment, in image guided radiation therapy.