Quality assurance for diagnostic imaging equipment

Introduction Purpose Definition Motivation Costs and benefits implementation Content of a QA program

Implementation A successful QA depends on the understanding and support of all those involved in the operation of the facility

Content of a QA program QA is a management tool that includes policies and procedures designed to optimize the performance of personnel and equipment ◦ Identify aspects of facility operation ◦ Establishing policies ◦ Encouraging compliance with policies ◦ Analyzing records of operation at regular intervals

General concepts of quality assurance and quality control

Approaches to QA and QC

Goal Accurate and timely diagnosis Minimization of radiation exposure Minimization of risk Minimization of discomfort Minimization of cost patient community

Factors in QA and QC Human factors ◦ Members of facility staff  Must be dedicated to the concept of QA  Must communicate freely with each other  Require a commitment to quality  Continuing dialogue regarding the quality of images Equipment factors ◦ Equipment function properly

General objectives

Accuracy in diagnosis Procedures to assure that radiological examinations are appropriate for clinical problem ◦ Risks, costs or complexity ◦ Types and availability of equipment

Minimizing radiation per examination Amount of radiation that is adequate but no more than enough to produce a diagnostic image In both underexposed and overexposed films, a subtle fracture or lesion can be missed

Provisions for comfort of the patient Comfort and privacy Patient waiting time Departmental conditions ◦ Room temperature ◦ Comfort of equipment Politeness and consideration of personnel

Communication Interpretation of the image to referring physician Patient’s film should be accurately identified Patient’s report form should be periodically audited Official report, either oral or written, must be provided speedily

Cost Reduction of cost to patient and department Minimum of technical and clerical errors should result in a lower cost per examination

Quality of images

Definition of image quality There are no hard and fast criteria for defining proper image quality The image quality needed will vary with the type of information needed An image with less than optimal definition is acceptable if it will answer the clinical problem Quality is perceived differently by different observers

Disadvantages of poor quality images Incorrect diagnosis ◦ Miss a fracture or a destructive lesion ◦ Improper or inadequate set of views Risk of repeating a hazardous procedure ◦ Non-radiological risks in angiographic procedure: reinjection, re-catheterization Unproductive patient radiation ◦ The radiation the patient has received has no benefit Patient inconvenience ◦ Increasing waiting time or make another visit Increased cost ◦ Patient, department and hospital

Cost-benefit consideration

Costs of a quality assurance program Personal costs ◦ Medical physicists or technologists Test equipment ◦ A small fraction of the total capital budget ◦ Must be available Decrease in patient flow from testing ◦ Testing may decrease the flow of patients, thus may involve a cost

Savings A monetary savings can be realized Result of a decrease in repeat studies A large fraction of repeats Result of technologist decision

Film and chemical savings The number of films used in quality control is usually smaller than the number used in repeat examinations

Less downtime of equipment The amount of downtime due to component failure may be decreased by a quality control program Preventive maintenance program

Saving of technologist time Repeat examinations cause unnecessary use of technologist time

Improvement in patient flow An increase in the number of patients can result in an increased return on the capital investment

Decreased cost of equipment service If the source of an image quality problem can be identified by facility personnel, the resultant service call will be less

Education and quality assurance

Facility personnel Technologist ◦ Positioning of the patient and exposure control Quality control technologist ◦ Adequate training in various aspects of quality control Practicing radiologist ◦ To maintain quality assurance ◦ Interaction with medical physicists and technologists Medical physicist ◦ Practical aspects of diagnostic radiology

Quality assurance – personnel performance and keeping of records

Introduction To assure the adequacy of personnel performance ◦ Influenced by many factors ◦ Records must be generated ◦ Periodic review of records To assure the proper functioning of equipment ◦ It will continue to function satisfactorily ◦ To detect malfunction before it degrade the diagnostic image or represent a hazard to patients

Elements of a personnel quality assurance program Identification of personnel activities Establishment of policies setting forth the method of performing these activities ◦ Person responsible for specific activities ◦ The way tasks to be performed ◦ The way decisions to be made ◦ The way personnel to relate to patient Institution of a system of record keeping ◦ Evidence of personnel performance Establishment of a system for the regular periodic review and analysis of such records ◦ Corrective action if deficiencies are found

Activities to be monitored Patient scheduling Patient reception Patient preparation Patient examination Film processing Image quality control Image interpretation Report preparation Report distribution File room operation Duties Participation Flow chart

Establishing policies to guide personnel performance To provide specific guidance to facility personnel Policies adopted should be tailored to the individual facility Policies must be clear and concise

Developing a record-keeping system to provide an index of compliance Request form Room log Report of the interpretation of an imaging study Incident report Patient’s film jacket Other records ◦ Daily work schedule, arrival / departure log, questionnaire of patient or referring physician satisfaction

Room log Daily activity of a given examining room ◦ Name of the patient ◦ Study performed ◦ Film exposed ◦ Reason for retake ◦ Reason for supplemental view ◦ Reason for room out of service Daily activity of a given dark room

Analyzing the records Method of review and analysis ◦ Identifying areas of deficiency ◦ Instituting corrective action Establish a schedule and assign staff personnel, rotation, to perform review Report findings as part of a regular staff meeting

Analyzing the records Periodic review ◦ imaging interpretation ◦ facility operation ◦ Imaging technique ◦ Report generation ◦ File room function

Analyzing the records How long dose it take to complete a study What fraction of images are repeated What equipment problems effect on image quality or patient exposure How long dose it take to get a report of an imaging study dispatched to its destination How frequently do reportable incidents occur How long does it take the file room staff to retrieve the images of a current case

Quality assurance committee (QAC) QAC ◦ Chief imaging physician ◦ Medical physicist ◦ Chief technologist ◦ Quality control technologist To raise the awareness of importance of quality assurance Meet at regular intervals to discuss problems

Evaluation of the findings and institution of corrective action Assessing the adequacy of performance ◦ Comparison with own previous performance ◦ Evidence of deterioration of performance should suggest prompt corrective action ◦ Each facility need to set its own standards of performance To assure that corrective action is taken ◦ The recommendation of previous deliberations be reviewed on the next meeting

Establishment of a quality control program

Introduction Quality control is an integral and most tangible aspect of quality assurance ◦ Acceptance testing ◦ Establishment of baseline performance ◦ Diagnosis of changes in equipment performance ◦ Verification of correction of causes of deterioration

Who dose it All members ◦ Imaging physician ◦ Medical physicist : supervise and consult ◦ Quality control technologist Must be trained Must have adequate time Carry out the day-to-day measurements Maintain quality control log

Responsibility Physician’s responsibility ◦ Quality control function User’s responsibility ◦ Equipment is working  properly  Safely  At optimum image quality

Documentation, recording and correction Measurements : clearly and readily Recording of data : control chart Evaluation of chart data and measurements Setting standards for variation allowed : upper and lower control limits Testing frequency : cost and benefit Method of interpretation and corrective action : reporting problems to service personnel Repair decisions : initiating the repair

Tools needed for a quality control program Size of the facility Expertise of individual Scope of the testing program

Beginning a quality control program for equipment Determine the type of equipment needed before purchase Selecting equipment and preparing specifications Service costs over the expected life Meet the specifications : after installation Users must be instructed in proper operation and trouble shooting techniques

General methodology of quality control and diagnostic testing Retake analysis ◦ Factors affecting retake rate ◦ Method of retake analysis ◦ The start-up effect ◦ Measured and actual retake rate ◦ Factors to record in retake analysis ◦ Radiograph artifacts

General methodology of quality control and diagnostic testing Recording equipment downtime and failure ◦ Log book for each room : listing problems, length of time for service Exposure per image ◦ Comparison of exposure within the facility Test objects for evaluation of equipment performance ◦ Particularly when changing imaging techniques ◦ Patient-simulating phantoms or test objects

Procedures, objectives, and policies- performance optimization

Management of personnel activities Importance of monitoring personnel performance Application of recommendations Policy statements

Importance of monitoring personnel performance Greatest possible benefit, least possible cost ◦ Patient irradiation ◦ Discomfort ◦ Inconvenience ◦ expense

Importance of monitoring personnel performance Unproductive patient irradiation ◦ Improper scheduling ◦ Preparation of the patient ◦ Inappropriate or inadequate examinations ◦ Errors in image exposure, identification or processing ◦ Delays in image interpretation ◦ Inability to retrieve images when required

QUALITY ASSURANCE PROGRAMS FOR DIAGNOSTIC RADIOLOGY FACILITIES (a) Applicability (b) Definitions (c) Elements

A quality assurance program should contain Responsibility Purchase specifications Monitoring and maintenance Standards for image quality Evaluation Records Manual Training Committee Review