1. QUALITY CONTROL
For the Technologist

2. TECHNOLOGIST RESPONSIBILITIES
DAILY
Darkroom Cleanliness
Sensitometry
WEEKLY
Screen Cleanliness
Viewbox cleanliness
Phantom Imaging
MONTHLY
Visual Checklist
QUARTERLY
Repeat/Reject Analysis
Fixer Retention
SEMIANNUALLY
Compression
Film/Screen Contact
Darkroom Fog

3. DARKROOM CLEANLINESS NEVER: ALWAYS: Carpet a darkroom
Store boxes or cartons and never open
ALWAYS:
Have shelving with doors
Replace filters and service air conditioning
Wipe countertops with damp cloth
Wipe film trays with anti-static solution
Use a black light

4. SENSITOMETRY Must use same box of film
Must be performed before clinical films
Check Developer temperature
Flash sensitometric strip on emulsion side
Speed and Contrast Index within +/-.15
B+F within +/-.03
Developer within +/-.5 degrees
An increase in developer temp will affect other values: increase in B+F and decrease in density difference.
If developer normal, those changes may indicate a need to change chemicals.

5. SENSITOMETRY When data falls outside of the limits Trends
Documentation

6. SCREEN CLEANLINESS Clean when 3-4 specks shown Use Antistatic solution
4x4 rayon or lintless 100% cotton pads
Wipe in circular motion from center out
Let dry
Use one of many tools available to get rid of dust
Check with black light
Discard old film (costly)
Load with new film

7. VIEWBOXES Clean weekly to remove dust, smudges, etc
Change bulbs every 12-18months
Test luminance with light meter (not required by MQSA)
When changing bulbs, clean inside of viewboxes and change all bulbs

8. PHANTOM IMAGING Monitors whole system
Simulates a 4.5 cm compressed breast
Consists of 6 nylon fibers, 5 oxide specks, 5 tumor masses
Should be performed:
After any service
After changes in chemistry or film
Whenever changes in image quality suspected

9. PHANTOM PROCEDURE AEC placed same as a 4.5 cm breast
4mm acrylic disc placed away from objects
Background density: center, 1.2 OD +/-.2
Density difference: .4 +/-.05 for films at 28kVp
Chart mAs to evaluate reproducibility (should not vary more than +/-.15)

10. PHANTOM ANALYSIS Must see 4 fibers, 3 specks, 3 masses (10)
Can vary +/-1 but no lower than 10 objects.
Viewed:
By same person
Same time of day
On same viewbox
Under same viewing conditions
Using same type of magnifying lens

13. VISUAL CHECKLIST
Takes inventory of room to ensure safety, comfort and convenience

14. FIXER RETENTION
Performed right after daily strip on emulsion side in clear area
Place drop of fixer and let sit 2 minutes (do not expose to bright light)
Blot dry and place on white cardboard
Compare to chart. No more than 5ug/cm squared (3 on the chart)

15. REASONS FOR ELEVATED FIXER
Inadequate wash water flow rate
Partially depleted fixer (enough activity for clearing but not enough for hardening)
Insufficiently hardened emulsion retains too much fixer for wash to remove.
RESULT: Degrades stability of image

16. FIXER CORRECTION
Increase fixer replenishment
Increase water flow

17. REPEAT/REJECT ANALYSIS
To evaluate reasons films are repeated
Points out insufficiencies, waste
Can improve efficiency

18. REPEAT ANALYSIS PROCEDURE
Quarterly and at least 250 patients examined
Films are categorized
ACR states number of repeats should be no greater than 5%.

19. WAKE UP! ITS OVER!

20. COMPRESSION Image quality and safety test
Test in both power drive and manual
MQSA states 25 – 47 lb range

21. How does compression improve quality?
Decrease scatter
Decrease dose
Decrease patient motion
Increase contrast
Increase uniformity of breast tissue
Increase image sharpness by decreasing thickness thus decrease focal spot degradation

22. COMPRESSION PROCEDURE
Place towel
Place scale
Place friend’s (soon to be enemy’s) breast on top of scale
Compress in power mode until it stops (never mind the screaming of your new enemy)
Compress in manual until it stops (same as above)

23. COMPRESSION PROCEDURE
Place towel
Place scale
Place several towels on top of scale
Compress in power until it stops
Compress in manual until it stops

24. FILM/SCREEN CONTACT Performed on all new cassettes and/or semi-annual
More critical than general radiography
Highlights areas of decreased sharpness
Fine copper wire mesh screen used
More critical because of its high resolution which is attained through single emulsion with small crystals and screens with small phosphors
Damage to screens not noticeable with clinical films so this test highlights areas of decreased sharpness.

25. FILM/SCREEN CONTACT PROCEDURE
Clean cassettes
Let sit for 15 minutes
Employ 25-28kVp, no grid, manual mas with .5 seconds
Paddle all the way up with acrylic
Wire mesh on top of screen

26. FILM/SCREEN ANALYSIS .7-.8OD near chest wall Stand 3-6ft back
If densities over 1 cm appear, clean and retest.
Remove if large density still appears.
Several small densities acceptable.

27. DARKROOM FOG Inspect with all lights off
Be aware of luminescent or phosphorescent items
Use radiation exposed film
MQSA states fog should be no >.05 OD when exposed for 2 min.
Problems usually lie in safelight position or filters

28. DARKROOM PROCEDURE Load cassette in total darkness
Expose phantom to 1.0 OD
Inspect safelights
Turn off lights, inspect
Remove film, insert into template emulsion up
Expose sections to safelights
Run film then measure densities on each side of lines

30. Safelights Filters should correspond with green light sensitive film
Lamps ~4 ft from work area
Wratten 1 or 2, Kodak GBX-2 good examples of filters
No >15watt bulb in overhead fixture
No >7.5 watt in closer fixtures
Printing on filter should face out
Change filters every 1-2 years
Heat from higher watt bulbs could ruin filters
Film should be stored away from radiation, heat, chemical fumes.

31. AIR QUALITY Temperature: 70 degrees F Humidity: 30-50%
Ventilation: for image quality and technologists’ health
When film is exposed to excessive heat, its emulsion softens and is more susceptible to scratching.
A cooler temp causes emulsion to crack and peel.
If air dry <30%, static marks appear.
If humidity above 50%, water droplets from air may cling to film and cause emulsion to clump. Image will appear as if misted with ink.
Ventilation of processor: if no air going in or coming out (remove hose and put hand over hole) then streaking and mottling of emulsion can occur.
Can give techs headaches and nausea due to chemical fume buildup.

33. PROCESSOR MAINTENANCE
Developer temperature
Increase can cause fog
Decrease can result in:
Decrease in film speed and contrast
Higher dose to pt
Fixer temperature
Decrease can affect archival of film
Wash-water temperature
Can cause biological growth in tank
Can affect developer and fixer temps, improper wash

34. PROCESSING CONTINUED…
Chemical replenishment
Rates inconsistent when processor left on and not used
Check solution levels
If solution levels too low, sediment could get in to the processor and cause damage. Would need to empty tanks and clean.

35. PROCESSING: STANDARD Typically used for general radiography
Faster cycle time (usually 90sec)
Developer immersion ~23 sec
Can accommodate single and double

36. PROCESSING: EXTENDED
Difference from standard is developer immersion time (~45sec)
“Push” more contrast and speed from the film
Less exposure needed with increase in film speed
Increase in tube life
Downfall is an increase in noise

37. TYPES OF PROCESSORS Small desktop DISADVANTAGES ADVANTAGES
Straight-through require careful adjustments to replenishment
Developer not sprayed evenly
ADVANTAGES
Cost, small, fewer rollers, two developer stations,
Less chance of oxidation

38. TYPES OF PROCESSORS Large stand-alone DISADVANTAGES ADVANTAGES
Artifacts from rollers
Space
ADVANTAGES
Agitates chemicals which increases supply of fresh chemicals

39. ARTIFACTS Processing Environmental Handling Positioning Equipment
White artifacts indicate pressure on emulsion before exposure

40. SENSITOMETRIC STRIP Establishing the baseline
Expose and process 5 strips
Average readings for temporary base
Process one strip per day for 5 days
If strip is out of tolerance, correct and repeat
Watch for trend due to seasoning effect
Average these 5 strips for new base
Baseline maintained unless film, chemistry or processing altered

41. CROSSOVER Performed when changing box of film
10-12 sheets remaining in old box
Do not perform after processor cleaning

42. CROSSOVER PROCEDURE Perform in total darkness Expose 5 old and 5 new
Alternate old and new
Distinguish old from new
Measure steps used in daily QC
Average 5 readings from each box
Subtract old from new
Add/Subtract results to/from original aim values

43. CROSSOVER RESULTS Results must be within +/- .10
If greater than .15 difference, contact film manufacturer representative

44. (Dudes Prefer) (Sex, Violence and Partying) over (Visiting) (Relatives For) (Christmas Day Feasts.)

46. QUALITY ASSURANCE
Defined as all those planned and systematic actions necessary to provide high image quality.

47. QUALITY MANAGEMENT
Part of the management function which determines and controls quality policy.
Making appointments
Call back protocol
Obtaining previous mammograms
Patient education
Patient intake
Problem solving

48. QUALITY CONTROL
The set of operations necessary to maintain or improve quality.

49. QUALITY SYSTEM Assignment of responsibility Establishment of standards
Staff training
Proper documentation of procedures
QC of equipment at installation and throughout its life

50. MQSA of 1992
As of Oct 1, 1994, all mammography facilities in the U.S. (except those of Dept of Veterans Affairs) were required to be certified by the FDA as meeting mammography quality in order to lawfully continue to perform Mammography.
Goal: to assure that Mammography is safe and reliable to allow detection of breast CA in its earliest most treatable stages.

51. MQSA REGULATIONS
To operate lawfully, a mammography facility must be certified by the FDA.
In order to be certified, a facility must first be accredited by a federally-approved private nonprofit or state accreditation body.
To be accredited, the facility must undergo periodic review of clinical images; surveyed annually by a medical physicist; meet standards for personnel qualifications, equipment QA programs, and record keeping and reporting.
Facility must undergo annual inspections.

52. ACCREDITATION A survey form completed by facility
Phantom images submitted to evaluate image quality
Dosimeter visible on phantom and dose measured
Clinical images submitted for evaluation
Once initial paperwork approved, facility submits 30 days of processor QC strips
CLINICAL IMAGES
One set of fatty breasts and 1 set of dense breast images evaluated. Must demonstrate adequate positioning, compression, exposure level, contrast, exam identification, etc.

53. CERTIFICATION
Awarded by the FDA as providing quality mammography services.
This is awarded upon accreditation by a federally-approved accreditation body: ACR; States of Arkansas, California, and Iowa

55. RESPONSIBLE INDIVIDUALS
TECHNOLOGIST
RADIOLOGIST
PHYSICIST

56. Interpreting Physicians Initial Qualifications
State license
Diagnostic radiology certification OR 3 months of formal training
60 hours of category I CME in mammography
240+ mammograms interpreted under direct supervision
In the 6 months immediately prior to independent interpretation OR
If board certified at first allowable time, within the last 2 years of residency

57. Interpreting Physicians Continuing Requirements
Continuing experience
Interpret at least 960 examinations / 24 months
Continuing education
At least 15 category I CME credits / 36 months
At least 6 of the 15 CME units must be in each mammographic modality used
8 hours of training in each mammographic modality before independent use

58. Radiologic Technologists Initial Qualifications
State license OR certified by FDA-approved body
40 hours of documented mammography training
Performing at least 25 examinations under direct supervision
8 hours of training in each mammographic modality to be used

59. Radiologic Technologists Continuing Requirements
Continuing experience
At least 200 examinations / 24 months
Continuing education
At least 15 CEUs / 36 months
At least 6 of the 15 CEUs must be in each mammographic modality used
8 hours of training in each mammographic modality used before independent use

60. Radiologic Technologists Reestablishing Qualifications
Continuing experience
Complete 25 examinations under direct supervision
Continuing education
Bring total continuing education credits up to 15 CEUs / 36 months

61. Medical Physicists Initial Requirements
Licensed or approved by a State OR Certified by FDA-approved body
Master’s or higher degree in a physical science
20 semester hours of physics
20 hours of documented mammography survey training
One facility and 10 units surveyed
8 hours of training in each modality surveyed before surveying independently

62. Medical Physicists Alternative Initial Requirements*
Licensed or approved by a State OR Certified by FDA-approved body
Maintained active status
For physicists who were qualified under the interim regulations

63. Medical Physicists Alternative Initial Requirements* (cont.)
Prior April 28, 1999, have:
Bachelor’s degree in physical science with at least 10 semester hours of physics
40 hours of documented mammography survey training after earning the bachelor’s degree
One facility and 20 units surveyed after earning the bachelor’s degree

64. Medical Physicists Continuing Requirements
Continuing experience
Survey at least 2 facilities and 6 units / 24 months
Continuing education
At least 15 CEUs / 36 months
8 hours of training in any modality before surveying independently

66. MANUAL
QC MANUAL
QA MANUAL

67. QA MANUAL Details of acceptance
Personnel qualifications and documentations.
Department policy
Safety standards
Biohazards

68. QC MANUAL
The QC manual is pertinent to ease the inspection process. It lists:
Test procedures
Test frequencies
Test standards
Unacceptable results as listed as well as the corrections made for them.