QUALITY MANAGEMENTQUALITY MANAGEMENTMohamed M Abdelfatah

Abuzaid

OBJECTIVES

Define quality assurance and control and discuss their

relationship to excellence in radiography.

Describe the process of identifying imaging requirements,

developing equipment specifications, selecting equipment,

installing and testing equipment, and training the technical

staff.

Describe the objectives and responsibilities of monitoring

equipment performance.

Explain the rationale behind the data collection process

and the basic analysis of a radiographic repeats rate study.

Quality AssuranceQuality Assurance

• QA consists of activities that provide adequate

confidence that a radiology service will render consistently

high quality images and services.

• Is a program designed by management to assure quality

of a product or service.

• Such a program can include customer feedback,

employee empowerment, and quality control.

Quality Assurance Activities

Activities are focused around people and

service.

Most quality assurance activities produce

quantitative data that can be analyzed.

These data can be used to monitor the

processes and determine whether the

process is working as it should and whether

the standard of quality has been met.

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•interpretation of examinations,

• maintenance of equipment,

• performance of procedure,

• filling system,

• staff development,

• scheduling of examinations and supply lines

• QA includes evaluation activities such as

Quality Assurance Example

Patient arrived to the front desk, there is a process that is followed to alert the technologist that a patient is waiting.

Positive patient care

Patients will not complain from long waiting time before

starting the procedure

Patient Arriving Alert System

Quality Control

Defined as a comprehensive set of activities

designed to monitor and maintain systems

that produce a product.

In a radiology department, QC activities are

performed to ensure that: The procedure was performed safely

The procedure was appropriate for the patient

The procedure was performed efficiently

The procedure produced a high-quality image to

be read7

Quality Control Example

Patient arrived to the front desk, Is there a process that is followed to alert

the technologist that a patient is waiting.

Waiting Time for the RT to

start the procedure

Negative patient care

Patients complain from long waiting time before starting the procedure

Check Patient Arriving Alert System

Quality Control

Three major categories of QC tests

are used at various times:

Acceptance testing

Routine maintenance

Error maintenance

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““A quality assurance program maximizes the possibility A quality assurance program maximizes the possibility

that the image will every time provide adequate that the image will every time provide adequate

diagnostic information for the least possible radiation diagnostic information for the least possible radiation

exposure and cost to the patient”.exposure and cost to the patient”.

Quality Assurance and Quality Control

Acceptance TestingWhen? Whom? Why?

Acceptance testing is performed: Before newly installed or

Equipment with major repairs is accepted by the department.

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Testing may be performed by: A designated technologist A radiation physicist Service personnel employed by the hospital

Testing is used to determine whether the equipment is performing within the vendor’s specifications and as promised.

Routine Maintenance

Performed to ensure that the equipment is performing as expected

Can catch problems before the problems become radiographically apparent

May be performed by: A designated technologist A radiation physicist Service personnel employed by the vendor

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Error Maintenance

When errors occur in equipment performance,

corrective action must occur.

Errors are detected by poor equipment

performance or poor-quality outcomes.

Corrections generally are made by service

personnel employed by the vendor.

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Continuous Quality Improvement (CQI)

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Vs

Continuous Quality Improvement (CQI)

CQI tends to focus on the process rather

than the people or the service.

Belief is that if the process is good, the

people will follow it and the service will

then be good.

CQI does not replace the quality

assurance/QC programs but comes

alongside as a higher level of thinking.

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Quality assurance/QC programs focus on

maintaining a certain level of quality, not

necessarily improving to a higher

quality.

CQI focuses on improving the process or

system in which the people function as

team members rather than focusing on

the individual’s work.

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Continuous Quality Improvement (CQI)

FOCUS-PDCA method Find and define a problem.

Organize a team to work on improvement.

Clarify the problem with current knowledge.

Understand the problem and its causes.

Select a method to improve the process.

Plan implementation.

Do the implementation and measure change.

Check the results.

Act to continue improvements.

• Develop a plan based on what needs to be done.

•Study the results of the plan to determine whether the plan worked.

• Execute the plan

• write a policy and standardize the change. If it didn’t work•go through the cycle again

Why QA & QC?The three Ds:

Dose Diagnosis Dollars

QUALITY CONTROL MANUAL

A QC Manual should be created and reviewed at least annually.

The manual should include the facility’s objectives, QC instructions, QC results, and personnel responsibility.

Items that should be included in a QC Manual are: A list of the tests to be performed and the frequency for each

test, including acceptable Test limits, test procedures, maintenance, and service records. A list of equipment to be used for testing. Policy and procedures for QC tests as well as for the facility. Sample forms.

RECOMMENDED QUALITY CONTROL TESTS FOR Such FACILITIES

Test Frequency ProcedureWarm-up Procedures Daily, and If Idle Over 2 Hours 1Processor QC Daily, Prior to Developing Films 2Darkroom QC Daily and Weekly 3System Constancy Check Monthly and After Service 4A, 4BViewboxes Monthly 5Visual Checklist Quarterly and After Service 6Repeat Analysis Quarterly 7Film and Chemical Storage Quarterly 8Artifact Evaluation Quarterly 9Cassettes and Screens Quarterly or Semiannually (As Needed) 10Darkroom Fog Semiannually* 11Screen-Film Contact Annually and As Needed 12Collimation Checks Annually 13SID Indication Annually 14Automatic Collimation Check Annually 15Lead Apron Check Annually 16Program Review Annually Form9Radiation Safety Survey Two Years Form7*Darkroom fog should be evaluated every time you change the filter, bulb, or film type, and at least every 6 months.

Total Quality

ControlSystem

Identification of imaging requirement

Development of equipment specifications

Selection of equipment

Installation and acceptance testing

Continuing education

Monitoring of equipment performance

Identification of imaging requirement

Decision should be made by the chief Decision should be made by the chief

radiologist & administrative radiologist & administrative

technologiststechnologists Determine the basic parameters, impose Determine the basic parameters, impose

financial and space restraintsfinancial and space restraints Provide information on patient flow and Provide information on patient flow and

staffing needsstaffing needs

Generic equipment specifications should be Generic equipment specifications should be

developeddeveloped

Technical background is needed to state Technical background is needed to state

exactly what is needed to meet the imaging exactly what is needed to meet the imaging

requirementsrequirements

An imaging physicist should be involved at An imaging physicist should be involved at

this pointthis point

Detailed statements of what the equipment Detailed statements of what the equipment

should be capable of doingshould be capable of doing

Development of Equipment Development of Equipment SpecificationsSpecifications

Selection of equipmentSelection of equipment

When the bid arrive they should be When the bid arrive they should be

compared to meet specifications, cost compared to meet specifications, cost

and servicesand services

A pitfall in the process can occur when A pitfall in the process can occur when

radiologists show a preference to a radiologists show a preference to a

particular vendor, thus weakening the particular vendor, thus weakening the

bargaining position of the department bargaining position of the department

administratoradministrator

Installing and Acceptance Installing and Acceptance Testing of EquipmentTesting of Equipment

Is the responsibility of the vendor and/or Is the responsibility of the vendor and/or

manufacturer.manufacturer.

Quality Control technologists must verify that the Quality Control technologists must verify that the

equipment specifications have been metequipment specifications have been met

Supervising the testing procedures and results

The exact methods for acceptance testing be

included in the original specifications

The data from these tests will form the standard for The data from these tests will form the standard for

all future quality control monitoring.all future quality control monitoring.

Continuing Education

Is the responsibility of the vendor to familiarize the Is the responsibility of the vendor to familiarize the

users of the equipment with its proper operation.users of the equipment with its proper operation.

The equipment manual should be available The equipment manual should be available

Training should be included at the purchase Training should be included at the purchase

contractcontract

Continuing education must be an ongoing Continuing education must be an ongoing

procedure procedure

A good in-service program will include an

orientation procedure as well as periodic updates

on all complex equipment

Monitoring Equipment Performance

Includes routine checks of all

radiographic equipment

Objectives for performance

monitoring system are to:

Monitor the quality of the film processing

system

Specify faults within these systems to

allow corrective measures to be taken

Monitoring Equipment Performance

• Reduce equipment down-time

• The number of repeated exposures

• Reduce patient dose,

• Patient waiting time,

• Supply costs

A properly working quality control system will:-

Monitoring Equipment Performance Responsibility

Medical physicists are not required to Medical physicists are not required to perform routine quality control proceduresperform routine quality control procedures

Many procedure must be done dailyMany procedure must be done daily RT, who are more available and RT, who are more available and

knowledgeable about potential problems, knowledgeable about potential problems, should do the equipment monitoringshould do the equipment monitoring

To maintain a program, staff technologists To maintain a program, staff technologists must be given time to perform the must be given time to perform the procedures and to evaluate them. procedures and to evaluate them.

Monitoring Equipment Performance The tests of x-ray tubes should include:The tests of x-ray tubes should include:

Focal Spot size estimationFocal Spot size estimation

Half-value layerHalf-value layer

Collimator, central ray, and Bucky tray accuracyCollimator, central ray, and Bucky tray accuracy

Distance and centering indicators’ accuracyDistance and centering indicators’ accuracy

Angulator or protector accuracyAngulator or protector accuracy

Kilovoltage accuracyKilovoltage accuracy

Timer accuracyTimer accuracy

mR/mAs and miliamperage linearitymR/mAs and miliamperage linearity

Exposure reproduceabilityExposure reproduceability

Repeat Film Studiesas a part of QA & QC

Why we need it? Significant reductions in patient

dose, radiographers time and effort and supply costs can be achieved.

Repeat Film StudiesObtaining DataObtaining Data

Retain all repeated radiographs, Retain all repeated radiographs,

regardless of cause, for analysisregardless of cause, for analysis

Films labeled as “cause of repeat, Films labeled as “cause of repeat,

the room and tube used should be the room and tube used should be

noted on each film before it is noted on each film before it is

discardeddiscarded

RT must be informed of the purpose of RT must be informed of the purpose of

the study and asked to cooperate in a the study and asked to cooperate in a

positive manner to improve patient care positive manner to improve patient care

and working condition.and working condition.

Incompetent radiographers should be Incompetent radiographers should be

disciplined through normal administrative disciplined through normal administrative

procedures based on actual performance, procedures based on actual performance,

not as a result of repeat film study.not as a result of repeat film study.

Repeat Film StudiesObtaining DataObtaining Data

Retake Percentage by Room

Room #Reason 1 2 3 4 5

Dark 29 37 36 33 33Light 45 31 32 32 37Positioning 20 18 18 19 17Centering 10 11 20 9 9Motion 6 7 6 5 5Other 8 6 7 7 6Total: 118 110 119 105 107

Technique exposureChart error?

Collimator misaligned?

Repeat Film StudiesAnalysis of DataAnalysis of Data

Retake Percentage by Technologist

Technologist #Reason 1 2 3 4 5

Dark 35 31 32 30 43Light 32 31 31 34 30Positioning 20 18 18 30 17Centering 13 12 11 12 11Motion 5 11 4 4 4Error 10 4 5 3 3Other 5 7 6 6 7Total: 120 112 107 119 115

Need to be more carful?

Has difficulty withSome exams?

Using long exposureTimes?

Repeat Film StudiesAnalysis of DataAnalysis of Data