Diagnostic X-Ray Imaging Quality Assurance: An Overview - October 1996

PART II. Hospital Diagnostic Imaging Quality Assurance Program Review

1996

Help on accessing alternative formats, such as PDF, MP3 and WAV files, can be obtained in the alternate format help section.

(65K)

Survey Worksheets

Contents

• 1. Hospital and radiology Department Quality Assurance Committees
  • 1.1 Hospital QA Committee
  • 1.2 Radiology Department QA Committee
• 2. Quality Assurance Training
• 3. Equipment Specification Writing
• 4. Quality Control Testing
• 5. Equipment Acceptance Testing
• 6. Quality Control Testing
  • 6.1 X-Ray Equipment QC
  • 6.2 Photographic Equipment QC
• 7. Equipment Performance Records and Record Keeping
• 8. Equipment Appraisal and Replacement Policy
• 9. Standardization of Exposure
  • 9.1 Radiographic Positioning
  • 9.2 Loading factors
  • 9.3 Entrance-Skin-Exposure
• 10. Acceptance criteria for Diagnostic Radigrams
• 11. Reject-Repeat Analysis Program
• 12. Summary of Quality Assurance and Quality Control Document Assessment

Abbreviations:

1. Hospital and Radiology Department QA Committees

1.1. Hospital Quality Assurance Committee (QAC)

1. Does the hospital have a QAC?
   Y/N
   
   
2. Does the hospital have documented QA program?
   Y/N
   
   
3. Is a copy of the hospital organization available (showing level of responsibility and reporting order)?
   Y/N

Comments: ________________________________________________

1.2. Radiology Department Quality Assurance Committee

1. Does the radiology department have a QAC?
   Y/N
   
   
2. Does the radiology department QAC have an overall strategy with clearly defined work plans?
   Y/N
   
   
3. Does the radiology department have a documented QA program?
   Y/N If yes,
   is a copy of the QA manual available?
   Y/N
   
   
4. Radiology QAC members:
   Radiology administrator: ________________________________
   Medical physicist: _____________________________________
   Chief x-ray technologist: ________________________________
   Quality control technologist: _____________________________
   Hospital service engineer: _______________________________
   Private consultants: ____________________________________
   Others: ______________________________________________

5. Radiology department QA program review and reporting structure:
   Who reviews the radiology QA program? ___________________
   _____________________________________________________
   Review schedule: .................................(M) (Q) (SA) (A) (N)
   Is a summary of the radiology QAC audit plan available?
   Y/N
   Describe the radiology QAC program reporting structure:_______
   ______________________________________________________
   
   
6. Is a copy of the radiology department's organization chart available (showing the level of responsibility and reporting order)?
   Y/N
   
   
7. Does the radiology QAC serve as an advising committee to give direction, training and/or advice on QA and QC protocols to other hospitals? ................................................(M) (Q) (SA) (A) (N)
   If yes, which hospitals? __________________________________
   
   
8. Is a member of the department's QAC on the hospital QAC? :
   Y/N

Comments: ________________________________________________

2. Quality Assurance Training

1. Is QA training available?
   Y/N
   
   
2. Type of QA training: _____________________________________
   In-house: ______________________________________________
   Other hospitals: ________________________________________
   Outside agency: ________________________________________
   Special courses: ________________________________________
   Refresher courses: ______________________________________
   Other: _________________________________________________
   
   
3. What priority level is placed on QA training?......(H) (M) (L) (N)
   

Comments: _________________________________________________

3. Equipment Specification Writing

1. Is the QAC involved in equipment specification writing?
   Y/N
   
   
2. Does QC technologist participate in equipment specification writing? Y/N
   
   
3. Who does equipment specification writing? (QAC ?, private consultants?, etc.) ____________________________________________
   
   
4. Is a copy of documented equipment specification writing guidelines available?
   Y/N
   
   
5. Do equipment specifications include acceptance testing criteria?
   Y/N
   
   
6. Is a copy of the equipment specification document sent out for tender for the last x-ray unit purchased by the hospital available?
   Y/N

Comments: ______________________________________________

4. Quality Control Test Equipment List

1. Are QC test equipment available?
   Y/N
   
   
2. List QC test equipment used: (including manufacturer, model and calibration date):

5. Equipment Acceptance Testing

1. Does the QAC have an equipment acceptance testing policy?
   Y/N
   
   
2. Who does the equipment acceptance testing (manufacturer, in-house, private consultants)?:__________________________________
   
   
3. Equipment acceptance test results recorded?
   Y/N
   
   
4. Equipment acceptance test results kept for QC base data?
   Y/N
   
   
5. Is a copy of equipment acceptance testing results available?
   Y/N

Comments: _______________________________________________

6. Quality Control Testing

The following are general questions regarding the QC testing program and the QC technologist's responsibilities. Further information, about x-ray imaging equipment QC testing, i.e., specific tests, test devices and frequency of testing, is collected based on information from "Radiographic Quality Control, Minimum Standards" from the CAMRT, Appendix A of NCRP Report No.99 and "Diagnostic X-ray Equipment and Facility Survey" of Health Canada publication 94-EHD-184. Questions are listed in a separate survey form.

6.1 X-Ray Equipment Quality Control

1. QC responsibilities (persons in charge and reporting order):
   Radiology department QC program: _______________________
   QC testing: ___________________________________________
   QC record keeping: _____________________________________
   QC data evaluation: _____________________________________
   Equipment control parameter setting: _______________________
   Equipment repair and services decisions: ____________________
   
   
2. Does the x-ray department have a documented equipment QC test protocol manual?
   Y/N
   
   If yes, is a copy of the equipment QC test protocol manual available?
   Y/N
   
   Does the manual include QC test protocol for the following equipment? : General radiographic equipment?
   Y/N
   
   Fluoroscopic equipment?
   Y/N
   
   Special procedures equipment?
   Y/N
   
   Mammographic equipment?
   Y/N
   
   CT equipment?
   Y/N
   Mobile fluoroscopic equipment?
   Y/N
   
   Dedicated procedure equipment?
   Y/N
   
   Film processors?
   Y/N

Other? : ___________________________________________________

3. Is the QC testing done by a private consulting agent?
   Y/N
   If yes, who? ____________________________________________
   Reporting protocol: ______________________________________
   Consultant objectives:____________________________________
   Radiation safety survey of equipment?_______________________
   Equipment specification writing? ___________________________
   Acceptance testing? _____________________________________
   QC testing of equipment? _________________________________
   Advisor on QA program? __________________________________
   Frequency of consultant contract:...... (M) (SA) (A) (N)
   Is copy of consultant contract objectives available?
   Y/N
4. QC technologist available? : .......(Full-time), (Part-time), (Occassional)
   To whom does the QC technologist report? : _________________
5. Does the QC technologist have a specific QC test schedule?
   Y/N
   If yes, how strictly is it followed? ___________________________
   QC testing schedule priority level: .........(H) (M) (L) (N)
   Is a copy of the equipment QC test schedule available?
   Y/N
   QC test schedule (time spent):
   ______ h/d; ______ d/w; ______ w/m
   Consequences of not meeting the QC schedule: ______________
6. QC technologist responsibility

7. How much time spent testing equipment (number of tubes, hours/unit)?
   General radiography? ____________________________________
   Fluoroscopy? __________________________________________
   Special procedure equipment?_____________________________
   Mammography?_________________________________________
   CT? __________________________________________________
   General film processors?_________________________________
   Dedicated film processors?_______________________________
   Other: ________________________________________________
8. Does QC technologist have adequate time to carry out QC test required?
   Y/N
9. Does QC technologist have adequate time to evaluate results of QC tests performed?
   Y/N
10. Does QC technologist have adequate time to update and maintain QC records? Y/N
11. Are samples of QC tests records (blanks) available?
    Y/N
12. QC test reporting:
    To whom are QC test results reported?
    Y/N
    What is the reporting structure? __________________________
    Priority of QC reporting:................... (H) (M) (L) (N)
    Consequences of late reporting: ___________________________
13. QC testing review activity:
    Is equipment QC test program audited?..... (W) (M) (Q) (SA) (A) (N)
    Review method of audit: __________________________________
    Is a copy of the QC audit plan available?
    Y/N
    Consequences of bad reviews: _____________________________
14. Is QC testing training available for the QC technologist?
    Y/N
    If yes, where? when? ____________________________________
15. Is QC technologist shared with other hospitals?
    Y/N
    If yes, list hospital and days per week: ______________________
16. Is the Hospital QC performance compared with other large city hospitals? Y/N
    If yes, who and frequency: Hospital.............. (M) (Q) (SA) (A) (N)

Comments: ________________________________________________

6.2. Photographic Equipment Quality Control

The following are general questions regarding the photographic QC testing program and the QC technologist's responsibilities. Further information, about photographic equipment QC testing, i.e., specific tests, test devices and frequency of testing, is collected based on information from "Radiographic Quality Control, Minimum Standards" from the CAMRT, Appendix A of NCRP Report No.99 and "Diagnostic X-ray Equipment and Facility Survey" of Health Canada publication 94-EHD-184. Questions are listed in a separate survey form.

1. Number of automatic processors: __________________________
   
   
2. Number of dedicated processors:___________________________
   
   
3. Processor sensitometric evaluation performed?....(D) (W) (SM) (N)
   
   
4. Is the developer temperature verified using a thermometer?.....
   
   
5. Replenishment rates checked?.... (D) (W) (SM) (N)
   
   
6. Transport time checked? ....(D) (W) (SM) (N)
   
   
7. Is the manufacturer's time/temperature chart followed?
   Y/N
   
   
8. Are film processors cleaned regularly?.... (D) (W) (SM) (M) (N)
   
   
9. Preventive maintenance program for the processor?
   Y/N
   
   
10. Are the cassette screens cleaned regularly? ....
    (D) (W) (SM) (M) (SA) (A) (N)
    
    
11. Are screen contact tests done?.... (W) (SM) (M) (SA) (A) (N)
    
    
12. Safelight integrity verified?.... (W) (M) (SA) (A) (N)
    
    
13. Darkroom fog test? ....(W) (M) (SA) (A) (N)

Comments:______________________________________________

1. Does the radiology department have a silver recovery program?
   Y/N
   
   
2. Who is in charge of the silver recovery program?
   
   
3. Is silver recovery done for all automatic processors?
   Y/N
   
   
4. Does the hospital have a policy on effluent disposal?
   Y/N
   
   
5. Are the developer and fixer treated before going to effluent
   Y/N
   
   
6. What happens to old or reject-repeat radiograms?

Comments:______________________________________________

7. Equipment Performance Records and Record Keeping

1. Are equipment performance records kept?
   Y/N
   
   
2. Do the equipment performance records include acceptance testing results?
   Y/N
   
   
3. Are the initial and current radiation safety surveys reports available?
   Y/N
   
   
4. Are the current year QC tests and results recorded?
   Y/N
   
   
5. Are the past year QC tests and results recorded?
   Y/N
   
   
6. Are the equipment repairs and servicing recorded (frequency and costs)? Y/N
   
   
7. Is the equipment down time recorded?
   Y/N
   
   
8. Is a copy of the equipment performance record available?
   Y/N

Comments: ______________________________________________

8. Equipment Appraisal and Replacement Policy

1. Does the QAC have an equipment appraisal and replacement policy?
   Y/N
   
   
2. Planned budget allocations for future purchases?
   Y/N
   
   
3. Describe the equipment appraisal and replacement policy budget strategy: _____________________________________________
   _____________________________________________________
   
   
   
4. Is a copy of the equipment appraisal and replacement policy available Y/N

9. Standardization of Exposure

9.1. Radiographic Positioning

1. Is a standard radiographic positioning manual available in each room?
   Y/N
   If no, is it easily accessible?
   Y/N
   Is a copy (sample) of radiographic positioning manual available?
   Y/N

Comments:_______________________________________________

2. Current condition of the radiographic positioning manual (indicate on a scale of 1 to 5):

Comments:________________________________________________

3. Does the radiographic positioning manual provide instructions about: body part to be x-rayed?
   Y/N
   
   number of projections required?
   Y/N
   
   size of image receptor to use?
   Y/N
   
   part rotation?
   Y/N
   
   tube angle?
   Y/N
   
   central ray location?
   Y/N
   
   source-to-image receptor distance?
   Y/N
   
   detail of structures to be shown?
   Y/N
   
   general instructions for positioning?
   Y/N
   
   illustrations?
   Y/N

Comments: ________________________________________________

4. Radiographic positioning manual update:
   Is the radiographic positioning manual updated?
   Y/N
   
   Who authorizes changes? ________________________________
   
   Are changes reported through QAC reporting channels?
   Y/N
   
   Are changes unreported and adopted?
   Y/N

Comments: ________________________________________________

9.2. Loading Factors

1. Is there a loading factors chart (or manual) posted in each x-ray room?
   Y/N
   
   
   Is a copy (sample) of loading factors manual available?
   Y/N
2. Current condition of Loading Factor charts (indicate on a scale of 1 to 5):

Comments: _____________________________________________

3. Does the loading factors chart contain the following information? : patient thickness?
   Y/N
   
   child/adult technique?
   Y/N
   
   optimum kVp?
   Y/N
   
   optimum time, mA, mAs or automatic exposure control?
   Y/N
   
   focal spot size?
   Y/N
   
   grid/no grid?
   Y/N
   
   film-screen combination?
   Y/N

Comments: _____________________________________________

4. Is the loading factors chart strictly followed? If not, why?
   Y/N
5. Loading factors chart changes:
   Is the loading factors chart updated or changed to compensate for equipment or processor problems?
   Y/N
   Who sets the loading factors chart factors?__________________
   Who authorizes the loading factors chart changes? ___________
   Are the loading factors chart changes reported to QC technologist?
   Y/N
   Are changes unreported and adopted?
   Y/N

Comments: ________________________________________________

9.3. Entrance-Skin-Exposure (ESE)

1. Are the ESEs measured for:
   each diagnostic procedure?
   Y/N
   
   each x-ray room?
   Y/N
   
   each fluoroscopic procedure?
   Y/N
   
   each fluoroscopic room?
   Y/N
   
   List the ESE procedures measured: ________________________
   
   
2. Is the ESE schedule reviewed : ........ (M) (SA) (A) (N)
   
   
3. Are the ESEs recorded in the QC log book?
   Y/N
   
   If yes,
   1) is a copy (sample) of the radiographic ESE record for each room available?
   Y/N
   
   2) is a copy (sample) of the fluoroscopic ESE record for each room available?
   Y/N
   
   
4. Is there an ESE comparison with other major city hospitals?
   If yes, who?_________________ How often? (M) (Q) (SA) (A) (N)

Comments: _______________________________________________

10. Acceptance Criteria for Diagnostic Radiograms

1. Have acceptance criteria for diagnostic radiograms established?
   Y/N
   
   
2. Do the acceptance criteria cover the following points:
   
   1) the visibility of predetermined landmarks clearly defined for each view? Y/N
   
   2) an acceptable density range measured at predetermined anatomical landmarks?
   Y/N
   
   3) also include three limits of acceptability clearly defined where:
   
   a) the x-ray technologist forwards radiogram to radiologist for reporting?
   Y/N
   
   b) or the x-ray technologist consults with the radiologist?
   Y/N
   
   c) or the radiogram is rejected and a repeat is done?
   Y/N
   
   
3. Are the acceptance criteria followed by technologist?
   Y/N
   
   
4. Are the acceptance criteria reviewed?
   Y/N
   
   Frequency of review: ........ (M) (Q) (SA) (A) (N)
   
   
5. Are acceptance criteria compared with that of other major city hospitals? Y/N
   
   
6. If yes, Who?, How often? ......(M) (Q) (SA) (A) (N)
   
   
7. If a QA criteria has not been established against which standard are the radiograms checked when the radiologist is not available? (e.g., evening or weekends) _________________________________________
   _____________________________________________________
   
   How does that affect the repeat rate when the radiologist does become available? _____________________________________________________
   
   
8. Is a copy of the acceptance criteria available?
   Y/N

Comments: ________________________________________________

11. Reject-Repeat Analysis Program (RRAP)

1. Does the radiology department have a comprehensive RRAP?
   Y/N
   
   
2. Is a copy of the documented RRAP parameters available?
   Y/N
   
   
3. Who sets the RRAP parameters? : _________________________
   
   
4. Reject-Repeat Analysis parameters:
   

Comments: _______________________________________________

5. Do the RRAP results show how many rejects or repeats were acceptable and should not have been repeated?
   Y/N
6. Are the RRAP results posted?
   Y/N
7. Is the repeat percentage analysis evaluated:
   ____ per technologist? ____ per room?
   Y/N
8. What is the current reject-repeat rate?______________________
9. What is the reject-repeat rate for the last six months? :
10. What corrective action is used to reduce the reject-repeat
    rate? ________________________________________________
11. Reject-repeat rate is based on what workload?_______________
12. What is radiology department total workload?________________
13. Is the RRAP compared with other hospitals?
    Y/N
    If yes, who? How often?:...... (M) (Q) (SA) (A) (N)

Note: RRAP should look at three separate categories:

1. Total waste films: all films in the scrap bin?
   Y/N
2. Total rejects: all films except clear and QC films?
   Y/N
3. Total repeats: only those where an additional radiogram was made?
   Y/N

RRAP should not include radiograms from special procedures areas (cardiovascular, neurological copy, nor subtraction films.)

Comments: ______________________________________________

12. QA/QC Document Assessment (Summary)

The following (current) documents should be collected as examples for assessing the Radiology Department's QA/QC program.