1. QUALITY MANAGEMENT University of Sharjah College of Health Sciences
Medical Diagnostic Imaging Department
2nd Quality Assurance & Quality Control Workshop
10-11 June 2012
QUALITY MANAGEMENT
Mohamed M Abdelfatah Abuzaid

2. 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.

3. Quality Assurance
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.
QA consists of activities that provide adequate confidence that a radiology service will render consistently high quality images and services.

4. 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.

5. interpretation of examinations, maintenance of equipment,
QA includes evaluation activities such as
interpretation of examinations,
maintenance of equipment,
performance of procedure,
filling system,
staff development,
scheduling of examinations and supply lines

6. Quality Assurance Example
Patient Arriving Alert System
Patient arrived to the front desk, there is a process that is followed to alert the technologist that a patient is waiting.
Patients will not complain from long waiting time before starting the procedure
Positive patient care

7. 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 read

8. Quality Control Example
Check Patient Arriving Alert System
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
Patients complain from long waiting time before starting the procedure
Negative patient care

9. Quality Control
Three major categories of QC tests are used at various times:
Acceptance testing
Routine maintenance
Error maintenance

10. Quality Assurance and Quality Control
“A quality assurance program maximizes the possibility that the image will every time provide adequate diagnostic information for the least possible radiation exposure and cost to the patient”.

11. Acceptance Testing When? Whom? Why?
Acceptance testing is performed:
Before newly installed or
Equipment with major repairs is accepted by the department.
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.

12. 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

13. 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.

14. Continuous Quality Improvement (CQI)Vs
QA & QC

15. 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.

16. Continuous Quality Improvement (CQI)
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.

17. 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.

18. Plan ACT Do Check Execute the plan
write a policy and standardize the change. If it didn’t work
go through the cycle again
Develop a plan based on what needs to be done.
Execute the plan
Study the results of the plan to determine whether the plan worked. Do
Check

19. FOCUS PDCA is a process improvement model that is used to identify improvement opportunities and a systematic approach to implementing changes. The original problem solving model was first birthed out of one of the early quality gurus by the name of Walter Shewhard. The model was then adapted by W. Edwards Deming as the Plan-Do-Check-Act (PDCA) cycle.

20. Why QA & QC? The three Ds:
Dose
Diagnosis
Dollars

21. 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.

22. RECOMMENDED QUALITY CONTROL TESTS FOR Such FACILITIES
Frequency
Procedure
Warm-up Procedures
Daily, and If Idle Over 2 Hours 1
Processor QC
Daily, Prior to Developing Films 2
Darkroom QC
Daily and Weekly 3
System Constancy Check
Monthly and After Service
4A, 4B
Viewboxes
Monthly 5
Visual Checklist
Quarterly and After Service 6
Repeat Analysis
Quarterly 7
Film and Chemical Storage 8
Artifact Evaluation 9
Cassettes and Screens
Quarterly or Semiannually (As Needed) 10
Darkroom Fog
Semiannually* 11
Screen-Film Contact
Annually and As Needed 12
Collimation Checks
Annually 13
SID Indication 14
Automatic Collimation Check 15
Lead Apron Check 16
Program Review
Form9
Radiation 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.

23. Total Quality Control System
Identification of imaging requirement
Total Quality Control System
Development of equipment specifications
Selection of equipment
Installation and acceptance testing
Continuing education
Monitoring of equipment performance

24. Identification of imaging requirement
Decision should be made by the chief radiologist & administrative technologists
Determine the basic parameters, impose financial and space restraints
Provide information on patient flow and staffing needs

25. Development of Equipment Specifications
Generic equipment specifications should be developed
Technical background is needed to state exactly what is needed to meet the imaging requirements
An imaging physicist should be involved at this point
Detailed statements of what the equipment should be capable of doing

26. Selection of equipment
When the bid arrive they should be compared to meet specifications, cost and services
A pitfall in the process can occur when radiologists show a preference to a particular vendor, thus weakening the bargaining position of the department administrator

27. Installing and Acceptance Testing of Equipment
Is the responsibility of the vendor and/or manufacturer.
Quality Control technologists must verify that the equipment 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 all future quality control monitoring.

28. Continuing Education
Is the responsibility of the vendor to familiarize the users of the equipment with its proper operation.
The equipment manual should be available
Training should be included at the purchase contract
Continuing education must be an ongoing procedure
A good in-service program will include an orientation procedure as well as periodic updates on all complex equipment

29. 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

30. Monitoring Equipment Performance
A properly working quality control system will:-
Reduce equipment down-time
The number of repeated exposures
Reduce patient dose,
Patient waiting time,
Supply costs

31. Monitoring Equipment Performance Responsibility
Medical physicists are not required to perform routine quality control procedures
Many procedure must be done daily
RT, who are more available and knowledgeable about potential problems, should do the equipment monitoring
To maintain a program, staff technologists must be given time to perform the procedures and to evaluate them.

32. Monitoring Equipment Performance
The tests of x-ray tubes should include:
Focal Spot size estimation
Half-value layer
Collimator, central ray, and Bucky tray accuracy
Distance and centering indicators’ accuracy
Angulator or protector accuracy
Kilovoltage accuracy
Timer accuracy
mR/mAs and miliamperage linearity
Exposure reproduceability

33. Repeat Film Studies as a part of QA & QC
Why we need it?
Significant reductions in patient dose, radiographers time and effort and supply costs can be achieved.

34. Repeat Film Studies Obtaining Data
Retain all repeated radiographs, regardless of cause, for analysis
Films labeled as “cause of repeat, the room and tube used should be noted on each film before it is discarded

35. Repeat Film Studies Obtaining Data
RT must be informed of the purpose of the study and asked to cooperate in a positive manner to improve patient care and working condition.
Incompetent radiographers should be disciplined through normal administrative procedures based on actual performance, not as a result of repeat film study.

36. Repeat Film Studies Analysis of Data
Retake Percentage by Room
Room #
Reason
Dark
Light
Positioning
Centering
Motion
Other
Total:
Technique exposure
Chart error?
Collimator misaligned?

37. Repeat Film Studies Analysis of Data
Retake Percentage by Technologist
Technologist #
Reason
Dark
Light
Positioning
Centering
Motion
Error
Other
Total:
Need to be more
carful?
Using long exposure
Times?
Has difficulty with
Some exams?

38. The End