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

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 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.

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.

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

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

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

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

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

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”.

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.

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

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.

Continuous Quality Improvement (CQI) Vs QA & QC

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.

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.

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.

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

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.

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 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.

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

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

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

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

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.

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

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

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.

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

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.

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

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.

Repeat Film Studies Analysis of Data Retake Percentage by Room Room # Reason 1 2 3 4 5 Dark 29 37 36 33 33 Light 45 31 32 32 37 Positioning 20 18 18 19 17 Centering 10 11 20 9 9 Motion 6 7 6 5 5 Other 8 6 7 7 6 Total: 118 110 119 105 107 Technique exposure Chart error? Collimator misaligned?

Repeat Film Studies Analysis of Data Retake Percentage by Technologist Technologist # Reason 1 2 3 4 5 Dark 35 31 32 30 43 Light 32 31 31 34 30 Positioning 20 18 18 30 17 Centering 13 12 11 12 11 Motion 5 11 4 4 4 Error 10 4 5 3 3 Other 5 7 6 6 7 Total: 120 112 107 119 115 Need to be more carful? Using long exposure Times? Has difficulty with Some exams?

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