Downloaded from www.ajronline.org by 150.214.146.47 on 11/05/15 from IP address 150.214.146.47. Copyright ARRS. For personal use only; all rights reserved
989
Editorial
I Quality
Assurance:
An Idea
Whose
Time
Has Come
Formal quality assurance (QA) programs in diagnostic radiology are now actively promoted by three major elements of the radiology community but not so eagerly ac-
readings objective
described by Felson et al. [1] allowed look at the quality of chest examinations
facilities
serving
cepted by the been directed. ernment,
facilities toward which Professional organizations,
and
ufacturers
several
major
all have
veloping
active
ticular,
the
Bureau
American
and
x-ray
programs
QA
organized
film
efforts
for
(BRH),
in a small
jointly
by
ACR
field and
trial
BRH,
of
QA
four
of
is the optimal
ment,
motivating
and
unacceptable
de-
In par-
the federal
National
urged
Institute
conducted
1 1 facilities
invited
facilities
to adopt
and
that
of techniques, will
implement
effective
QA
to
the
qualiaty
took
The much
years modern
970s
ers
of
and many
other
processed of the
operators active of coal
out
film title
radiologic quality
tered
workers’
to determine
of
exposures,
tube but
later,
the availability correctly
1 969
legislation chest
the possible The
early
and its medical Coal
quoted the
x-ray
examinations. problem came
II of the
pneumoconiosis.
days
to assure
of NIOSH
a periodic
early cathode
of x-ray
enough
Act (PL 91 -1 73). That miners
hot
60
of perin the
advis-
Mine
Health
and
required
coal
mine
x-ray
examination
presence program
and
for extent
for multiple
that
were
could
not
to 3%.
usually
processing
is bad,
automatic
Some
processing
equipment
were
overexposed,
examinations
concerned
reviewers
some
due
to failure
regularly.
Some
underexposed;
in
some cases, geometry was bad. Thus, in the final analysis, the problem of radiographic quality is not equipment or processing, but the willingness of somebody to accept a poor product. One finds it difficult to believe that some of these radiographs were received from facilities where the
programs.
been
the
the
developments
the experience
to provide
have
since of
is not
in implementing
Safety
images
mystique
equipment
from
colleagues
development
of the
formed and Indications 1
their
films
is adequate.
were
carried
out
that
by
radiologists
and
regis-
technologists.
institutions and
The
to interpret
The BRH looked at reject an indication of radiographic neff et al. [3] cited retake
Radiologists science.
radiologists.
effort
to bad radiographs rejected films. The be blamed on poor case the equipment
radiographs
equip-
Background
with
every
Every imaginable cause that can lead is evidenced in the more than 2000 percentage of total rejects cannot equipment, because in virtually every to clean
radiologic
encourage
by reviewing
to make
60,000 of films clinically
be repeated, and the final rejection rate was reduced Trout et al. [2] described the problems:
and film manAgfa-Gevaert
techniques
combination
devices
nearly
manand
participate dropped out early in the trial period, and some of the seven others failed to perform the routine tests involved during much of the 1 year eftort. A continuing concern for those organizations taking an active interest in
QA efforts
For
equipment
for Occupational Safety and Health (NIOSH), ufacturers like Dupont, Eastman Kodak, and have taken leading roles. Yet,
areas.
miners examined in the first round, some 30% submitted by local facilities were judged to be
(ACR), the
mining
have gov-
facilities.
of Radiology
Health
coal
programs the federal
motivating
in radiology
College
of Radiological
QA
a reasonably in medical
and
a study
indicated
rates during the early 1 970s as quality. In a 1 974 study, Burrates of 2%-i 0% in American
1 %-6%
in
British
at the University a 5%
retake
of retakes in this study (film too dark or light),
hospitals.
They
of Virginia Hospital The most common
rate:
‘ ‘
were found collimation,
also
in 1972 causes
to be errors in exposure and patient positioning.”
Burnett’s own study of two Massachusetts hospitals mdicated a retake rate of 5.3%. Errors of exposure and positioning again were the principal causes of rejection. The growing interest in the NIOSH experience and concerns for radiation exposures led the BRH Division of Training and Medical Applications in 1 974 to initiate a formal program
a catalog several
scribing
to promote
QA [4].
and supplement field
studies,
QA techniques,
This
included
of QA materials,
a series
and
of instructional
the
proposed
the publication
the conduct manuals
publication
of
of de-
of
990
EDITORIAL
recommendations
for QA in diagnostic
radiography
facilities
Only one film technologists
[51.
During
the
same
years,
three
film
suppliers
Downloaded from www.ajronline.org by 150.214.146.47 on 11/05/15 from IP address 150.214.146.47. Copyright ARRS. For personal use only; all rights reserved
their QA efforts. Eastman Kodak Company tomers an opportunity to send radiologic a 2-week course in QA at the Kodak center in Rochester, N.Y. Participants
with
a set
of QA
test
implemented in their nical representatives
cessing
conditions
tions.
Dupont in QA. of
other
joined
the
and
ditional QA Following ACR
rate
Board
committee
with
equipment
with
industry,
a series
Force
cosponsored
5%
retake
estimated
prompted
from
to look
at the
developed
conferences
on
combinations, processors, and QA methods developed a set of QA instruments.
quality
with
BRH,
and
of $27,000 Medical
from
QA
a savings Hall
in
to
effort
[8]
reported
efforts
a
and
super-
effort would be a et al. [6] claimed
at the
University
of
Lapayowker
University
[7]
resulting Hospital
institutions
began
for
assurance
a month
that
reduced on film,
for film
costs
training
at Temple
after
costs.
yearly
Birmingham.
study
profes-
added
quality
of $4,000-$5,000
QA
1979
also, the in signifi-
in supply
personnel
Center
an intensive
$9,000
in
participating
with
an average
implementation
reject
of QA
efforts,
to 7%. For a hospital spending this amounted to a savings of
[8].
Savings
of
reductions.
and
and
devoted
improved
some
retakes; results
$200,000
a year
$5,000
in a Dupont QA program rate of 1 3%. By 6 months
liaison
film-screen
Perhaps
overhead
$1 0,000
If
rejects had been $1 50,000 yearly
a sepa-
committee
rate.
Philadelphia.
ad-
quality.
that spends
pays
November
may be repeated and for radiologists known
vision resulted in halving the retakes, the break-even project the first year. Barnes
stimulated
to begin
study films
unmeasured,
instrumentation
The
established
mandate
That
chemicals
soon
on Pneumoconiosis,
in 1 974
and
Alabama
equipment
film
department
a savings
tech-
about
if usually
of regional
manufacturers
a broad
radiology.
a slide and
and auxiliary
of the Task
be
a multifilm only repeat
could be saved by eliminating to retrieve patients for retakes
A large
its techand pro-
in developing
techniques.
of Chancellors
of diagnostic
to
sional time time spent cant,
for correc-
technologists
chemical
programs. the work
a routine
by radiologists
QA and
x-ray
ACR developed
covering
radiologists
worked
Dupont trained local exposure
interest
film manufacturers,
suppliers,
and
education
course
recommendations
Agfa-Gevaert
sessions
interest
the
and make
to stimulate
nologists
2 day
instruments
departments. to analyze
also
presentation
marketing
from may
to be particular
expanded
offered its custechnologists for
in the
AJR:133,
radiation
Such
man-rem
or
in the
individuals.
But
exposure
savings
also
are
more
avoidance
result
of real
if repetition
or
of a single
from
retake
to quantify potential harm
difficult
view
chest
in to
examina-
tion
Objectives
of Quality
Three
objectives
is avoided, the radiation savings is one-half. Reductions in repeat rates are cited as a measureable impact of QA activities. To minimize repetition, it is important
Assurance
are
customarily
cited
as motivations
QA efforts:
(1 ) cost
containment,
(2) reduction
exposure,
and
(3)
improvement
of
is
not
though
QA
objectives,
the
only
it addresses
that can be defined routine efforts. The radiologists could not
and black
of radiation
medical
approach
elements
to
imaging. attaining
Althese
in the radiologic
controlled by lung programs
for
process
certain types of convinced many
that the acceptability of routine radiography be aken for granted, even in the hands of radiol-
and radiologic technologists, and the observations et al. and many others indicated that acceptance
ogists
Trout
poor and variable images detracted interpreter to make a diagnosis, aware of the imposed limitations.
Justification
of Quality
Department have
could
the national
national
eliminated, savings
can
or should
and
other
Such
be
be avoided. cannot could
beyond
estimates
imaging
argued
might
Patient the
be eliminated be avoided,
services
that
result.
motion,
control
of
entirely. a savings
the 5% of et al. [3]) a potential
Not
all retakes
defective
film,
a conscientious However, of $1 95
if half million
overstate
the
raw
economics
the
density
Presumably,
causes
and
many
of
poor
films
film
rejection.
positioning
accepted
Hall
as as
major
marginally
adequate, as in the black lung programs, were overpenetrated and poorly positioned, bringing other organs not of immediate interest into the primary beam. A QA program that
emphasizes
potential
improved
exposure
of contributing
The
continuing
U.S. Department
benefits
has the retake
techniques
beyond
a reduced
analysis
of
of Labor
(DOL)
of QA.
chest
films
submitted
in support
to
the
of compensation
claims by former coal miners reflects persisting prevalence of exposure and processing errors cited in the NIOSH program by Trout et al. [2]. William S. Cole (personal corna DOL
radiologic
absence
The active
technologist
the
regulations
radiologists
round
II to
[9].
or
1 .4%
[1 0].
clinically
other
third
specific and
The
maintenance
rounds
physicians
of NIOSH
requirements
minimal
requirements
This
responsible.
of regular
and
facilities
Current
that
lack unby either
stock of fresh film and chemicals operating conditions. detail
QA programs. radiographs
30#{176}/odeemed
observed
physician
lack
for the second
in approved
facilities have unacceptable the
or the
examinations
program
radiologist,
charts,
and inadequate to be the normal
miner
equipment for local
consultant
unacceptable films frequently elements of proper radiography
of technique
schedules, are found
in
attained. generalizations
factors.
the
and Welfare
be
million
correct
improper
facilities producing derstanding of the
of diagnostic
it could
of $390
factors
technologist the retakes might
the ability of the or not he was
as $7.8 billion a year. If, to oversimplify, (the middle of the range cited by Burnett be
and
cited
munication),
Education cost
[8]
rate.
of of
Assurance
of Health,
placed
as high retakes
from whether
to determine
who also
for
requirements participate specify
in that
One result was a reduction in submitted to the NIOSH program figure
compares
substandard
favorably
and
the
3%
with
found
November
AJR:133,
absolutely
EDITORIAL
1979
unreadable
round
NIOSH
by
consultant
radiologists
in
991
participants.
ments
Downloaded from www.ajronline.org by 150.214.146.47 on 11/05/15 from IP address 150.214.146.47. Copyright ARRS. For personal use only; all rights reserved
BRH
Initiatives
In April Federal of
1 978,
of
the
testing
were
published include
elements.
responsibilities
developed ing needs.
for
of
the
and
new
should outlined
might
be included
nostic
radiography
the
responsi-
medical
physicist.
equipment.
out as key and defining
involved
should
in a QA
program
systems.
They
for
elements
that
conventional
were:
diag-
processors
and
processing conditions, fluoroscopes, image intensifiers, diographic units, automatic exposure control devices, settes, grids, view boxes, and tomographic systems. BRH
stated
determine
that the
it is the
responsibility of to be monitored.
components
each The
rather
to develop QA than attempting
adherence
programs suitable for their to spell out the kind
to specifics
found
in regulations.
One purpose elicit comments, ham North
of the federal many of which
[1 2], in his 1 978 America,
oration
criticized
on
departown needs of detailed
for are like
stressed
was to Tudden-
Radiological
Society
for its approach
on Quality Association mittee
on
Physics
and
turers
as
representing
the guidelines in Medicine, the
indications
its suppliers recognized and formal QA programs More recently a field was
undertaken
programs
that
to assess
voluntary
of
made
site
conclusions
test
procedures,
provided
to evaluate
performance.
relate
to
the
attitudes
the
indicated
or standard
changes.
a general
protocols
for
abexami-
nations. There was little or no support or enthusiasm conveyed to the technologists by their physician supervisors. The technologists suggested that they adapted technique to known idiosyncracies but seldom measured This
of the radiologist and to the observed output of the equipment and proces-
experience
ance
still
ACR,
BRH,
indicated
persists
at a low
that level
interest
in quality
despite
the
assur-
efforts
of the
and manufacturers.
Beginning
Quality
A primary
Assurance
need
the interest and The radiologists
in the
establishment
involvement must make
of QA
programs
is
of the radiologists in charge. departmental commitments of
personnel and equipment. On a continuing basis, they must review results. Equally important, radiologists must agree on contrast, density levels, collimation, and other imaging characteristics
that
can
be expressed
standards. As a facility initiates steps. A retake survey
QA
is controlled, to the x-ray
screen/cassette
programs,
is a good
one baseline measurement areas. A logical next step Once this be isolated
as formal
department
it should
beginning.
proceed
in
It establishes
and aids in defining problem is the film processor performance.
further generating
conditions,
variation in film quality can equipment, film supplies,
and
other
elements.
Many
film
of
baselines
should be defined analyses, equipment routine measurements an organized
and
objectives
for
performance
that
and discussed with personnel. Repeat checks, and establishment of periodic of performance are fundamental to
QA effort.
Benefits One
of Quality intangible
Assurance motivation
for
QA
is a desire
of
many
x-ray
More specific are demonstrable improvements in cost containment, radiation safety, and diagnostic accuracy. Recognition of these prompted the Joint Commission on Accreditation of Hospitals in 1 976 to assert an obligation
the
manufac-
profession
for
more
by ACR
initial and
or reporting
facilities suffer the deficiencies found many have exemplary performance
participation
visits
1
the American the ACR Comand
vigorous and
BRH
in QA and
to evaluate two sets of QA instruments (draft report, Div. of Training and Medical Applications, Bureau of Radiological Health, Rockville, Md.). BRH personnel suggested the recommended
in the
radiologists, to do the
of
a general need [1 3, 14]. study sponsored
early
to the activities its Committee
and of the
techniques technologists charts
out
to a respon-
[1 1 ], BRH pointed on Pneumoconiosis,
Radiographs, of Physicists
with
of technique
ment
sibility that he asserted should be intrinsic to the practice of radiology. ACR comment criticized the apparent detail and failure to specify priorities in programs suitable for smaller facilities. In its discussion of the ACR Task Force
altering
dropped
the agreed tests sporadically. processors, and other ele-
and equipment manufacturers now have programs to assist their customers in beginning QA activities. Effective QA efforts in a facility also depend on establish-
comment not subject regulations
agency publication were forthcoming. to the
BRH
based
BRH
that its recommendations, though published and dissemination in the Federal Register, to enforcement or inspection procedures issued by a similar process.
racasThe
facility to monitoring
frequency must also be determined by the facility its individual needs. The intent of the BRH was to stimulate radiology ments
of 1 1 facilities
be
should be given to staff trainof the program to determine its
be carried out. nine major equipment
sence
sor.
Monitoring,
were pointed the program
individuals
and consideration Periodic review
effectiveness BRH then
comment in the for 1 0 elements
defining
technologist,
and record-keeping A manual describing
evaluation,
for
establishment of a QA committee was Purchase specifications and acceptance
encouraged
without
Conversations
recommendations
physician,
facilities,
large
BRH
[1 1 ]. These
recommended.
the
the
Assurance
detailed
programs
bilities For
on Quality
Register
QA
Four
year study. Others completed Some changed films, screens,
I.
The
training, most
responses
and
for
QA
issued
physicists, best possible
program
jointly
technologists, and job of diagnostic
their colleagues imaging. Not all
in the NIOSH on their own
program; initiative.
activities [1 5]. Likewise, a set of guidelines by the Environmental Protection Agency (EPA)
and BRH and signed by President Carter in February, 1978 prescribe diagnostic radiographic procedures in federal health facilities [1 6]. Among the specifics are recommended
useful
equipment
entrance
skin exposure levels for selected and performance specifications
procedures. detailed for
The par-
of the
ticipation
in the NIOSH
a precedent
that
coal programs
offer
992
may
be adopted
workers
with
Cost icais,
Downloaded from www.ajronline.org by 150.214.146.47 on 11/05/15 from IP address 150.214.146.47. Copyright ARRS. For personal use only; all rights reserved
and
AJR:133,
EDITORIAL
in other
containment wear
the
tear
Questions
on of
may occupy
standards review the appropriateness
3.
but more QA
decision.
QA allows from which
the work
than
the
provide
a greater he must
sense make
a more
objective
of technologists
eyeball
testing
none have products
is better
with
expressed nor have
poor
films
they
widely
accepted
ones.
the motivations, QA programs
as an idea whose
the obligations, may soon
be
time has come. Otha W. Linton
American
College
Chevy
Chase,
Food
and
MD
Burnett
BM,
1 2.
Administration.
of intent
RL:
Barnes
OW,
WKC, Reger
Bristol RB:
U,
GT,
on
results
DM:
Lapayowker
M, quoted
in: Quality
Mangement,
Wilmington,
Del.,
of Docu-
facilities, HEW
ad-
Food
and
41 :18863-18864,
Quality
Whitten
HEW pub-
Assurance
Catalog,
Washington, D.C., Supt. of Office, 1 977; supplement, 1978 A comprehensive
quality
years experience at the SPIE Proc 96:19-23,
program: a report of four of Alabama in Birmingham.
control
duPont,
radiology
facilities
recommendation.
in action,
in Imaging
1978
quality
assurance
Federal
Register
programs-
43:18207-
1978
Tuddenham
WJ: view
Quality of
1 3.
Basic
1 4.
Chicago, Guidelines
Quality
assurance
a sacred
cow.
in diagnostic
radiology:
Radiology
an
1 31 : 579-588,
Control
1 6. of
Accreditation Radiation tic
x-rays.
in Diagnostic
AAPM
Radiology,
report
American Association of Physicists in Medicine, 1977 for Quality Assurance in Diagnostic Radiology.
Washington, D.C., lished monograph
EP, Dessen the
RE,
of Retakes
x-ray
Register
Radiology
coal
1973
Supt.
regulations.
Federal
Nelson
D.C.,
of the the
1979
Drug Administration Rockville, MD 20852
Pendergrass
Observations
during
Office, 1975 for diagnostic
to propose
Diagnostic
ACR Committee
Manual
for Accreditation B, Morgan
pneumoconio-
EP: Analysis
obtained
Washington,
Printing program
Drug 1976 Burkhart
radiographs
76-8016.
notice
irreverent
S. Properzio
1 5.
Linton
miners
lung program. Radiology 109:25-27, Massaferro RJ, Church WW: A Study Departments of Two Large Hospitals,
vance
18213,
20015
of chest
(FDA)
proposed
REFERENCES EL,
black
1 1 . Diagnostic
James P. Steele Sacred Heart Hospital Yankton, SD 57078
1 . Felson
in coal
1979
8. Hall CL: Economic analysis of a quality control program. SPIE Proc 127:271-275, 1977 9. Specifications for medical examinations of underground coal miners-chest roentgenographic examinations. Federal Register 38:20076-20081 , 1973; 43:33713-33720, 1978 1 0. Shoub EP, Boyce LF: Coal Miner Medical Examinations: Preliminary Report. Morgantown, W.V., Appalachian Laboratory for Occupational Respiratory Diseases, 1 974, unpublished
of Radiology
William
miners
assurance University 1976 7.
any preference for technically suggested their performance
than with good
Given the circumstances, and the penalties, organized
films
HEW pubication (FDA) 77-8028. Documents, Government Printing HEW publication (FDA) 78-8025,
applied
to each image. Whereas some radiologists assert with conviction that they can salvage a valid diagnosis from inferior films, inferior
5.
of a
and the output
inescapably
of chest
ments, Government 4. Quality assurance
organizations, once they of radiologic proce-
QA measures
for evaluating
of equipment
effective image
rate
lication
the interest
situations. A pattern of repeated likely to attract reprimands and for the offending radiology de-
rejection
in Radiology
6.
radiologist, about the
diagnostic
basis
Comprehen-
of implementing
readings
sis. Radiology 1 09 : 1 9-23, 1973 2. Trout ED, Jacobson G, Moore RT, Shoub
of retakes,
radiologists.
expense
multiple
for dusts.
of film, chem-
avoidance
accuracy
dures for various clinical examinations would be demands for improvement
other
benefits is still lacking, have asserted savings
the
of diagnostic
and
in the savings and
these of QA
programs
silica,
equipment,
to offset
of professional begin to define
partment. For the reliability
coke,
of technologists
sive documentation individual proponents than adequate programs [6-8].
compensation
cotton,
is manifest
and
time
federal
asbestos,
November
protection
Federal
for Hospitals.
of Hospitals, guidance
Register
1 976,
on Physics,
1 979,
unpub-
Chicago, Joint Commission pp 1 55-160
to federal
43 : 4377-4380,
agencies
1978
for diagnos-
4.
989
Editorial
I Quality
Assurance:
An Idea
Whose
Time
Has Come
Formal quality assurance (QA) programs in diagnostic radiology are now actively promoted by three major elements of the radiology community but not so eagerly ac-
readings objective
described by Felson et al. [1] allowed look at the quality of chest examinations
facilities
serving
cepted by the been directed. ernment,
facilities toward which Professional organizations,
and
ufacturers
several
major
all have
veloping
active
ticular,
the
Bureau
American
and
x-ray
programs
QA
organized
film
efforts
for
(BRH),
in a small
jointly
by
ACR
field and
trial
BRH,
of
QA
four
of
is the optimal
ment,
motivating
and
unacceptable
de-
In par-
the federal
National
urged
Institute
conducted
1 1 facilities
invited
facilities
to adopt
and
that
of techniques, will
implement
effective
QA
to
the
qualiaty
took
The much
years modern
970s
ers
of
and many
other
processed of the
operators active of coal
out
film title
radiologic quality
tered
workers’
to determine
of
exposures,
tube but
later,
the availability correctly
1 969
legislation chest
the possible The
early
and its medical Coal
quoted the
x-ray
examinations. problem came
II of the
pneumoconiosis.
days
to assure
of NIOSH
a periodic
early cathode
of x-ray
enough
Act (PL 91 -1 73). That miners
hot
60
of perin the
advis-
Mine
Health
and
required
coal
mine
x-ray
examination
presence program
and
for extent
for multiple
that
were
could
not
to 3%.
usually
processing
is bad,
automatic
Some
processing
equipment
were
overexposed,
examinations
concerned
reviewers
some
due
to failure
regularly.
Some
underexposed;
in
some cases, geometry was bad. Thus, in the final analysis, the problem of radiographic quality is not equipment or processing, but the willingness of somebody to accept a poor product. One finds it difficult to believe that some of these radiographs were received from facilities where the
programs.
been
the
the
developments
the experience
to provide
have
since of
is not
in implementing
Safety
images
mystique
equipment
from
colleagues
development
of the
formed and Indications 1
their
films
is adequate.
were
carried
out
that
by
radiologists
and
regis-
technologists.
institutions and
The
to interpret
The BRH looked at reject an indication of radiographic neff et al. [3] cited retake
Radiologists science.
radiologists.
effort
to bad radiographs rejected films. The be blamed on poor case the equipment
radiographs
equip-
Background
with
every
Every imaginable cause that can lead is evidenced in the more than 2000 percentage of total rejects cannot equipment, because in virtually every to clean
radiologic
encourage
by reviewing
to make
60,000 of films clinically
be repeated, and the final rejection rate was reduced Trout et al. [2] described the problems:
and film manAgfa-Gevaert
techniques
combination
devices
nearly
manand
participate dropped out early in the trial period, and some of the seven others failed to perform the routine tests involved during much of the 1 year eftort. A continuing concern for those organizations taking an active interest in
QA efforts
For
equipment
for Occupational Safety and Health (NIOSH), ufacturers like Dupont, Eastman Kodak, and have taken leading roles. Yet,
areas.
miners examined in the first round, some 30% submitted by local facilities were judged to be
(ACR), the
mining
have gov-
facilities.
of Radiology
Health
coal
programs the federal
motivating
in radiology
College
of Radiological
QA
a reasonably in medical
and
a study
indicated
rates during the early 1 970s as quality. In a 1 974 study, Burrates of 2%-i 0% in American
1 %-6%
in
British
at the University a 5%
retake
of retakes in this study (film too dark or light),
hospitals.
They
of Virginia Hospital The most common
rate:
‘ ‘
were found collimation,
also
in 1972 causes
to be errors in exposure and patient positioning.”
Burnett’s own study of two Massachusetts hospitals mdicated a retake rate of 5.3%. Errors of exposure and positioning again were the principal causes of rejection. The growing interest in the NIOSH experience and concerns for radiation exposures led the BRH Division of Training and Medical Applications in 1 974 to initiate a formal program
a catalog several
scribing
to promote
QA [4].
and supplement field
studies,
QA techniques,
This
included
of QA materials,
a series
and
of instructional
the
proposed
the publication
the conduct manuals
publication
of
of de-
of
990
EDITORIAL
recommendations
for QA in diagnostic
radiography
facilities
Only one film technologists
[51.
During
the
same
years,
three
film
suppliers
Downloaded from www.ajronline.org by 150.214.146.47 on 11/05/15 from IP address 150.214.146.47. Copyright ARRS. For personal use only; all rights reserved
their QA efforts. Eastman Kodak Company tomers an opportunity to send radiologic a 2-week course in QA at the Kodak center in Rochester, N.Y. Participants
with
a set
of QA
test
implemented in their nical representatives
cessing
conditions
tions.
Dupont in QA. of
other
joined
the
and
ditional QA Following ACR
rate
Board
committee
with
equipment
with
industry,
a series
Force
cosponsored
5%
retake
estimated
prompted
from
to look
at the
developed
conferences
on
combinations, processors, and QA methods developed a set of QA instruments.
quality
with
BRH,
and
of $27,000 Medical
from
QA
a savings Hall
in
to
effort
[8]
reported
efforts
a
and
super-
effort would be a et al. [6] claimed
at the
University
of
Lapayowker
University
[7]
resulting Hospital
institutions
began
for
assurance
a month
that
reduced on film,
for film
costs
training
at Temple
after
costs.
yearly
Birmingham.
study
profes-
added
quality
of $4,000-$5,000
QA
1979
also, the in signifi-
in supply
personnel
Center
an intensive
$9,000
in
participating
with
an average
implementation
reject
of QA
efforts,
to 7%. For a hospital spending this amounted to a savings of
[8].
Savings
of
reductions.
and
and
devoted
improved
some
retakes; results
$200,000
a year
$5,000
in a Dupont QA program rate of 1 3%. By 6 months
liaison
film-screen
Perhaps
overhead
$1 0,000
If
rejects had been $1 50,000 yearly
a sepa-
committee
rate.
Philadelphia.
ad-
quality.
that spends
pays
November
may be repeated and for radiologists known
vision resulted in halving the retakes, the break-even project the first year. Barnes
stimulated
to begin
study films
unmeasured,
instrumentation
The
established
mandate
That
chemicals
soon
on Pneumoconiosis,
in 1 974
and
Alabama
equipment
film
department
a savings
tech-
about
if usually
of regional
manufacturers
a broad
radiology.
a slide and
and auxiliary
of the Task
be
a multifilm only repeat
could be saved by eliminating to retrieve patients for retakes
A large
its techand pro-
in developing
techniques.
of Chancellors
of diagnostic
to
sional time time spent cant,
for correc-
technologists
chemical
programs. the work
a routine
by radiologists
QA and
x-ray
ACR developed
covering
radiologists
worked
Dupont trained local exposure
interest
film manufacturers,
suppliers,
and
education
course
recommendations
Agfa-Gevaert
sessions
interest
the
and make
to stimulate
nologists
2 day
instruments
departments. to analyze
also
presentation
marketing
from may
to be particular
expanded
offered its custechnologists for
in the
AJR:133,
radiation
Such
man-rem
or
in the
individuals.
But
exposure
savings
also
are
more
avoidance
result
of real
if repetition
or
of a single
from
retake
to quantify potential harm
difficult
view
chest
in to
examina-
tion
Objectives
of Quality
Three
objectives
is avoided, the radiation savings is one-half. Reductions in repeat rates are cited as a measureable impact of QA activities. To minimize repetition, it is important
Assurance
are
customarily
cited
as motivations
QA efforts:
(1 ) cost
containment,
(2) reduction
exposure,
and
(3)
improvement
of
is
not
though
QA
objectives,
the
only
it addresses
that can be defined routine efforts. The radiologists could not
and black
of radiation
medical
approach
elements
to
imaging. attaining
Althese
in the radiologic
controlled by lung programs
for
process
certain types of convinced many
that the acceptability of routine radiography be aken for granted, even in the hands of radiol-
and radiologic technologists, and the observations et al. and many others indicated that acceptance
ogists
Trout
poor and variable images detracted interpreter to make a diagnosis, aware of the imposed limitations.
Justification
of Quality
Department have
could
the national
national
eliminated, savings
can
or should
and
other
Such
be
be avoided. cannot could
beyond
estimates
imaging
argued
might
Patient the
be eliminated be avoided,
services
that
result.
motion,
control
of
entirely. a savings
the 5% of et al. [3]) a potential
Not
all retakes
defective
film,
a conscientious However, of $1 95
if half million
overstate
the
raw
economics
the
density
Presumably,
causes
and
many
of
poor
films
film
rejection.
positioning
accepted
Hall
as as
major
marginally
adequate, as in the black lung programs, were overpenetrated and poorly positioned, bringing other organs not of immediate interest into the primary beam. A QA program that
emphasizes
potential
improved
exposure
of contributing
The
continuing
U.S. Department
benefits
has the retake
techniques
beyond
a reduced
analysis
of
of Labor
(DOL)
of QA.
chest
films
submitted
in support
to
the
of compensation
claims by former coal miners reflects persisting prevalence of exposure and processing errors cited in the NIOSH program by Trout et al. [2]. William S. Cole (personal corna DOL
radiologic
absence
The active
technologist
the
regulations
radiologists
round
II to
[9].
or
1 .4%
[1 0].
clinically
other
third
specific and
The
maintenance
rounds
physicians
of NIOSH
requirements
minimal
requirements
This
responsible.
of regular
and
facilities
Current
that
lack unby either
stock of fresh film and chemicals operating conditions. detail
QA programs. radiographs
30#{176}/odeemed
observed
physician
lack
for the second
in approved
facilities have unacceptable the
or the
examinations
program
radiologist,
charts,
and inadequate to be the normal
miner
equipment for local
consultant
unacceptable films frequently elements of proper radiography
of technique
schedules, are found
in
attained. generalizations
factors.
the
and Welfare
be
million
correct
improper
facilities producing derstanding of the
of diagnostic
it could
of $390
factors
technologist the retakes might
the ability of the or not he was
as $7.8 billion a year. If, to oversimplify, (the middle of the range cited by Burnett be
and
cited
munication),
Education cost
[8]
rate.
of of
Assurance
of Health,
placed
as high retakes
from whether
to determine
who also
for
requirements participate specify
in that
One result was a reduction in submitted to the NIOSH program figure
compares
substandard
favorably
and
the
3%
with
found
November
AJR:133,
absolutely
EDITORIAL
1979
unreadable
round
NIOSH
by
consultant
radiologists
in
991
participants.
ments
Downloaded from www.ajronline.org by 150.214.146.47 on 11/05/15 from IP address 150.214.146.47. Copyright ARRS. For personal use only; all rights reserved
BRH
Initiatives
In April Federal of
1 978,
of
the
testing
were
published include
elements.
responsibilities
developed ing needs.
for
of
the
and
new
should outlined
might
be included
nostic
radiography
the
responsi-
medical
physicist.
equipment.
out as key and defining
involved
should
in a QA
program
systems.
They
for
elements
that
conventional
were:
diag-
processors
and
processing conditions, fluoroscopes, image intensifiers, diographic units, automatic exposure control devices, settes, grids, view boxes, and tomographic systems. BRH
stated
determine
that the
it is the
responsibility of to be monitored.
components
each The
rather
to develop QA than attempting
adherence
programs suitable for their to spell out the kind
to specifics
found
in regulations.
One purpose elicit comments, ham North
of the federal many of which
[1 2], in his 1 978 America,
oration
criticized
on
departown needs of detailed
for are like
stressed
was to Tudden-
Radiological
Society
for its approach
on Quality Association mittee
on
Physics
and
turers
as
representing
the guidelines in Medicine, the
indications
its suppliers recognized and formal QA programs More recently a field was
undertaken
programs
that
to assess
voluntary
of
made
site
conclusions
test
procedures,
provided
to evaluate
performance.
relate
to
the
attitudes
the
indicated
or standard
changes.
a general
protocols
for
abexami-
nations. There was little or no support or enthusiasm conveyed to the technologists by their physician supervisors. The technologists suggested that they adapted technique to known idiosyncracies but seldom measured This
of the radiologist and to the observed output of the equipment and proces-
experience
ance
still
ACR,
BRH,
indicated
persists
at a low
that level
interest
in quality
despite
the
assur-
efforts
of the
and manufacturers.
Beginning
Quality
A primary
Assurance
need
the interest and The radiologists
in the
establishment
involvement must make
of QA
programs
is
of the radiologists in charge. departmental commitments of
personnel and equipment. On a continuing basis, they must review results. Equally important, radiologists must agree on contrast, density levels, collimation, and other imaging characteristics
that
can
be expressed
standards. As a facility initiates steps. A retake survey
QA
is controlled, to the x-ray
screen/cassette
programs,
is a good
one baseline measurement areas. A logical next step Once this be isolated
as formal
department
it should
beginning.
proceed
in
It establishes
and aids in defining problem is the film processor performance.
further generating
conditions,
variation in film quality can equipment, film supplies,
and
other
elements.
Many
film
of
baselines
should be defined analyses, equipment routine measurements an organized
and
objectives
for
performance
that
and discussed with personnel. Repeat checks, and establishment of periodic of performance are fundamental to
QA effort.
Benefits One
of Quality intangible
Assurance motivation
for
QA
is a desire
of
many
x-ray
More specific are demonstrable improvements in cost containment, radiation safety, and diagnostic accuracy. Recognition of these prompted the Joint Commission on Accreditation of Hospitals in 1 976 to assert an obligation
the
manufac-
profession
for
more
by ACR
initial and
or reporting
facilities suffer the deficiencies found many have exemplary performance
participation
visits
1
the American the ACR Comand
vigorous and
BRH
in QA and
to evaluate two sets of QA instruments (draft report, Div. of Training and Medical Applications, Bureau of Radiological Health, Rockville, Md.). BRH personnel suggested the recommended
in the
radiologists, to do the
of
a general need [1 3, 14]. study sponsored
early
to the activities its Committee
and of the
techniques technologists charts
out
to a respon-
[1 1 ], BRH pointed on Pneumoconiosis,
Radiographs, of Physicists
with
of technique
ment
sibility that he asserted should be intrinsic to the practice of radiology. ACR comment criticized the apparent detail and failure to specify priorities in programs suitable for smaller facilities. In its discussion of the ACR Task Force
altering
dropped
the agreed tests sporadically. processors, and other ele-
and equipment manufacturers now have programs to assist their customers in beginning QA activities. Effective QA efforts in a facility also depend on establish-
comment not subject regulations
agency publication were forthcoming. to the
BRH
based
BRH
that its recommendations, though published and dissemination in the Federal Register, to enforcement or inspection procedures issued by a similar process.
racasThe
facility to monitoring
frequency must also be determined by the facility its individual needs. The intent of the BRH was to stimulate radiology ments
of 1 1 facilities
be
should be given to staff trainof the program to determine its
be carried out. nine major equipment
sence
sor.
Monitoring,
were pointed the program
individuals
and consideration Periodic review
effectiveness BRH then
comment in the for 1 0 elements
defining
technologist,
and record-keeping A manual describing
evaluation,
for
establishment of a QA committee was Purchase specifications and acceptance
encouraged
without
Conversations
recommendations
physician,
facilities,
large
BRH
[1 1 ]. These
recommended.
the
the
Assurance
detailed
programs
bilities For
on Quality
Register
QA
Four
year study. Others completed Some changed films, screens,
I.
The
training, most
responses
and
for
QA
issued
physicists, best possible
program
jointly
technologists, and job of diagnostic
their colleagues imaging. Not all
in the NIOSH on their own
program; initiative.
activities [1 5]. Likewise, a set of guidelines by the Environmental Protection Agency (EPA)
and BRH and signed by President Carter in February, 1978 prescribe diagnostic radiographic procedures in federal health facilities [1 6]. Among the specifics are recommended
useful
equipment
entrance
skin exposure levels for selected and performance specifications
procedures. detailed for
The par-
of the
ticipation
in the NIOSH
a precedent
that
coal programs
offer
992
may
be adopted
workers
with
Cost icais,
Downloaded from www.ajronline.org by 150.214.146.47 on 11/05/15 from IP address 150.214.146.47. Copyright ARRS. For personal use only; all rights reserved
and
AJR:133,
EDITORIAL
in other
containment wear
the
tear
Questions
on of
may occupy
standards review the appropriateness
3.
but more QA
decision.
QA allows from which
the work
than
the
provide
a greater he must
sense make
a more
objective
of technologists
eyeball
testing
none have products
is better
with
expressed nor have
poor
films
they
widely
accepted
ones.
the motivations, QA programs
as an idea whose
the obligations, may soon
be
time has come. Otha W. Linton
American
College
Chevy
Chase,
Food
and
MD
Burnett
BM,
1 2.
Administration.
of intent
RL:
Barnes
OW,
WKC, Reger
Bristol RB:
U,
GT,
on
results
DM:
Lapayowker
M, quoted
in: Quality
Mangement,
Wilmington,
Del.,
of Docu-
facilities, HEW
ad-
Food
and
41 :18863-18864,
Quality
Whitten
HEW pub-
Assurance
Catalog,
Washington, D.C., Supt. of Office, 1 977; supplement, 1978 A comprehensive
quality
years experience at the SPIE Proc 96:19-23,
program: a report of four of Alabama in Birmingham.
control
duPont,
radiology
facilities
recommendation.
in action,
in Imaging
1978
quality
assurance
Federal
Register
programs-
43:18207-
1978
Tuddenham
WJ: view
Quality of
1 3.
Basic
1 4.
Chicago, Guidelines
Quality
assurance
a sacred
cow.
in diagnostic
radiology:
Radiology
an
1 31 : 579-588,
Control
1 6. of
Accreditation Radiation tic
x-rays.
in Diagnostic
AAPM
Radiology,
report
American Association of Physicists in Medicine, 1977 for Quality Assurance in Diagnostic Radiology.
Washington, D.C., lished monograph
EP, Dessen the
RE,
of Retakes
x-ray
Register
Radiology
coal
1973
Supt.
regulations.
Federal
Nelson
D.C.,
of the the
1979
Drug Administration Rockville, MD 20852
Pendergrass
Observations
during
Office, 1975 for diagnostic
to propose
Diagnostic
ACR Committee
Manual
for Accreditation B, Morgan
pneumoconio-
EP: Analysis
obtained
Washington,
Printing program
Drug 1976 Burkhart
radiographs
76-8016.
notice
irreverent
S. Properzio
1 5.
Linton
miners
lung program. Radiology 109:25-27, Massaferro RJ, Church WW: A Study Departments of Two Large Hospitals,
vance
18213,
20015
of chest
(FDA)
proposed
REFERENCES EL,
black
1 1 . Diagnostic
James P. Steele Sacred Heart Hospital Yankton, SD 57078
1 . Felson
in coal
1979
8. Hall CL: Economic analysis of a quality control program. SPIE Proc 127:271-275, 1977 9. Specifications for medical examinations of underground coal miners-chest roentgenographic examinations. Federal Register 38:20076-20081 , 1973; 43:33713-33720, 1978 1 0. Shoub EP, Boyce LF: Coal Miner Medical Examinations: Preliminary Report. Morgantown, W.V., Appalachian Laboratory for Occupational Respiratory Diseases, 1 974, unpublished
of Radiology
William
miners
assurance University 1976 7.
any preference for technically suggested their performance
than with good
Given the circumstances, and the penalties, organized
films
HEW pubication (FDA) 77-8028. Documents, Government Printing HEW publication (FDA) 78-8025,
applied
to each image. Whereas some radiologists assert with conviction that they can salvage a valid diagnosis from inferior films, inferior
5.
of a
and the output
inescapably
of chest
ments, Government 4. Quality assurance
organizations, once they of radiologic proce-
QA measures
for evaluating
of equipment
effective image
rate
lication
the interest
situations. A pattern of repeated likely to attract reprimands and for the offending radiology de-
rejection
in Radiology
6.
radiologist, about the
diagnostic
basis
Comprehen-
of implementing
readings
sis. Radiology 1 09 : 1 9-23, 1973 2. Trout ED, Jacobson G, Moore RT, Shoub
of retakes,
radiologists.
expense
multiple
for dusts.
of film, chem-
avoidance
accuracy
dures for various clinical examinations would be demands for improvement
other
benefits is still lacking, have asserted savings
the
of diagnostic
and
in the savings and
these of QA
programs
silica,
equipment,
to offset
of professional begin to define
partment. For the reliability
coke,
of technologists
sive documentation individual proponents than adequate programs [6-8].
compensation
cotton,
is manifest
and
time
federal
asbestos,
November
protection
Federal
for Hospitals.
of Hospitals, guidance
Register
1 976,
on Physics,
1 979,
unpub-
Chicago, Joint Commission pp 1 55-160
to federal
43 : 4377-4380,
agencies
1978
for diagnos-
4.
