Notebook #11

CHAPTER 31: QUALITY MANAGEMENT

Quality Assurance

1. Definition: consists of activities that provide adequate confidence that a

radiology service will render consistently high-quality images and services.
a. Assesses everything that affects patient care
b. Medically, technically, or managerially oriented
c. Includes evaluating activities such as:
i. Interpretation of exams
ii. Maintenance of equipment
iii. Performance of procedures
iv. Filing systems
v. Staff development
vi. Scheduling of examinations
vii. Supply lines
d. Operates by:
i. Identifying problems or potential problem areas
ii. Monitoring the problem
1. Establishing criteria
2. Performing monitoring
3. Collecting, analyzing, and evaluating data
iii. Then resolving it
2. Quality Control
a. Definition: the aspect of quality assurance that monitors technical
equipment to maintain quality standards
b. Concept of quality control is rooted in the need to stabilize the various
equipment components of the radiographic imaging chain
i. Erratic equipment performances causes repeat radiographs and
unnecessary patient exposure to radiation
c. Because radiographic equipment changes as it ages, there are often
great differences between the results obtained on one unit and those
obtained on another
i. The same unit cannot be counted on to produce exactly the
same beam for the radiographer to control and analyze unless it
is properly checked on a regular basis
1. The system of checks to accomplish a measure of
consistency in beam output is the quality control
d. It is important that quality control be seen as a method of controlling
the radiographic image from start to finish

External Beam Evaluation 2nd part of performance monitoring involves the

evaluation of the external primary radiation
beam
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1. Diagnostic Radiographic
Systems
A. Focal Spot Size Estimation
B. Half-Value Layer
C. Collimator, Central Ray, &
Bucky Tray Accuracy
Semiannual performance review
-Important to keep within acceptable limits to
ensure proper image detail
-3 types of focal spot test tools
-1 line pair resolution tools
-2 star test patterns
-3 pinhole cameras
-1&2 function by imaging a resolution
patter on a film
-3 permits measurement of the focal spot
by creating an image of the effective focal spot
on a film
-focal spots < 0.3mm = star test pattern
-focal spot > 0.3mm = pinhole camera
-Amount of total filtration in the primary beam
is important for both radiation protection and
image quality
-radiation protection is ensured by getting
rid of low-energy photons that are not able to
reach the IR
-image quality is ensured by making
appropriate contrast adjustments
-half-value layers are measured by using
dosimetry equipment to detect quality of
aluminum filtration that will reduce the beam
intensity to half the original value
-if insufficient filtration is present, the tube
housing must be modified to supply additional
aluminum filtration
-radiation protection is ensured by avoiding
repeated images due to over-collimation errors
and by avoiding irradiation of tissue unless it
will be imaged
-2% SID error is allowed between primary beam
image and the light field size
-positive beam limitation (PBL) should not
permit the primary beam to be larger than the
cassette in the Bucky tray unless the override
lock is activated
-when these margins of error are exceeded,
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D. Distance & Centering
Indicators Accuracy accurate avoids the need for repeated
E. Angulator or Protractor
Accuracy
F. Kilovoltage Accuracy
G. Timer Accuracy
the collimator light or PBL mechanism must be
adjusted
-Assurance that distance and centering are
exposures due to the inverse square law,
misalignment of the central ray, and primary
beam collimation
-distance indicators should be checked with
a tape measure (+/- 10%)
-centering indicators can be checked by
visual inspection of the collimator light beam
(+/- 2%)
-if the indicators are not within these
limits they should be adjusted
-Must provide accurate readings for positioning
baselines
-they may be evaluated by using a large
protractor for angle measurements and a level
to verify that locks, stops, and detents are set
to establish horizontal and perpendicular
surfaces
-angles should be +/- 1% with adjustments
when necessary
-kVp settings tend to drift over time (result of
tube aging)
-accuracy is essential in maintaining image
quality
-scale of contrast and density cant be predicted
if kVp is incorrect
-verification and calibration of the kVp ensure
that technique exposure charts will produce
diagnostic quality images
-If the settings drift beyond +/- 5kVp of the
labeled setting, the generator must be
recalibrated
-also tend to drift over time
-accuracy is essential in maintaining image
quality because exposure cannot be predicted
unless the time is accurate
-verification and calibration of the timer ensure
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H. mR/mAs & Milliamperage
Linearity
I. Exposure Reproducibility
2.Fluoroscopic Systems
A. Exposure Reproducibility
B. Exposure Rate
that technique exposure charts will produce
diagnostic quality images
-exposure time settings should be maintained
within +/-5% of the label
-if it drifts beyond, the timing circuit or
mechanism must be recalibrated
-also tend to drift over time (tube aging)
-accuracy is essential to maintaining image
quality because exposure cannot be predicted
unless the mAs is accurate
-mA station accuracy must be inferred by
comparing mR/mAs measurements after both
time and kVp accuracy have been verified
-comparative measurements are made for
the same mAs at different mA and time settings
to evaluate the linearity of the mA stations
-mA should be maintained within +/-10%
-if settings drift beyond, the generator must
be recalibrated
-generators must be capable of repeating
exposures accurately
-ensured by measuring the mR/mA of several
different exposures with the same technical
factors
-reproducibility should be maintained within +/-
5%
-if the readings are beyond, the entire series
of tube and generator tests should be analyzed
to attempt to isolate the problem
-Fluorscopic spot film devices use automatic
exposure controls (AEC)
-they should be evaluated according to the AEC
tests that follow
-fluoroscopic exposure rates are measured by a
dosimeter exactly as diagnostic mR/mAs
-the exposure rate should not exceed 5 R/min
-if the rate exceeds this limit, the automatic
brightness control or other systems may require
calibration or repair
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B. Field Size Accuracy & Beam
Alignment
C. Source-to-skin Distance
Limits
D. Intensifier Viewing System
Resolution
E. Intensifier Viewing System
Contrast
F. Image Display Systems
-fluoroscopic units should not be capable of
irradiating tissue outside the IR area
-should display everything within 1cm of the
edges of the image intensifier tube
-the primary beam should be aligned to the
center of the image intensifier
-correction of the tube collimation, image
intensification system, or video display system
may be required
-Fluoroscopic units should not be capable of
placing the tube target closer than 15 to the
patients skin surface
-without any exposure, the SID should be
verified
-if it is not within limits, the unit should not
be used until a mechanical device is fitted to
set a minimum source-to-skin distance
-because fluoroscopic resolution is much poorer
than radiographic resolution, periodic assurance
that is has not deteriorated is critical in
maintaining confidence in diagnosis
-if the resolution appears to be deteriorating, a
service engineer should be consulted
-because fluoroscopic contrast is much higher
than radiographic contrast, it is important to
periodically determine approximately how low
contrast a structure may be images
-2 plates of aluminum with holes of 1-7mm
frilled on one of the plates
-when the plates are sandwiched together
and imaged fluoroscopically, low contrast
evaluation can be made based on the smallest
visible hole
-fluoroscopic systems use video systems for
image display because of the reduction in
patient dose
-commonly used:
-fluoroscopic mesh tool (permit visualization
of distortion)
-resolution test tool (permits visual
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G. Automatic Brightness
Control
3.Tomographic Systems
A. Uniformity & Completeness
of Motion
measurement of the system resolution)
-when degradation in resolution or distortion is
observed, a service engineer should be
consulted
-controls are designed to function like an AEC in
that variations in subject density are
automatically compensated for, resulting in
relatively uniform image density
-when the phantom thickness is decreased by
half, the exposure should be similarly reduced
-if there is a great discrepancy between
phantom thickness and exposure reduction, a
service engineer should be consulted
-tomography relies on the motion of the tube
during exposure to produce a sectional image of
the subject
-test tool is a lead mask with a pinhole that is
positioned several cm above the tomographic
fulcrum
-if the pinhole is centered to the IR and then
imaged with a full tomographic motion this is
seen:
-erratic tube motion is demonstrated by the
uneven densities
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B. Section Depth Indicator
Accuracy
C. Section Thickness Accuracy
D. Resolution
4.Automatic Exposure Controls
A. Exposure Reproducibility
-if the densities were incomplete, there
would not be a full length of the tracing
-if the motion is erratic or incomplete, the
mechanisms involved in the tomographic
motion should be cleaned and the test repeated
-if problem persists, a service engineer
should be consulted
-tomography units are designed to provide an
image that is sharp only at the fulcrum level
-when a tomographic image is made of the test
tool, the number that was at the level of the
fulcrum should appear sharp
-if it doesnt, the fulcrum indicator should be
adjusted to the appropriate level
-the sharpness of a tomograph should be of a
known thickness, depending on the total arc of
the tomographic motion
-when the angled resolution mesh is imaged,
the section thickness can be determined by
measuring the region of sharpness on the
image
-if section thickness is inaccurate, the
pinhole trace should be consulted
-if it appears unacceptable, a service
engineer should be consulted
-tomographic resolution is determined by
imaging a resolution test pattern at the fulcrum
level
-the resulting image can be visually
inspected to determine the resolving capability
of the system
-when resolution deteriorates, standard
diagnostic quality control measures should be
consulted first, then a service engineer
-The same reproducibility standards for
diagnostic radiography systems are applied to
AECs
-using the same procedure, densitometer
readings of images produced with the AEC
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B. Ion Chamber Sensitivity
C. IR Exposure Variation Control
Accuracy
D. Response Capability
E. Backup Timer Verification
should be within OID +/-0.1 in the same areas
-radiographs must be produced and measured
with a densitometer
-if the readings are not within limits, the
generator circuits must be calibrated
-most AECs utilize 3 ion chambers and permit
activation of various combinations during
exposures
-need to make sure individual ion chambers are
equally sensitive
-do this by using AEC without a subject at
extremely low kVp
-then the test is done by using a lead brick
to block all chambers but one to be tested
-the AEC reproducibility test is then
performed for the unblocked chamber
-if all chambers dont respond within +/-10%
then a service engineer should be consulted to
recalibrate the generator AEC circuitry
-nearly all AEC units provide controls to
decrease and increase IR exposure by changing
the sensitivity of the ion chamber
-if the controls are inaccurate, the generator
AEC circuits must be calibrated
-each AEC has a minimum response capability
-if the AEC cant respond at the minimum time,
there is no assurance that diagnostic quality
images can be made
-as the phantom thickness is reduced, the AEC
should produce exposures within +/-10%
mR/mA of one another until a time below the
minimum exposure time is used
-if the minimum response time is greater
than specified, the AEC should not be used until
the problem is corrected
-when you forget to set AEC or activate the
proper tube, patient protection requires that
AEC backup timers be functioning to terminate
exposures and protect both patient and tube
-when a lead plate is placed over the AEC
Notebook #11

ionization chamber and an exposure is made,

the backup timer should terminate the exposure
and visual and an audible warning should occur
-if the backup timer or signal fails, the AEC
should not be used until the problem is
corrected

F. Digital Radiography -DQE measures the ratio of the transfer

Detectors efficiency of the detector as the signal-to-noise
ratio squared going into the system compared
to that coming out
-higher DQE values increase the ability to
view small or low contrast structures and are
greatly valued in digital mammography systems

Physicist Responsibilities: semiannual or annual review of department images to

reestablish baseline values, check exposure indicator accuracy with ion chamber,
determine exposure trends, analyze repeat rates, review QCs records, and analyze
service history

Technologist Responsibilities:

1. Daily QC duties: general system inspection which is using a sensitometry for

measurement of film densities; clean cassettes due to dust particles
scratches marks; inspect hinge and latch, erase imaging plates, verify digital
interfaces and network transmission, and inspect laser printer
2. Weekly QC duties: clean and inspect receptors, clean air intakes of imaging
plate reader, clean display screen, and clean computer keyboard and mouse
3. Monthly QC duties: reject analysis, reject reasons, positioning errors, marker
errors, equipment malfunction errors, clean imaging plates, artifact
identification, and problem reporting

SMPTE: Society of Motion Picture and Television Engineers

1. You want to clean the monitor for fingerprints.

2. This test is done daily and it has 4 corners, contrast, resolution of numbers or
words.
3. Geometric distortion and luminescence is tested with a TG18QC pattern
thats developed by American Association of Physicist Medicine