When you think of quality, what is the first thing that comes to mind? Is it the service at a restaurant or the backpack purchased at the beginning of the semester? Both examples deal with quality in some way: one is people-centered, and the other is product-centered. Likewise, radiology has both a people-centered quality and a product-centered quality.

The traditional radiology department with film and chemistry has many quality procedures that must be followed. Many of these same protocols are used in the digital department, but they have been modified to be relevant to digital equipment and processes.

The next section introduces the terms used to talk about quality within a radiology department. The following sections introduce various routines that should be followed in the department to ensure that the picture archiving and communication system (PACS) is functioning properly and that the images are being produced at a certain quality level. Chapter 12 discusses quality issues related to digital radiographic equipment and processes.

Terms of Quality

Quality has always been a part of health care, whether as a service or product. Health care institutions pride themselves on providing the highest quality possible, and they put many measures into place to ensure that the highest quality is provided to each patient. The ultimate focus in health care is to improve patient care and provide a high-quality service so that patients will want to return. Most health care institutions are accredited by The Joint Commission (TJC), formerly known as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). This accreditation is voluntary but necessary in many instances to obtain Medicaid certification, hold certain licenses, obtain reimbursements from insurance companies, and receive malpractice insurance. Rather than simply referring to quality, today TJC uses the more encompassing terms continuous quality improvement or total quality management. The next few sections define these concepts and provide examples of some basic applications in a digital department.

Quality Assurance

Quality assurance (QA) can be defined as a plan for the systematic observation and assessment of the different aspects of a project, service, or facility to make certain that standards of quality are being met. QA activities are focused around people and service. In a radiology department there are many processes involved in the day-to-day activities. For example, once a patient has been checked in at the front desk, there is a process that is followed to alert the technologist that a patient is waiting. If this process is not followed, the patient may have to wait for an extended period before a technologist arrives to check for waiting patients. This extended wait time affects patient care in a negative manner, and therefore it will be seen as poor quality of service. A QA measure should be in place to monitor patient wait times to ensure that the process of alerting a technologist that a patient is waiting is working properly.

Most QA activities will 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.

Quality Control

Quality control (QC) can be defined as a comprehensive set of activities designed to monitor and maintain systems that produce a product. QC measures are instituted to ensure that radiologic procedures are performed safely, are appropriate for the patient, are performed efficiently, and produce a high-quality image. For example, tests are performed on the radiographic room to make sure that all of the parts, such as the collimator, generator, and focal spots, are functioning properly. All of these parts make up the whole of the room, and if one part is off, it can cause harm to the patient or reduce the quality of the examination.

QC measures are required by law to maintain the license for the room or department. The data from the various activities are kept by a designated individual within the department. Most QC activities are part of a QA program, and the data are used to improve the quality of the processes and department. There are three major categories of QC test that are used at various times:

• Acceptance testing: This type of testing is performed before newly installed or majorly repaired equipment can be accepted by the department. The testing may be performed by a designated technologist, a radiation physicist, or by service personnel employed by the hospital. The acceptance testing is used to determine whether the equipment is performing within the vendor’s specifications and as promised.

• Routine maintenance: Routine maintenance is performed to ensure that the equipment is performing as expected. This type of testing can catch problems before they become radiographically apparent. This testing may be performed by a designated technologist, a radiation physicist, or by service personnel employed by the vendor.

• Error maintenance: When errors occur in equipment performance, corrective action must occur. Errors will be detected by poor equipment performance or poor quality outcomes. These corrections will generally be made by service personnel employed by the vendor.

Continuous Quality Improvement

Continuous quality improvement (CQI) tends to focus on the process rather than on the people or the service. The belief is that if the process is good, health care workers will follow it, and service will be good. The CQI process does not replace QA/QC programs. The QA/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 within which the people function as team members rather than focusing on an individual’s work.

One of the most important concepts to understand with CQI is that all levels of people within the organization must be involved in the process of improvement. Because CQI focuses not on individuals and their mistakes but rather on the process, each team member is more apt to participate in improving the organization. It is important that everyone participate because if one spoke is not involved, the wheel will fall off, and the quality cart cannot move forward.

PACS Equipment QC

When beginning a QC program, care must be taken to document all surrounding variables so that each quality measure can be repeated without harm to the process. Documentation is very important in any QC activity, and all paperwork must be kept up to date to make a valid performance measure. As with all quality activities, documentation is the most difficult part of the process and the easiest part to not complete. Without the documentation to back up the findings, it will be difficult to prove the need for repair or update of a system.

The next several sections focus on QC activities that should be monitored in a PACS environment, including display quality for both monitor and film, processing speed, network transfer speed, and the data integrity of data that are called back from the archive. This is not an all-encompassing list. Many vendors have suggestions for what should be monitored for their systems. It is very important that the vendor’s list and timetable for these various activities be followed. According to the American College of Radiology (ACR) Technical Standard for Digital Image Data Management: “Any facility using a digital image data management system must have documented policies and procedures for monitoring and evaluating the effective management, safety, and proper performance of acquisition, digitization, compression, transmission, display, archiving, and retrieval functions of the system. The quality control program should be designed to maximize the quality and accessibility of diagnostic information.”

The ACR also suggests that all the quality tests described later in this chapter be carried out with a Society of Motion Pictures and Television Engineers (SMPTE) test pattern (Figure 11-1) to ensure continuity of measurements. A test pattern developed by the American Association of Physicists in Medicine (AAPM) Task Group 18 (TG18) (Figure 11-2) is also becoming more widely accepted for use in these QC tests. The ACR suggests that QC tasks be performed at least monthly, whereas the AAPM has a much more rigorous schedule. The AAPM suggests that the testing be performed on acceptance and annually by a trained physicist, and the daily and monthly/quarterly tests can be performed by a trained QC technologist or a physicist. If any of the following tests fails or produces out-of-range readings, corrective action and continued monitoring should be done. The technologist should follow the radiology department’s policy on equipment maintenance procedures. It may be necessary to contact a radiation physicist to follow up on the findings.