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Diagnostic X-Ray Imaging Quality Assurance: An Overview

PART II. Hospital Diagnostic Imaging Quality Assurance Program Review

1996

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Survey Worksheets

  • Facility:
  • Address:

  • Radiology Manager:
  • QC Technologist:
  • QA Co-ordinator:
  • Reviewer:
  • Date:

Contents

Abbreviations:

  • (D) Daily
  • (W) Weekly
  • (SM) Semi-Monthly
  • (M) Monthly
  • (Q) Quarterly
  • (SA) Semi-Annually
  • (A) Annually
  • (N) Never
  • (H) High
  • (M) Medium
  • (L) Low
  • (N) None

1. Hospital and Radiology Department QA Committees

1.1. Hospital Quality Assurance Committee (QAC)

  1. Does the hospital have a QAC? Y/N
  2. Does the hospital have documented QA program? Y/N
  3. Is a copy of the hospital organization available (showing level of responsibility and reporting order)? Y/N

Comments:

1.2. Radiology Department Quality Assurance Committee

  1. Does the radiology department have a QAC? Y/N
  2. Does the radiology department QAC have an overall strategy with clearly defined work plans? Y/N
  3. Does the radiology department have a documented QA program? Y/N
    If yes, is a copy of the QA manual available? Y/N
  4. Radiology QAC members:
    • Radiology administrator:
    • Medical physicist:
    • Chief x-ray technologist:
    • Quality control technologist:
    • Hospital service engineer:
    • Private consultants:
    • Others:
    • Comments:
  5. Radiology department QA program review and reporting structure:
    • Who reviews the radiology QA program?
    • Review schedule: (M) (Q) (SA) (A) (N)
    • Is a summary of the radiology QAC audit plan available? Y/N
    • Describe the radiology QAC program reporting structure:
  6. Is a copy of the radiology department's organization chart available (showing the level of responsibility and reporting order)? Y/N
  7. Does the radiology QAC serve as an advising committee to give direction, training and/or advice on QA and QC protocols to other hospitals? (M) (Q) (SA) (A) (N)
    If yes, which hospitals?
  8. Is a member of the department's QAC on the hospital QAC? : Y/N

Comments:

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2. Quality Assurance Training

  1. Is QA training available? Y/N

  2. Type of QA training:
    • In-house:
    • Other hospitals:
    • Outside agency:
    • Special courses:
    • Refresher courses:
    • Other:

  3. What priority level is placed on QA training? (H) (M) (L) (N)

Comments:

3. Equipment Specification Writing

  1. Is the QAC involved in equipment specification writing? Y/N

  2. Does QC technologist participate in equipment specification writing? Y/N

  3. Who does equipment specification writing? (QAC ?, private consultants?, etc.)

  4. Is a copy of documented equipment specification writing guidelines available? Y/N

  5. Do equipment specifications include acceptance testing criteria? Y/N

  6. Is a copy of the equipment specification document sent out for tender for the last x-ray unit purchased by the hospital available? Y/N

Comments:

4. Quality Control Test Equipment List

  1. Are QC test equipment available? Y/N

  2. List QC test equipment used: (including manufacturer, model and calibration date):
Processing test equipment
Processing test equipment: Manufacturer Model Calibration Date
sensitometer:      
densitometer:      
thermometer:      
stop watch:      
graduated transparent beaker:      
darkroom fog test tool:      
Radiographic test equipment
Radiographic test equipment: Manufacturer Model Calibration Date
exposure and exposure rate meter:      
full range of ionization chambers:      
electronic irradiation time measuring device:      
electronic x-ray tube voltage measuring device:      
collimator and beam alignment tool:      
aluminum filters:      
film screen contact wire mesh:      
star focal spot patterns:      
Tomography phantoms
Tomography phantoms: Manufacturer Model Calibration Date
tomogram scale:      
tomogram aperture plate:      
full range body part phantom:      
uniform density phantom:      
resolution phantom:      
step wedge:      
Image Intensifier test tools
Image Intensifier test tools: Manufacturer Model Calibration Date
full range of lead (resolution) test patterns:      
low contrast resolution test tool:      
high contrast resolution test tool:      
Video test equipment
Video test equipment: Manufacturer Model Calibration Date
oscilloscope:      
scope camera:      
video waveform monitor:      
video signal generator:      
photometer:      
General purpose test equipment
General purpose test equipment: Manufacturer Model Calibration Date
chart recorder:      
other:      

5. Equipment Acceptance Testing

  1. Does the QAC have an equipment acceptance testing policy? Y/N

  2. Who does the equipment acceptance testing (manufacturer, in-house, private consultants)?:

  3. Equipment acceptance test results recorded? Y/N

  4. Equipment acceptance test results kept for QC base data? Y/N

  5. Is a copy of equipment acceptance testing results available? Y/N

Comments:

6. Quality Control Testing

The following are general questions regarding the QC testing program and the QC technologist's responsibilities. Further information, about x-ray imaging equipment QC testing, i.e., specific tests, test devices and frequency of testing, is collected based on information from "Radiographic Quality Control, Minimum Standards" from the CAMRT, Appendix A of NCRP Report No.99 and "Diagnostic X-ray Equipment and Facility Survey" of Health Canada publication 94-EHD-184. Questions are listed in a separate survey form.

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6.1 X-Ray Equipment Quality Control

  1. QC responsibilities (persons in charge and reporting order):
    • Radiology department QC program:
    • QC testing:
    • QC record keeping:
    • QC data evaluation:
    • Equipment control parameter setting:
    • Equipment repair and services decisions:
  2. Does the x-ray department have a documented equipment QC test protocol manual? Y/N

    If yes, is a copy of the equipment QC test protocol manual available? Y/N

    Does the manual include QC test protocol for the following equipment? :
    • General radiographic equipment? Y/N
    • Fluoroscopic equipment? Y/N
    • Special procedures equipment? Y/N
    • Mammographic equipment? Y/N
    • CT equipment? Y/N
    • Mobile fluoroscopic equipment? Y/N
    • Dedicated procedure equipment? Y/N
    • Film processors? Y/N
    • Other? :
  3. Is the QC testing done by a private consulting agent? Y/N
    • If yes, who?
    • Reporting protocol:
    • Consultant objectives:
    • Radiation safety survey of equipment?
    • Equipment specification writing?
    • Acceptance testing?
    • QC testing of equipment?
    • Advisor on QA program?
    • Frequency of consultant contract: (M) (SA) (A) (N)
    • Is copy of consultant contract objectives available? Y/N
  4. QC technologist available?: (Full-time), (Part-time), (Occassional)
    To whom does the QC technologist report? :
  5. Does the QC technologist have a specific QC test schedule? Y/N
    • If yes, how strictly is it followed?
    • QC testing schedule priority level: (H) (M) (L) (N)
    • Is a copy of the equipment QC test schedule available? Y/N
    • QC test schedule (time spent): h/d; d/w; w/m
    • Consequences of not meeting the QC schedule:
  6. QC technologist responsibility
    • x-ray rooms
    • darkrooms
    • processors
    • radiographic tubes
    • fluoroscopic tubes
    • mobile units
    • mammography units
    • CT units
    • other
  7. How much time spent testing equipment (number of tubes, hours/unit)?
    • General radiography?
    • Fluoroscopy?
    • Special procedure equipment?
    • Mammography?
    • CT?
    • General film processors?
    • Dedicated film processors?
    • Other:
  8. Does QC technologist have adequate time to carry out QC test required? Y/N
  9. Does QC technologist have adequate time to evaluate results of QC tests performed? Y/N
  10. Does QC technologist have adequate time to update and maintain QC records? Y/N
  11. Are samples of QC tests records (blanks) available? Y/N
  12. QC test reporting:
    • To whom are QC test results reported? Y/N
    • What is the reporting structure?
    • Priority of QC reporting: (H) (M) (L) (N)
    • Consequences of late reporting:
  13. QC testing review activity:
    • Is equipment QC test program audited? (W) (M) (Q) (SA) (A) (N)
    • Review method of audit:
    • Is a copy of the QC audit plan available? Y/N
    • Consequences of bad reviews:
  14. Is QC testing training available for the QC technologist? Y/N
    If yes, where? when?
  15. Is QC technologist shared with other hospitals? Y/N
    If yes, list hospital and days per week:
  16. Is the Hospital QC performance compared with other large city hospitals? Y/N
    If yes, who and frequency: Hospital (M) (Q) (SA) (A) (N)

Comments:

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6.2. Photographic Equipment Quality Control

The following are general questions regarding the photographic QC testing program and the QC technologist's responsibilities. Further information, about photographic equipment QC testing, i.e., specific tests, test devices and frequency of testing, is collected based on information from "Radiographic Quality Control, Minimum Standards" from the CAMRT, Appendix A of NCRP Report No.99 and "Diagnostic X-ray Equipment and Facility Survey" of Health Canada publication 94-EHD-184. Questions are listed in a separate survey form.

  1. Number of automatic processors:
  2. Number of dedicated processors:
  3. Processor sensitometric evaluation performed? (D) (W) (SM) (N)
  4. Is the developer temperature verified using a thermometer?
  5. Replenishment rates checked? (D) (W) (SM) (N)
  6. Transport time checked? (D) (W) (SM) (N)
  7. Is the manufacturer's time/temperature chart followed? Y/N
  8. Are film processors cleaned regularly? (D) (W) (SM) (M) (N)
  9. Preventive maintenance program for the processor? Y/N
  10. Are the cassette screens cleaned regularly?
    (D) (W) (SM) (M) (SA) (A) (N)
  11. Are screen contact tests done? (W) (SM) (M) (SA) (A) (N)
  12. Safelight integrity verified? (W) (M) (SA) (A) (N)
  13. Darkroom fog test? (W) (M) (SA) (A) (N)

Comments:

  1. Does the radiology department have a silver recovery program? Y/N
  2. Who is in charge of the silver recovery program?
  3. Is silver recovery done for all automatic processors? Y/N
  4. Does the hospital have a policy on effluent disposal? Y/N
  5. Are the developer and fixer treated before going to effluent Y/N
  6. What happens to old or reject-repeat radiograms?

Comments:

7. Equipment Performance Records and Record Keeping

  1. Are equipment performance records kept? Y/N
  2. Do the equipment performance records include acceptance testing results? Y/N
  3. Are the initial and current radiation safety surveys reports available? Y/N
  4. Are the current year QC tests and results recorded? Y/N
  5. Are the past year QC tests and results recorded? Y/N
  6. Are the equipment repairs and servicing recorded (frequency and costs)? Y/N
  7. Is the equipment down time recorded? Y/N
  8. Is a copy of the equipment performance record available? Y/N

Comments:

8. Equipment Appraisal and Replacement Policy

  1. Does the QAC have an equipment appraisal and replacement policy? Y/N

  2. Planned budget allocations for future purchases? Y/N

  3. Describe the equipment appraisal and replacement policy budget strategy:

  4. Is a copy of the equipment appraisal and replacement policy available Y/N

9. Standardization of Exposure

9.1. Radiographic Positioning

  1. Is a standard radiographic positioning manual available in each room? Y/N
    • If no, is it easily accessible? Y/N
    • Is a copy (sample) of radiographic positioning manual available? Y/N

    Comments:
  2. Current condition of the radiographic positioning manual (indicate on a scale of 1 to 5):
    • Poor - Good
    • Disorganized - Tidy
    • Ambiguous - Clear
    • Vague - Precise
    • Incomplete - Comprehensive
    • Neglected - Updated

    Comments:
  3. Does the radiographic positioning manual provide instructions about: body part to be x-rayed? Y/N
    • number of projections required? Y/N
    • size of image receptor to use? Y/N
    • part rotation? Y/N
    • tube angle? Y/N
    • central ray location? Y/N
    • source-to-image receptor distance? Y/N
    • detail of structures to be shown? Y/N
    • general instructions for positioning? Y/N
      illustrations? Y/N

    Comments:
  4. Radiographic positioning manual update:
    • Is the radiographic positioning manual updated? Y/N
    • Who authorizes changes?
    • Are changes reported through QAC reporting channels? Y/N
    • Are changes unreported and adopted? Y/N

    Comments:

9.2. Loading Factors

  1. Is there a loading factors chart (or manual) posted in each x-ray room? Y/N
    Is a copy (sample) of loading factors manual available? Y/N
  2. Current condition of Loading Factor charts (indicate on a scale of 1 to 5):
    • Poor - Good
    • Disorganized - Tidy
    • Ambiguous - Clear
    • Vague - Precise
    • Incomplete - Comprehensive
    • Neglected - Updated

    • Comments:

  3. Does the loading factors chart contain the following information?: patient thickness? Y/N
    • child/adult technique? Y/N
    • optimum kVp? Y/N
    • optimum time, mA, mAs or automatic exposure control? Y/N
    • focal spot size? Y/N
    • grid/no grid? Y/N
    • film-screen combination? Y/N

    • Comments:
  4. Is the loading factors chart strictly followed? If not, why? Y/N
  5. Loading factors chart changes:
    • Is the loading factors chart updated or changed to compensate for equipment or processor problems? Y/N
    • Who sets the loading factors chart factors?
    • Who authorizes the loading factors chart changes?
    • Are the loading factors chart changes reported to QC technologist? Y/N
    • Are changes unreported and adopted? Y/N

    • Comments:
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9.3. Entrance-Skin-Exposure (ESE)

  1. Are the ESEs measured for:
    • each diagnostic procedure? Y/N
    • each x-ray room? Y/N
    • each fluoroscopic procedure? Y/N
    • each fluoroscopic room? Y/N
    • List the ESE procedures measured:

  2. Is the ESE schedule reviewed : (M) (SA) (A) (N)

  3. Are the ESEs recorded in the QC log book? Y/N
    If yes,
    1. is a copy (sample) of the radiographic ESE record for each room available? Y/N
    2. is a copy (sample) of the fluoroscopic ESE record for each room available? Y/N

  4. Is there an ESE comparison with other major city hospitals?
    If yes, who?   How often? (M) (Q) (SA) (A) (N)

Comments:

10. Acceptance Criteria for Diagnostic Radiograms

  1. Have acceptance criteria for diagnostic radiograms established? Y/N
  2. Do the acceptance criteria cover the following points:
    1. the visibility of predetermined landmarks clearly defined for each view? Y/N
    2. an acceptable density range measured at predetermined anatomical landmarks? Y/N
    3. also include three limits of acceptability clearly defined where:
      1. the x-ray technologist forwards radiogram to radiologist for reporting? Y/N
      2. or the x-ray technologist consults with the radiologist? Y/N
      3. or the radiogram is rejected and a repeat is done? Y/N
  3. Are the acceptance criteria followed by technologist? Y/N
  4. Are the acceptance criteria reviewed? Y/N
    • Frequency of review: (M) (Q) (SA) (A) (N)
  5. Are acceptance criteria compared with that of other major city hospitals? Y/N
  6. If yes, Who?, How often? (M) (Q) (SA) (A) (N)
  7. If a QA criteria has not been established against which standard are the radiograms checked when the radiologist is not available? (e.g., evening or weekends)
    • How does that affect the repeat rate when the radiologist does become available?
  8. Is a copy of the acceptance criteria available? Y/N

Comments:

11. Reject-Repeat Analysis Program (RRAP)

  1. Does the radiology department have a comprehensive RRAP? Y/N
  2. Is a copy of the documented RRAP parameters available? Y/N
  3. Who sets the RRAP parameters?:
  4. Reject-Repeat Analysis parameters:
    • patient positioning
    • radiograms too dark
    • artifacts
    • fog
    • medical reasons
    • mechanical
    • clear
    • Good radiograms
    • Total waste
    • Total repeats
    • patient motion
    • radiograms too light
    • tomographic scout radiograms
    • static
    • processor malfunction
    • quality control films
    • black film
    • Other
    • Total rejects
    • Total repeats

    • Comments:

  5. Do the RRAP results show how many rejects or repeats were acceptable and should not have been repeated? Y/N
  6. Are the RRAP results posted? Y/N
  7. Is the repeat percentage analysis evaluated:
    • per technologist?
    • per room? Y/N
  8. What is the current reject-repeat rate?
  9. What is the reject-repeat rate for the last six months?:
  10. What corrective action is used to reduce the reject-repeat rate?
  11. Reject-repeat rate is based on what workload?
  12. What is radiology department total workload?
  13. Is the RRAP compared with other hospitals? Y/N
    • If yes, who? How often?: (M) (Q) (SA) (A) (N)
    • Note: RRAP should look at three separate categories:
      1. Total waste films: all films in the scrap bin? Y/N
      2. Total rejects: all films except clear and QC films? Y/N
      3. Total repeats: only those where an additional radiogram was made? Y/N

    • RRAP should not include radiograms from special procedures areas (cardiovascular, neurological copy, nor subtraction films.)

      Comments:

12. QA/QC Document Assessment (Summary)

The following (current) documents should be collected as examples for assessing the Radiology Department's QA/QC program.
Section Reference Documents
1.1.3. Hospital organization chart (with reporting order)
1.2.3. Radiology department QA manual
1.2.5. Summary of radiology department's QAC audit plan
1.2.6. Radiology department's organization chart (with reporting order)
3.4. Equipment specification writing guidelines
3.6. Equipment specification document (e.g., last purchase)
4.2. List of all QC test equipment
5.5. Equipment acceptance test results
6.1.2. Equipment QC test protocol manual
6.1.3. QC consultant contract objectives
6.1.5. Equipment QC test schedule
6.1.11. Sample QC test records (blanks)
6.1.13. QC audit plan
7.8. Equipment performance record
8.4. Equipment appraisal replacement policy
9.1.1. Radiographic positioning manual (sample)
9.2.1. Loading factors chart (sample)
9.3.3. ESE (sample list of ESEs recorded and date in QC log for radiographic and fluoroscopic examinations for each room)
10.8. Acceptance criteria for diagnostic radiograms
11.2. Reject-Repeat Analysis Program parameters
Date Modified: 2006-03-30

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