D.23 VANTVHCS SOP 114-12 RADIOLOGY QUALITY CONTROL.pdf

DEPARTMENT OF VETERANS AFFAIRS

NORTH TEXAS HEALTH CARE SYSTEM

DALLAS, TEXAS

RADIOLOGY SERVICE

June 1, 2017 549/114

RADIOLOGY SERVICE POLICY AND PROCEDURE: NO. 114-12

QUALITY CONTROL

1. PURPOSE:

To define aspects of quality control (QC) in Radiology Service.

2. POLICY:

Quality control will occur throughout the Radiology department in order to ensure good patient care.

3. PROCEDURE:

A. Radiology service will conduct monthly reviews of all Radiology QC processes required to be conducted daily, weekly or monthly, via the Process Improvement Committee and Quality Assurance in Radiology (PIC-QAR) activities. The Minutes of the monthly PIC-QAR meeting will reflect all ongoing QC activities. Specific Radiology QC processes include:

Radiology Quality Control

Cassette cleaning Quarterly Lead apron, lead gloves and thyroid Annually shield tests Crash Cart Daily

Mammographic Technologist Quality Control

Darkroom cleanliness Daily Processor Quality Control Daily Screen cleanliness Weekly – corrections done immediately Viewboxes and viewing conditions Weekly Phantom images Weekly – corrections done immediately Visual checklist Monthly

Repeat analysis Quarterly – corrections done within 30 days of test

D.23 RFP: 36C25722R0015

Analysis of fixer retention in film Quarterly – corrections done within 30 days of test

Darkroom fog Semi-annually – corrections done immediately

Screen-film contact Semi-annually – corrections done immediately

Compression Semi-annually – corrections done immediately

Medical Physicist Tests for Mammography

Mammographic unit assembly evaluation Annually Collimation assessment Annually Evaluation of system resolution Annually AEC system performance Annually Uniformity of screen speed Annually Artifact evaluation Annually Image quality evaluation Annually kVp accuracy and reproducibility Annually Beam quality assessment Annually Breast exposure and AEC reproducibility Annually Average glandular dose Annually Radiation output rate Annually Measurement of viewbox luminance and room illuminance Annually

B. Radiology Service will also report national VA mandated radiology performance measures on a monthly or quarterly basis to VACO, as mandated.

C. QC efforts are very much a function of evolving technologies in all imaging modalities, and our procedures will reflect these changes. Our QC efforts also include our Picture Archiving and Communication Systems (PACS), the radiology computer networks, and tele-radiology links.

D. Annual QC tests are performed on all radiological units by a certified medical physicist. If deficiencies are noted, Biomedical Engineering is notified for corrective action.

E. The Manual of Radiologic Procedures has standardized all the positions and procedures done in the service.

F. When a patient's condition prevents proper positioning, it will be noted on the x-ray CR reader by the technologist. This information will also be made known to the radiologist so image review can occur and advice from the radiologist can be made.

G. Images will be monitored for quality by the supervisory technologist or designee.

H. Radiological technologists will review all images for quality before releasing the patient. If unacceptable, a repeat of the study will be done before releasing the patient.

I. The computed radiography (CR) cassette fronts are cleaned with alcohol whenever they are found to be soiled, or at a minimum on a quarterly basis. The imaging plates that are inside the cassettes are cleaned when artifacts are noticed.

4. RESPONSIBILITY:

A. The medical physicist is responsible for annual inspections. These are scheduled by the radiation safety office of Quality Management Service.

B. Biomedical Engineering is responsible for remedying any deficiencies found by the physicist and inspecting all machines radiologically, mechanically, and electrically at prescribed intervals as stated in service literature. In general, equipment will be calibrated every year or whenever a major repair is made. The official calibration is done by Biomedical Section under guidance of the physicist with the exception of the MRI units which are calibrated by the Radiology Service physicist.

C. The mammography technologist(s) is responsible for ensuring MQSA standards for QA, as listed above, are followed.

D. The supervisory technologist or designee is responsible for monitoring images for quality.

E. The technologists are responsible for monitoring images for quality before releasing the patient; for cleaning the CR cassettes and imaging plates on a regular basis.

5. REFERENCE:

VHA Handbook 1104.1, Mammography Standards.

American College of Radiology Practice Guidelines: Performance of Screening Mammography, Diagnostic Mammography, Whole Breast Digital Mammography, and Breast Ultrasound.

21 CFR Parts 16 and 900, Mammography Quality Standards Act (MQSA)

Michael Ginsburg, MD Chief, Radiology Service