When an
organization decides to invest in new technology for computed radiography
(CR) and digital radiography (DR), questions arise concerning quality
assurance, training, continuing education, image quality, and picture
archiving and communications systems (PACS). The radiology group may also
wonder how to determine whether optimal image quality is being obtained at
the lowest possible radiation dose.
Searching for CR and DR quality-control (QC)
information on the Internet and in radiology journals may prove fruitless
because little has been published in this area and standards have not yet
been established. As a result, the diagnostic radiology department at
Spectrum Health, Grand Rapids, Mich, found it necessary to design its own
QC programs for CR and DR.
Spectrum Health is a not-for-profit health system
in western Michigan that offers a full continuum of care through seven
hospitals, more than 140 service sites, and a 450,000-member health plan
(Priority Health). The system's 13,000 employees, 1,400 medical staff, and
2,000 volunteers are committed to delivering care of the highest quality
to those in medical need; the system provided $88 million in community
benefit during 2005.
In 2003, the organization decided to invest in a
comprehensive, one-vendor CR-DR system to help achieve its organizational
vision (to be the nation's highest quality and most successful health care
enterprise by 2010). Spectrum Health diagnostic radiology group wanted to
help the organization achieve that vision by implementing a CR-DR program
of high quality. This called for the creation of a QC plan and a program
team.
THE QC PROGRAM TEAM
Several key members should be involved in any QC
program. These include representatives of the system vendor, the
physicists, the clinical engineering department, the PACS team, the
education department, and the radiologists. The vendor plays an important
role not only in deploying the equipment, but also in providing basic
education and QC tools. CR and DR are new technologies to many
organizations, so the vendor should provide basic education for
technologists, creating an understanding of the technology in use.
However, this level of education may not be provided by the vendor unless
the purchaser makes this an expectation at the outset. Developing a strong
partnership with the vendor is vital to maintaining an effective, lasting
CR-DR program. A vendor should be highly interested in listening to
feedback from users concerning how to improve the product; a good vendor
may base development strategy upon such feedback.
At Spectrum Health, the physicist group has
played a supportive role in the QC program; an internal radiology
physicist was also hired recently. When the CR-DR system was implemented,
the contracted physicist group was asked to help outline a QC program, but
found no examples available. As the department began to create the
program, the physicist group reviewed the program and ensured its
completeness.
All vendors will issue warranties for their
products for a period of time (typically a year). Once the warranty period
has ended, the buyer must decide whether to extend the vendor's service
contract or rely on an in-house biomedical department. Spectrum Health
combined these options by extending its service contract while sending
biomedical staff for training in CR-DR equipment service and maintenance.
When equipment is down, lost operating time equals lost revenue. If
in-house service can handle basic problems, costly service calls and
downtime can be prevented.
Any organization acquiring CR-DR equipment is
likely to have a PACS in place or to be considering PACS implementation in
the near future. Spectrum Health created a division of radiology and
information technology that focuses solely on PACS development and
quality. The PACS group is headed by a manager and staffed by analysts who
monitor PACS patient data and image quality.
In health care, education and communication are
vital to the success of any new venture. It is important to engage the
staff early, teaching them what CR and DR technologies are, what makes
them different from analog imaging methods, and what new factors will be
most important to image quality. At Spectrum Health, the diagnostic
radiology manager developed a basic pamphlet for the staff that covered
these three areas and a timeline for the changes being made as the
department converted to CR-DR use. The vendor also provided the department
with various educational tools and with access to an applications
specialist.
In 2004, the department hired a diagnostic
radiology applications coordinator to implement and monitor the QC
program, to help educate and train staff, to maintain complete
understanding of the equipment and technology, to work with radiologists
on their concerns or projects, and to work with the diagnostic radiology
manager to develop QC strategies and other quality enhancements. The
applications coordinator had 8 years of experience as a diagnostic
radiographer and holds a bachelor's degree in health care administration.
This individual has had a positive influence in the transition to filmless
operation and is available to help technologists with their questions
about positioning, image quality, and technology. The applications
coordinator travels to the vendor's customer-feedback programs and
applications training school, as well as to other education programs. Upon
returning, the applications coordinator then informs the staff of current
and future CR-DR innovations.
Radiologists, as the end users of the
department's CR-DR services, must be involved in the QC program. The
department should ensure that its staff is sending the radiologists images
of the highest possible quality, obtained at the lowest possible radiation
dose. Spectrum Health has a high-volume imaging department, and its
radiologist group, Advanced Radiology Services, Grand Rapids, Mich, has
been an integral part of the QC program's success. The radiologists have
been patient and have provided great insight and constructive criticism on
image quality. This in turn allows the department to meet its needs and
those of the patients as well. In the reading areas of the radiology area,
the department has placed QC trays for radiologists to leave
comments/questions for the applications coordinator each day. Immediate
concerns are addressed at once; the applications coordinator or diagnostic
radiology manager contacts the commenting radiologist for clarification or
to report that the situation has been resolved.
QC RESPONSIBILITIES
The applications coordinator and diagnostic
radiology manager developed a QC program that assigns responsibilities
(see figure at right) and goals. When the department meets quarterly
goals, the staff as a whole is rewarded (with a pizza party, cafeteria
lunch, or other token of appreciation). This encourages the staff members
to work together toward a common goal; it also makes the QC program
positive, not punitive. Since the QC program has been in place for more
than a year, some of its goals have now been incorporated into staff
performance reviews.
Four basic components are monitored, with results
reported to the staff monthly. These four components are the overall CR-DR
repeat rate, the exposure indicator, the number of PACS edit
notifications, and the applications coordinator's image-review statistics.
CR-DR Repeat Rate. The repeat rate is a
statistic that radiology departments have always monitored. However, the
CR-DR product allows repeat rates to be tracked by technology and by
individual technologists. The monthly and quarterly figures reported by
the department are the overall repeat rate, the CR repeat rate, the DR
repeat rate, and the individual technologists' repeat rates; goals to be
met or exceeded are also set. The overall repeat rate has ranged from 6.6%
to 10.3% since CR-DR installation.
Exposure Indicator. The exposure indicator
shows whether the image was overexposed, underexposed, or ideal. Exposure
indicator is the generic term used in the CR-DR industry, but each vendor
changes the name and value system to be specific to its own equipment.
This has made learning the value system for equipment from different
vendors difficult. Currently, the industry is developing a name for the
exposure indicator and a consistent numeric value system. This unit of
measure is very important to monitor because unwanted exposure creep is a
common problem with CR and DR. An image can be adjusted to look ideal if
too high a radiation dose is used (overexposing the patient to radiation).
If underexposed, however, it cannot be adjusted as easily and will look
noisy or grainy. Each vendor has a different numeric value used to reach
ideal exposure. It is important to ensure that the department's staff is
neither underexposing nor overexposing the image, but trying to come close
to the ideal exposure indicator. The goal is to use the lowest exposure
indictor that creates an ideal image, as this indicates that a
high-quality diagnostic image was produced at the lowest practical level
of radiation exposure.
PACS Edit Notifications. PACS edit
notifications are forms that the PACS team and applications coordinator
use to notify staff and document issues when data have not properly
crossed over into the PACS database. These notices are tracked for the
department as a whole and for individual staff members. Technologists must
check the PACS after every patient, just as if they were taking their
films to be filed in the film library, because the PACS now serves as the
film library. If a staff member does not check the PACS and there is a
discrepancy in patient data, a PACS edit notification form will be
generated.
Image Reviews. The applications
coordinator performs daily and weekly image reviews. If an image could
have been improved for any reason, the applications coordinator will
document the problem and share it with the appropriate staff member. This
process allows the applications coordinator and diagnostic radiology
manager to see individual and departmental trends. The image review is
also a great opportunity to share positive feedback with the staff and
recognize high-quality work. It is vital to keep reviewing images daily in
order to detect any quality problems before they become established. It is
easy to conduct image review at any PACS workstation, since it is no
longer necessary to locate and hang films for review.
CONCLUSION
While standards for QC in DR and CR do not exist
yet, radiology departments must take steps to create their own metrics. It
is necessary to work with all involved parties and create a program that
works for each department's staff, radiologists, and the organization
overall. CR and DR technologies will continue to grow and change; QC
programs must evolve with them.
