QAQC Final

QA

The overall management program, put in place to ensure that a comprehensive range of quality control activities work effectively.

QC

The means by which, each area of interest is monitored and evaluated.

• Care Planning

• Test Ordering

• Test Scheduling

• Test Protocoling

• Imaging Procedure

• Image Interpretation

• Reporting

• Report Communication

Diagnostic Procedure Chain

Care Planning

Patient-physician discussion: entails the explicit enumeration and description of the recommended imaging procedure, its harms and benefits, and its need as a part of the patient’s care plan. Discussion by providers on the care team about decisions regarding diagnostic imaging.

Test Ordering

Requires ordering physician to generate formal request of imaging modality and body part to be performed

Test Scheduling

Involves patient/scheduling department communication to plan on a date and time for imaging

Test Protocoling

Radiologist review of appropriateness of test for given indication and contrast safety if indicated

Imaging Procedure

Involves actual capture/performance of imaging exam of any given modality

Image Interpretation

Radiologist reads ordered images correlating to any clinical features provided or any diagnostic possibilities

Reporting

Involves the actual dictation into written language of image interpretation and enumeration of any findings

Report Communication

Relay of relevant information to ordering provider of given imaging test

QA

• As applied to medical radiography is the organized effort of the staff to ensure that the diagnostic images produced are of high quality.

• Its purpose is to provide adequate diagnostic information with the least possible cost and the least possible radiation exposure to the patient and staff.

QC

a series of distinct technical procedures which ensure the production of a satisfactory product.

• FDA

• PNRI

• CDRRHR

Regulatory Agencies for Governing the Use of Radiation

Philippine Nuclear Research Institute

Regulates the use of radioactive materials such as those used in cobalt 60 radiotherapy facilities and brachytherapy units.

Center for Device Regulation, Radiation Health, and Research

• Regulates the use of devices emitting radiation such as x-ray machines and linear accelerators.

• Formerly known as Bureau of Health Devices and Technology

QAQC Program

• It requires the combined efforts of the whole radiology staff.

• A hospital committee and a team must be created to institutionalize the program.

• Chief of hospital

• Admin officer

• Chief radiologist

• Chief rad tech

• Chief physicist

• Maintenance engineer

Hospital QAQC Committee

• Film analysis

• Maintain technique/darkroom charts

• Perform QC tests

• Keep logbooks and manuals

• Hold meetings and decide corrective actions

Responsibilities of QAQC Committee

Hospital Chief

The creation of QAQC groups within the hospital should be formalized with the issuance of a hospital order signed by the ———.

QA

• A program used by management to maintain optimal diagnostic image quality with minimum hazard and distress to patients.

• The primary goal is to ensure the consistent provision of prompt and accurate diagnosis of patients.

  • Maintain diagnostic image quality

  • Minimize radiation to patients/staff

  • Be cost-effective

QA

• The program includes periodic quality control tests, preventive maintenance procedures, administrative methods and training.

• It also includes continuous assessment of the efficacy of the imaging service and the means to initiate corrective action.

QC

Consists of a series of standardized tests developed to detect changes in x-ray equipment function from its original level of performance.

QC

• The objective of such tests, when carried out routinely, allows prompt corrective action to maintain x-ray image quality.

• It is important to note that the ultimate responsibility for this rests with the physician in charge of the x-ray facility, not with the regulatory agency.

• QA Committee members + responsibilities

• QC personnel + responsibilities

• Equipment parameters + monitoring frequency

• Test protocols + tolerance limits

• QC forms and charts

• Equipment acceptance testing procedures

• Reject-repeat analysis guidelines

• Equipment replacement + exposure standardization

QA Program Manual Essentials

• Conduct QC tests (photo, radio, fluoro)

• Record and evaluate data

• Report performance issues

• Supervise repairs

• Confirm post-repair performance

• Submit monthly reports

• Innovate new procedures

QC Technologist Duties

• Must reflect:

  • Design quality

  • Compliance (e.g., safety codes)

  • Performance tolerances

  • Delivery and warranties

  • Cost and service terms

• Acceptance Testing:

  • Done after installation

  • Validates contract specs and safety regs

  • Requires report with:

    • Measured data

    • Graphs, charts, test films

Equipment Specification & Acceptance

QC Testing Program

• Purpose: Ensure image quality through routine checks

• Types:

  • General Radiography

  • Mammography

  • CT

• Goals:

  • Detect deterioration

  • Enable corrective action

  • Spot installation/repair defects

  • Standardize machine usage

Equipment Performance Records and Record Keeping

• Maintained in logbooks or digital format

• Must include:

  • Equipment IDs and location

  • Acceptance test report

  • Safety survey

  • Registration certs

  • QC data (charts, graphs)

  • Repair/service records

  • Downtime log

• Maintains high radiographic standards

• Improves work environment

• Makes tasks easier

• Minimizes repeat films

• Increases staff job satisfaction

• Reduces patient radiation and inconvenience

• Reduces equipment failure

• Keeps costs down

• Maintains a record/audit trail

Results of a QA Program

• QA is everyone’s responsibility

• Head of the department: ultimate responsibility

• Designated QC officer: technical aspects

• Create a QA committee with clear roles

• Effective record-keeping system

• Complete documentation of:

  • Equipment data

  • Imaging procedures (incl. repeats)

  • Equipment downtime/service

  • QC test procedures and control charts

• Perform periodic film retake analysis

How to Establish a QA Program

Darkroom Standards

• Light-proof

• Safe lighting (correct wattage and filters)

• Adequate:

  • Ventilation

  • Drainage

  • Water supply (hot/cold)

  • White lighting

  • Layout and surface workspace

  • Electrical supply

  • Temperature and humidity control

  • Storage space

• Secure entrance

• Cleaned regularly

• Radiation proof

• Equipped with:

  • Processing unit

  • Accessory equipment

  • Health & safety measures

Film & Chemical Storage

• Practice stock rotation

• Ensure proper storage conditions

• Secure storage for film/chemicals

• Efficient working routines

• Adequate staff training

• Regular maintenance

• Fault reporting and quick response

• Safe disposal of:

  • Used chemicals

  • Contaminated water

  • Empty containers

  • Unwanted films

Other Darkroom Issues

• Follow correct processing routines

• Use darkroom safely and correctly

• Perform regular QC routines

• Ensure cleaning is thorough and consistent

• Report/fix faults immediately

• Monitor stock levels

Staff Responsibilities (Darkroom)

White Light Leakage Test

• Frequency:

  • Every 6 months

  • After darkroom work

  • As needed

• Tools:

  • Insulation tape

  • Chalk

• Steps:

  1. Turn on adjacent room lights

  2. Turn off all darkroom lights

  3. Close doors, wait 10 mins (eye adaptation)

  4. Look for leaks (doors, fans, vents)

  5. Mark and seal leaks

  6. Repeat test

  7. Optional: Film fogging test

  8. File report

White Light Leakage Test

Film should only be handled in correct safelight conditions. White light should not be allowed to leak into the darkroom.

White Light Fogging Test

• Frequency:

  • Every 6 months

  • As needed

• Tools:

  • 1 sheet of 18×24 cm film + card

• Method:

  1. Turn on lights adjacent to darkroom

  2. Turn off all darkroom lights

  3. Place film on workbench

  4. Cover half with card for 3 minutes

  5. Process film

• Evaluation:

  • If uncovered part is denser than covered → fogging has occurred

• Conventional Safelight

• Simple bulb with filter coating

• Colored fluorescent light tube

A darkroom should be fitted with appropriate safe lighting. There are several different forms of safe lighting available.

• Good condition

• Correct filter for film sensitivity

• Correct wattage (check manufacturer)

• Safe electrical fittings

• Installed properly

• No white light leaks

Safelight Requirements

Safelight Efficiency Test

• Frequency: Every 6 or 12 months

• Tools:

  • 24×30 cm cassette + new film

  • 2 cards, lead rubber, timer

• Method:

  1. Expose cassette using low exposure

  2. Unload in darkroom

  3. Place film on workbench

  4. Cover sections with card

  5. Turn on safelight, shift card every 30s

  6. Turn off light, process film

• Evaluation:

  • Section A: Radiation only, no safelight

  • Section B: Radiation + safelight (30s to 4min)

  • Section C: Safelight only, no radiation

  • Compare B vs C to find increased density

  • Handling time limit: 3 minutes

• Action (if handling time too short):

  • Raise safelight height

  • Lower bulb wattage

  • Replace filter

  • Block white light leaks

  • Reduce number of safelights

  • Re-test and file a report

Cassettes

Light-tight container holding X-ray film between intensifying screens.

Cassettes

• Features:

  • Available in various sizes.

  • Easily damaged—prone to light leakage and poor film/screen contact.

  • Should be clearly numbered on the outside + inside (using indelible marker).

  • Screen type and speed must be labeled.

• Maintenance:

  • Inspect and clean regularly.

  • Keep records of all inspections, maintenance, replacements.

Cassette Inspection

• Frequency: Yearly or as necessary

• Check:

  • Hinges

  • Catches

  • Casing

  • Cleanliness

• Action:

  • Repair/replace

  • Perform film/screen contact test

  • Clean with damp cloth

  • File a report

Light Leakage Test

• Frequency: Yearly or as needed

• Steps:

  1. Load new film

  2. Expose cassette to bright light for 15–30 mins

  3. Rotate and repeat

  4. Process film

• Evaluation: Black fogging on film edges = leakage

• Action: Repair/replace cassette, file report

Intensifying Screen

• Emit light (fluoresce) when struck by radiation to aid image formation

• Types:

  • Blue light screens: for blue-sensitive film

  • Green light screens: for green-sensitive film

• Note: Damage or dirt will show on the film

IS Inspection

• Frequency: Monthly

• Check:

  • Firm fit

  • Correct screen type (per label)

  • Numbering matches cassette

  • Surface condition (abrasions, discoloration)

• Action:

  • Refit with double-sided tape

  • Replace if damaged

  • Clean if needed

  • File report

IS Cleaning

• Frequency: Monthly

• Tools:

  • Soft brush or puffer

  • Lint-free cloth (gauze)

  • Screen cleaner or mild soap (not detergent)

• Method:

  1. Clean in bright light

  2. Brush off loose dirt

  3. Apply cleaner with cloth in circular motion

  4. Finish with vertical strokes

  5. Air dry cassette open for 30 minutes

• Evaluation: Check for smears or dirt

• Action: Repeat cleaning or replace screen

Film/Screen Contact Test

• When: Yearly or if image blur occurs

• Tools:

  • Perforated zinc, mesh, or paper clips

  • Lead marker (if no lead window)

• Steps:

  1. Load cassette and place test tool

  2. Set SID to 150 cm

  3. Use 50 kV and 6 mAs

  4. Process and inspect film

• Evaluation:

  • Look for blurring or high-density areas

  • Possible causes: air pockets, damage, screen wear

• Action: Repair cassette, replace packing, re-test

Film/Screen Compatibility (Light Color Test)

• Purpose: Ensure screen light matches film sensitivity

• When: As necessary

• Steps:

  1. Open cassette, remove film

  2. Place cassette on table, screen side up

  3. Use 80 kV and long exposure

  4. Reduce lighting and observe light color and intensity

• Action:

  • If film/screen color mismatch: change film

  • If intensities vary: check screen type or do consistency test

IS Consistency Test

• Purpose: Compare performance of screens over time

• Frequency: Yearly or as needed

• Method I:

  • Use step wedge and film strips from the same batch

  • Load film into each cassette

  • Place step wedge centrally

  • Set SID to 100 cm

  • Make identical exposures

• Evaluation:

  • Use densitometer if available

  • Place all films side-by-side on a view box

  • Compare densities

  • Acceptable difference: ≤ 10%

Reject Film Analysis

Films are often rejected due to:

• Incorrect exposure

• Poor positioning

• Processing errors

This helps:

• Identify main causes

• Reduce unacceptable radiographs

• Back decisions with data, not impressions

Parallel Testing

Run sensitometry and radiation consistency tests alongside reject analysis

• Identify major errors + apply corrective measures

• Save costs by reducing waste

• Lower radiation exposure for patients

• Save staff time and effort

• Provide consistent data for:

  • Trends

  • Funding support

  • Equipment upgrade justifications

Benefits of Reject Analysis

• Lack of staff cooperation

• Substandard films kept by clinicians

• Incomplete record-keeping

Common Problems in Reject Analysis

Monthly

Frequency of Reject Film Analysis

Reject Film Analysis

Setting Up

• Design the program

• Set start & end dates

• Inform staff:

  • Purpose

  • Procedure

  • Timing

  • Responsible person(s)

• Decide what data to collect

• Prepare data recording sheets

• Place reject film boxes in strategic locations

Before Start

• Count:

  • Films in store

  • Films in cassettes, hoppers, open boxes

• Dispose of existing reject films

• Record all counts

Reject Film Analysis

Method

• Collect and record reject films daily

• At program end, re-count film stock

• Films used = Starting count – Ending count

• Analyze all data

Reject Film Analysis

Analysis

• Total reject films

• Rejects per film size

• Rejects per type of fault

• Rejects per room or radiographer

• Overall cost

• % reject rate = Rejects / Films used

🔺 ≥10% = unacceptable
🔸 5–10% = needs monitoring

Reject Film Analysis

Corrective Action

• Rank most common faults

• Develop remedial actions

• Inform staff of findings + action plan

• Start training or corrective programs

• Schedule next analysis (if needed)

• File all data

Viewing Box

Purpose

• Allows proper viewing of radiographs under optimal light

• Should be:

  • Well-placed and stable

  • Even lighting

  • Clean and safe

Design Requirements

• 2 parallel fluorescent tubes

• Optional spotlight

• Firm film anchor

• Good switch

• Safe wiring

Frequency

• Outside: Daily

• Inside: Every 6 months

Equipment

• Clean cloth, screwdriver

• (Optional) Intensifying screen cleaner

Steps

1. Unplug and remove front window

2. Clean both sides of window

3. Clean back plate and tubes

4. Check:

   • Tubes + starters are secure

   • No damage or dirt remains

5. Replace window and test

Electrical Check

• Frequency: Every 6 months

• Performed by: Electrician or under supervision

• Steps:

  • Check wiring, switch, tube installation

  • Ensure:

    • Connections are firm

    • Tubes work properly

    • Light output is even

Viewing Conditions

• Room light must be dim

• Spotlight should be available for dark areas

• Viewing box:

  • At proper height

  • Has even lighting like other boxes

X-ray Beam Alignment Test

Purpose

• Ensures the collimator light field accurately matches the X-ray field

• Prevents:

  • Cutting off areas of interest

  • Overexposure to unnecessary regions

• Relies on proper alignment of collimator light bulb and angled mirror

Frequency

• Every 6 months

• Or as necessary

Equipment Required

• One 24×30 cm loaded cassette

• Alignment test tool (commercial or DIY):

  • 8 coins (or 4 paper clips bent at right angles)

  • Lead marker or 9th coin

X-ray Beam Alignment Test

Method

1. Level the table and ensure central ray is 90° to tabletop.

2. Place cassette face up on the table.

3. Set FFD (SID) to 100 cm.

4. Turn on collimator light.

5. Center the light to the middle of the cassette.

6. Collimate to leave a 3 cm border outside the light field.

7. Place coins in pairs where they touch the edge of the light field (all four sides).

8. Add a lead marker in one corner to identify light/X-ray position.

9. Make an exposure sufficient to blacken the film.

10. Process the film.

🟢 Alternative: Use 4 right-angled paper clips at each corner of the light field.

Optional Dual Exposure Method

• Perform two exposures with different collimator sizes on one film to check accuracy across field sizes.

• Reposition markers between exposures.

X-ray Beam Alignment Test

Evaluation

• Light field borders (coin positions) should match X-ray field.

• Irradiated area must not exceed light field.

• At 100 cm SID, irradiated area must be within ±10 mm of light field (≤1% error).

Action

• If misalignment is found, call an X-ray engineer for adjustment.

• Also applicable to cones and diaphragms.

Shutter Efficiency Test

Purpose

• Verifies that fully closed collimator shutters prevent radiation leakage.

• Important for:

  • Radiation safety

  • Testing capacitor discharge mobiles

  • Making tube warm-up exposures

Frequency

• Every 6 months

Equipment Required

• One 24×30 cm loaded cassette

Shutter Efficiency Test

Method

1. Place cassette face up on tabletop.

2. Set FFD (SID) to 100 cm.

3. Use ~80 kV, 40 mAs exposure settings.

4. Open one set of shutters fully, leave the other closed.

5. Make an exposure.

6. Switch: Close the first set, open the other.

7. Make a second exposure.

8. Process the film.

Evaluation

• If shutters are working, film will show no radiation exposure.

Action

• If exposure is visible where shutters were closed: call an X-ray engineer.

Constancy of Radiation Output at Different mA Settings Test

Purpose

• Checks reliability of the mA and time settings

• Ensures that for the same mAs, the radiation output (film density) remains constant

• Validates that the system delivers consistent output even when mA and time are varied

📌 mAs = mA × time, so changing mA/time should still yield same density if functioning correctly.

Frequency

• At the start of a QC program

• Yearly

• As necessary

Equipment Required

• Step wedge or 10 cm water phantom

• Two sheets of lead rubber

• One 24×30 cm cassette

Constancy of Radiation Output at Different mA Settings Test

Method

1. Use the same kV and mAs for all exposures, but different combinations of mA and time

2. Example exposures:

   • Exposure 1: 80 kV, 10 mAs → 50 mA @ 0.2 sec

   • Exposure 2: 80 kV, 10 mAs → 100 mA @ 0.1 sec

   • Exposure 3: 80 kV, 10 mAs → 200 mA @ 0.05 sec

3. Follow the same setup as the reproducibility test (but vary mA/time as above)

4. Process the films

Evaluation

• All film densities should be the same

• If densities differ, this means:

  • One or more exposure values are inaccurate

  • mA settings may be inconsistent

🔍 If the same mA setting always gives a faulty result (e.g., 100 mA), then that specific mA level is the problem.

• Try a similar pattern with 50 mAs:

  • 80 kV, 50 mAs → 50 mA @ 1.0 sec

  • 80 kV, 50 mAs → 100 mA @ 0.5 sec

  • 80 kV, 50 mAs → 200 mA @ 0.25 sec

⚠ Also check kV and exposure time for accuracy while performing this test.

Action

• Repeat the test multiple times to confirm results

• If densities still vary:

  • Call an X-ray technician

• If inconsistencies are:

  • Minor → Unit may still be usable

  • Major → Stop using the unit until fixed

• Label each film with:

  • Date, time, exposures

• Record:

  • kV, mA, time, mAs

  • FFD (SID)

  • Step wedge/water phantom

  • X-ray field size

  • Cassette number + film type

• File a report with all data

Exposure

• The amount of radiation the patient is exposed to.

• Refers to the combination of kV, mA, and time used to produce the exposure that creates the desired image quality.

• kV

• mA

• time

• FFD (SID)

Exposure Factors Affecting Image Quality

kV

• Controls penetrating power (beam quality)

• Influences:

  • Image contrast

  • Patient dose

  • Film density (less than mA/time)

• Higher kV = lower contrast

• Lower kV = higher contrast

mA

• Controls radiation intensity

• Affects:

  • Film density

  • Patient dose

• Higher mA = Higher density and dose

Time

• Controls duration of radiation exposure

• Affects:

  • Film density

  • Patient dose

• Longer time = More density and dose

mAs

• mA × Time

• Controls total radiation quantity

• Many modern machines use mAs instead of mA and time separately

FFD (SID)

• Affects intensity of radiation reaching the film

• Greater distance = Less radiation effectiveness

• Requires exposure compensation when changing SID

Exposure Chart

Purpose

• Quick reference for standard exposures

• Helps radiographers produce consistent, high-quality radiographs

How to Establish

1. Create a blank chart

2. List anatomical areas and views

3. Group based on similar conditions (e.g., no grid, 100 cm SID)

4. Produce a reference radiograph (e.g., PA hand)

5. Record exposures used

6. Measure patient thickness for each view

7. Use “Patient Thickness to Exposure Change” chart to calculate for other body parts

Example:

• PA Hand (2 cm): 50 kV, 6 mAs

• Lateral Wrist (7 cm) = 5 cm thicker → +3 steps → 100% more exposure

• New exposure: 50 kV, 12 mAs

Step System

Purpose

• Standardized method to adjust exposure factors accurately

• Reduces guesswork

• Based on 25% change per step

Example

• Original exposure: 60 kV, 20 mAs

• Increase kV to 70 → +10 kV = +3 steps

• To maintain same density, reduce mAs by 3 steps:

  • New exposure: 70 kV, 10 mAs

Step System

• 1 step = 25% change in exposure

• Visible density change = at least 3 step change

• Step changes can apply to:

  • kV

  • mA

  • mAs

  • Time

  • FFD (SID)

• Step changes can be split between charts