Brief definition of Multi-modality Diagnostic facility, Teleradiology, PACS, RIS, Quality Assurance Programme Explanation of the Quality assurance Committee Introduction to Chest X-ray technology and CR cassette Quality Control Tests for Chest x-ray Technology Introduction to Fluoroscopy Technology Quality Control test for Fluoroscopy Quality Assurance Program Review Test Quality Assurance Drawback

2. Outline
 Brief Definition of Terms
 Quality Assurance Program
 Quality Control
 Administrative Procedure
 Preventive Maintenance Procedure
 Training
 Quality Assurance Committee
 Chest X-ray Technology
 Quality Control Test for Chest X-ray Equipment
 Fluoroscopy Technology
 Quality Control Test For Fluoroscopy Equipment
 Quality Assurance Program Review Test
 Integration of Quality Control Test into Multimodality System
 Quality Assurance Drawback
 Health and Safety
 Conclusion
 References

3. Definitions

4. Diagnostic Facility
A diagnostic radiology facility is any facility in which an x-
ray system(s) is used in any procedure that involves
irradiation of any part of the human for the purpose of
diagnosis or visualization.

5. Radiology Department Organization Chart

6. Radiology Information System
(RIS)
A RIS is an information system where;
 Patients are registered,
 Examinations are scheduled and
 Radiologists’ reports are recorded,
 Stored and distributed.
The RIS can also provide management information and
may hold information that is important for revenue
generation

7. Picture Archiving and Communication System
(PACS)
PACS is a healthcare technology use for;
 The short- and long-term storage,
 Retrieval,
 Management,
 Distribution and
 Presentation of medical images.
PACS and a RIS need to work seamlessly together

8. PACS Workflow

9. Teleradiology
Teleradiology is considered to be the transmission of a full set
of full integrity images to a Centre distant from where the
images were generated.
Purposes of teleradiology includes;
 Primary diagnostic interpretation
 Expert secondary consultation
 Preoperative surgical planning

10. Teleradiology
Benefits of Teleradiology
 Provide access to medical image reporting for underserviced centers.
 Support patient consultations and inform patient treatment decisions
 Provide access to image interpretation for remote regions
 Provide reporting in shifts to provide timely interpretation after
normal working hours

11. Teleradiology Workflow

12. PACS and Teleradiology

13. Quality Assurance
Program

14. Quality Assurance Program
What is a Quality Assurance Program ?
An organized effort by the staff operating a facility to ensure that
the diagnostic images produced are of a sufficiently high quality
so that they consistently provide adequate diagnostic information
at the lowest possible cost and with the least possible exposure of
the patient to radiation.
_World Health Organization (WHO)

15. Quality Assurance Program
Objectives of QA Program
 to maintain optimal quality of diagnostic images;
 to reduce unnecessary radiation exposure to patient and staff; and
 to be cost effective
The primary goal of a radiology QA program is to ensure the consistent
provision of prompt and accurate diagnosis of patients

16. Quality Assurance Program
This program has many facets, including,
1. Quality Control tests,
2. Administrative procedures,
3. Preventive maintenance procedures and
4. Training.

17. Quality Assurance Program
1. Quality Control
Quality control (QC) is an integral part of quality assurance
It involves specific actions designed to keep measurable aspects
of the process involved in manufacturing a product (image) or
providing a service within specified limits.

18. Quality Assurance Program
QC is summarized in four principal steps.
I. Acceptance testing to detect defects in equipment that is newly
installed or has undergone major repair
II. Establishment of baseline performance of the equipment
(commissioning test)
III. Detection and diagnosis of changes in equipment performance before
they become apparent in images
IV. Verification that the causes of deterioration in equipment performance
have been corrected

19. Quality Assurance Program
The frequency of any QC test depends on the following variables;
 The inherent variability of the process or equipment
 The age, reliability, and frequency of use of the equipment
 The criticality of the element in the imaging chain

20. Quality Assurance Program
2. Administrative Procedure
These procedures are design to verify that QC testing is effective, i.e., the
tests are performed regularly and correctly, the results evaluated promptly
and accurately, and the necessary action taken.
They include recommendations regarding the responsibility for quality
assurance action, staff training, equipment standards, and the selection of
the appropriate equipment for each examination

21. Summary Of Administrative Procedure

22. Quality Assurance Program
3. Preventive Maintenance Procedure
These are performed on a regularly scheduled basis with the goal of preventing
breakdowns due to equipment failing without warning signs detectable by monitoring.
These procedures includes;
 Visual inspection of the mechanical and electrical characteristics of the x-ray system
Assuring cleanliness with respect to spilling of contaminants in the examination
room.
 Following the manufacturer’s recommended procedures for cleaning and
maintenance of the equipment
 Regular inspection and replacement of switches and parts that routinely wear out or
fail

23. Quality Assurance Program
4. Training
The QA program include the means to provide appropriate training for all
personnel with QA responsibilities (especially those directly involved with
QC testing) to ensure each meet a minimum level of competency to
perform QC test correctly and consistently.
Companies whose sole purpose is training as well as service and repair
companies and the facility’s medical physicist can provide seminars and
training courses on the how to perform Quality Control tests.

24. Quality Assurance
Committee

25. Quality Assurance Committee
What is the Quality Assurance Committee ?
Personnel in the QA program who are responsibility for oversight of the QA
program, setting the goals and direction, determining policies, and
assessing the effectiveness of QA activities.
They have an overall documented strategy with clearly defined work plans
to achieve the goals and objectives of the radiology department.

26. Quality Assurance Committee
QA committee members includes;
 Medical Physicist
 Radiologist
 Biomedical engineer
 Medical Imaging Technologist (MIT) and Radiographer
 Information Technology (IT) Technician

27. Quality Assurance Committee
Medical Physicist
An individual who is competent to independently practice in one or more of
the subfields in medical physics.
 Advising the facility on radiation protection of the patient, staff and members of the
public.
 Conducting tests to ensure the safety and proper performance of imaging equipment
used.
 Assignment of Bio-medical engineering service staff for corrective maintenance or
preventive actions.
 Training of personnel utilized for quality control
 Develop and implement a radiation protection program

28. Quality Assurance Committee
Radiologist
A medical doctor who specializes in the diagnosis and treatment of disease
and injury by using medical imaging technologies.
 Determine the overall quality of the output image
 Select the technologist to be the primary QC technologist, performing the prescribed
QC tests.
 Ensure that appropriate test equipment and materials are available to perform the QC
tests.
 Ensuring that medical physicists and radiographers have adequate training and
continuous education

29. Quality Assurance Committee
Biomedical Engineer
Biomedical engineers use their knowledge of modern biological principles
in their engineering principle to design and develop devices and
procedures that solve medical and health-related problems.
Biomedical engineer are involve in;
 Corrective and preventative maintenance
 Fault Reporting

30. Quality Assurance Committee
Medical Imaging Technologist (MIT) and Radiographer
 Ensuring that the appropriate protocol and technique factors are used for
the requested examination.
 Ensuring that the QC tests are performed, interpreted and recorded
appropriately.
 Perform all the checks for the daily, monthly and quarterly QC testing of
equipment
 Report faults immediately any deviation in trend of equipment
performance to QA manager
 Undertaking additional continuous education courses

31. Quality Assurance Committee
Information Technology (IT) Technician
IT is a key element of any digital radiology facility that intends to store,
review and distribute images electronically or using hard copy. There
responsibility includes;
 Maintenance of the integrity of system databases to ensure continuous
and accurate operation of the information systems
 Planning,
 Deployment,
 Testing

32. Chest X-ray

33. X-ray Tube

34. Chest X-ray Technology
The technology use for chest examination is similar to that of any
other x-ray examination,
however it is perform with the patient in an upright position
against a tube stand.

35. Chest X-ray Technology
The x-ray tube emits x-rays directed towards the patient, which interacts
with the patient's anatomy.
The computed radiography (CR) image receptor records the altered x-ray
distribution to form the image.
CR system firstly converts the incoming x-ray photons
to light then converts light into an electronic signal.
The images are read by a reader device where it is scanned by a laser
beam and the final image appearing on the computer screen.

36. Quality Control Test
Acceptance Test
 Equipment Visual Check Test
 Control Panel
 Collimator/Indicator/Locks
 Upright Bucky
 General
Commissioning Test
 System assembly evaluation
 Collimation assessment
 kVp accuracy and reproducibility
 Exposure reproducibility and beam quantity (mR/mAs)
 Radiographic AEC system performance assessment
 Focal Spot Size
 Beam quality assessment (HVL)
 Equipment warm-up test
 View boxes and viewing conditions
 Phantom image quality evaluation
 Laser Film Printer Quality Control Test
 Protective Shielding Test

37. Quality Control Test

38. Quality Control Test
Focal Spot test
Objective
To determine effective focal spot size, the magnification factor must be known (image
size/object size)
Frequency
Initially and after tube replacement
Equipment required
Star test Pattern- e.g. 9 - 2,0°; 9 - 1, 5°-360 (A disk with radiating bars is used to produce
a radiographic image).
Cassette 35cm×35cm

39. Quality Control Test
Procedure
1. Mount the star test plate so that the radiographic central ray is perpendicular to the star pattern and
passes through the center of the star.
2. Place a image plate at about the same distance from the test plate as the plate is from the focal spot,
and align it so that the central ray strikes the center of the film.
3. If the blur pattern is too small, magnification can be increased by moving the film further from the
test plate. If the blur pattern is too large, magnification can be decreased by moving the film closer to
the tube.
4. The kV and mA should be comparable to that used clinically, to get the true focal size which is
somewhat dependent upon the electrical factors. Recommended technique should be one half the
maximum mA at 75 kVp. The density of the image should be about 1.5.

40. Quality Control Test
5. Process the CR cassette. Determine the magnification (M) by dividing the diameter
of the radiographic image of the star pattern by the true star test pattern diameter
(45 mm).
6. Scan the star pattern on the radiograph inward from the periphery to find the
outermost region in which the image of the sectors disappears. This is the region of
zero contrast. Measure the diameter of this region across its greatest extent and also
in the perpendicular dimension. Let these diameters be called D1 and D2.
7. The focal spot size corresponding to the individual diameter dimensions can be
determined by the following formula:
𝑭 =
𝑵
𝟓𝟕. 𝟑
×
𝑫
(𝑴 − 𝟏)
Where:
F - Focal spot size in mm
N - Angle of the star pattern line
D- Diameter of the zero contrast region in mm
M- Magnification

41. Quality Control Test
8. Several regions of zero contrast may be found on a single film. It is extremely
important that the largest one be used.
Analysis
Measurements of the radiographic image of the star are taken lengthwise and
crosswise. Along with the magnification factor, the measurements are put into the
formula.
𝑭 =
𝑵
𝟓𝟕. 𝟑
×
𝑫
(𝑴 − 𝟏)
𝑴 =
𝟓𝟑𝒎𝒎
𝟒𝟑𝒎𝒎
= 𝟏. 𝟏𝟖𝒎𝒎
N=2
Magnification (M - 1) = 0.18

42. Quality Control Test
For the Anode-Cathode Diameter:
D u- d =2 mm
𝑭𝒖 − 𝒅 =
𝟐
𝟓𝟕. 𝟑
×
𝟐𝟖
𝟎. 𝟏𝟖
=
𝑭𝒖 − 𝒅 = 𝟓. 𝟒 𝒎𝒎
For the Transverse Diameter:
D a- c = 28 mm
𝑭𝒂 − 𝒄 =
𝟐
𝟓𝟕. 𝟑
×
𝟑𝟒
𝟎. 𝟏𝟖
=
𝑭𝒂 − 𝒄 = 𝟔. 𝟔 𝒎𝒎
Therefore
The focal spot is 5.4 mm x 6.6 mm at the kVp and mA setting used.

43. Fluoroscopy

44. Fluoroscopy Technology
Fluoroscopy refers to the continuous acquisition of a sequence of
x-ray images over time.
A standard fluoroscopic imaging system contains an x-ray tube,
filters, and collimation similar to the technologies used in
radiography
The principal component of the imaging system that
distinguishes fluoroscopy from radiography is the image
intensifier

45. Fluoroscopy Technology
An x-ray beam is passed through the patient body
The antiscatter grid removes contrast degrading
scattered radiation from the x ray beam
The intensifying screen converts the low intensity x
ray photon fluence exiting the patient into a high
fluence of visible photons by using multiple
conversion layers and a series of electrodes inside a
vacuum container.
The distribution of the visible photons are capture by
the video camera to form the image seen on the
monitor.

46. Quality Control Test
Acceptance Test
 Equipment Visual Checklist
 Table
 Fluoroscopy Image Intensifier Assembly
 Monitor
 General
Commissioning Test
 System assembly evaluation
 Fluoroscopy System high and low contrast resolution test
 Laser Film Printer Test
 Fluoroscopy Collimation field size Test
 kVp accuracy and reproducibility
 mAs Linearity Test
 Spot film AEC system performance
 Entrance skin air kerma and air kerma rate
 Maximum air kerma (exposure) rate
 Beam quality assessment (HVL)
 Equipment warm-up test
 Artifact evaluation
 Phantom image quality evaluation
 CR Cassette Integrity Check
 View Box
 Protective Shielding integrity check

47. Quality Control Test

48. Quality Control Test
kVp Reproducibility Test
Objective
To measures the ability of the x-ray generator to faithfully deliver the same output when the
same exposure factors are used.
Suggested performance criteria
Limit (±5%)
Frequency
Initially, annually
Equipment required
Multifunction meter

49. Quality Control Test
Procedure
1. Take 5 consecutive measurements at the same SID (~150cm for the
chest detector and 110cm for the table detector)
2. Use any combination of operating loading factors (kVp and mAs), while
kVp is kept fixed.
3. From the recorded output readings, the maximum and minimum
readings are plugged into the following formula;
𝑹𝒆𝒑𝒓𝒐𝒅𝒖𝒄𝒊𝒃𝒊𝒍𝒊𝒕𝒚 𝑽𝒂𝒓𝒊𝒂𝒏𝒄𝒆 =
𝒎𝑹 𝐦𝐚𝐱 − 𝒎𝑹 𝒎𝒊𝒏
𝒎𝑹 𝒎𝒂𝒙 + 𝒎𝑹 𝒎𝒊𝒏
× 𝟏𝟎𝟎

50. Quality Control Test
Example
A test of reproducibility using 70kVp, 100 mA and 0.10 seconds resulted in the
following readings;
𝑹𝒆𝒑𝒓𝒐𝒅𝒖𝒄𝒊𝒃𝒊𝒍𝒊𝒕𝒚 𝑽𝒂𝒓𝒊𝒂𝒏𝒄𝒆 =
𝒎𝑹 𝒎𝒂𝒙 − 𝒎𝑹 𝒎𝒊𝒏
𝒎𝑹 𝒎𝒂𝒙 + 𝒎𝑹 𝒎𝒊𝒏
× 𝟏𝟎𝟎
=
𝟎. 𝟒𝟓 − 𝟎. 𝟑𝟖
𝟎. 𝟒𝟓 + 𝟎. 𝟑𝟖
𝒙 𝟏𝟎𝟎
= 𝟖. 𝟒𝟑%
The control limit for reproducibility is no more than 5%. In this case, a variance of 8.4%
is clearly unacceptable and corrective action is needed.
Exposure 1 Exposure 2 Exposure 3 Exposure 4 Exposure 5
0.45 0.38 0.45 0.44 0.40

51. Quality Assurance Program Review Test
Objective
The Quality Assurance Program must be reviewed in its entirety to ensure that all information is current
and accurate.
Frequency
Annually, After any equipment or personnel change
Procedure
1. Review and update as necessary the following information
 QA personnel
 QC measures
 Policies and procedure
 Corrective action
 Record keeping

52. QA Program Drawback
Costly
The QA program is based on, planning, delegating responsibility, training and purchasing the proper
equipment, then establishing a high standard of quality and maintaining it.
Personnel
 Unclear responsibility
 Lack of qualification
 Lack of commitment to perform QC test
Any program lacking genuine interest from its staff and initiated only to satisfy a regulatory requirement
is unlikely to produce optimal results.

53. Health And Safety
Health and safety issues in any work environment are very important
All heads of department are responsible for ensuring that injury or sickness, due to
working conditions, is kept to a minimum
To make the environment as safe as possible, make certain the following;
 Regular maintenance inspections are carried out
 Safety procedures are followed
 Adequate staff instruction is given
 Safety equipment is readily available

54. Conclusion
QA promote the effective use of radiation for a diagnostic outcome
through achieving and maintaining appropriate image quality and
reduction of patient dose.
An established QA program monitor the imaging process from start to
finish and reveal potential problems that may otherwise go unrecognized,
through a sequences of QC tests
QA in medical imaging is a rapidly evolving concept and each facility is
encouraged to continually pursue ways to improve and expand its
program.

55. References
Quality Assurance Programme for Computed Tomography; Diagnostic and Therapy Application, International Atomic Energy Agency IAEA,
Human Health Series No. 19, 2012, ISBN 978–92–0–128910–0
Worldwide Implementation of Digital Imaging in Radiology, Atomic Energy Agency IAEA, Human Health Series 28, 2015, ISBN 978–92–0–
102114–4
Radiation Protection in Diagnostic and Interventional Radiology, International Atomic Energy Agency, Part 15.1: Optimization of
protection in radiography Practical exercise
Quality Assurance Programme for Digital Mammography, Atomic Energy Agency IAEA, Human Health Series 17, 2011, ISBN 978–92–0–
111410–5
Quality assurance workbook for radiographers & radiological technologists, World Health Organization, 2001, ISBN 9241546425
X-ray equipment maintenance and repairs workbook for radiographers & radiologic technologists, World Health Organization, 2004, ISBN
9241591633
Quality Control Recommendations for Diagnostic Radiography Conference of Radiation Control Program Directors Inc. CRCPD, Volume 2,
2001
Quality Control Recommendations for Diagnostic Radiography, Volume 3: Radiographic or Fluoroscopic Machines, Conference of
Radiation Control Program Director Inc. CRCPD Publication 01-6 (July 2001)..
Quality Control in Diagnostic Radiology, American Association of Physicist in Medicine AAPM, Report No. 74. ISBN 1-888340-33-9
Basic Quality Control in Diagnostic Radiology, American Association of Physicist in Medicine AAPM, Report No. 4, 1981
Compliance Guidance for Fluoroscopic Quality Control, New Jersey Department of Environmental Protection, Bureau of Radiological
Health

56. References
Quality Control Program Department of Radiology, X-Ray Equipment Procedure manual, Mary Hitchcock Memorial Hospital Dartmouth-
Hitchcock Medical Center Lebanon, new Hampshire, June 2009
A. Dimov, J. Vassileva, Quality Control Of The X-Ray Fluoroscopy Equipment In The Period Of Their Clinical Use - Methods And First Results,
National Centre of Radiobiology and Radiation Protection, Sofia, Bulgaria
Charles R. Wilson, Ph.D., F.A.C.R., American College of Radiology ACR Radiography and Fluoroscopy Accreditation.
https://www.inlandimaging.com/what-is-a-radiologist
M.A. Périard and P. Chaloner, Diagnostic X-Ray Imaging Quality Assurance: An Overview, X-Ray Section, Consumer And Clinical Radiation
Hazards Division Radiation Protection Bureau, Environmental Health Directorate Health Protection Branch, Health Canada
Quality Control Programme for Radiodiagnostic Equipment: Acceptance tests, the radiation protection and nuclear safety authorities in
Denmark, 1999 ISSN: 0804-5038
https://www.acr.org/Quality-Safety/Radiology-Safety/Patient-Resources/About-Radiology
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