RT 118

Quality Assurance and Quality

Control
 Course Description :

Study of organized effort in the management of a

radiological facility to ensure consistent production of
high standard of quality images with minimum
exposure to patient and personnel.
Course Objective :

At the end of the course, student is expected to have

a general understanding of a good quality assurance
program in medical imaging through a predetermined
criteria of minimizing patient radiation exposure,
maximizing film quality, reducing retake, optimizing
the use of the staff as well as an ongoing assessment
of variable that could affect image quality and
diagnosis.
Course Outline :

I. Overview

( 6 Hours Lec.; 8 Hours Lab. )

1. Diagnostic procedure chain

2. Quality Assurance process
3. Requirements of a Quality Assurance and Quality
Control
II. Quality Assurance and Quality Control Tests.

1. Darkroom quality control and standard darkroom

processing techniques

1.1. Basic test for darkroom facility

1.2. Darkroom quality control
1.3. Test for assessing the speed of film and film-screen
combination
1.4. Test for darkroom fog and safelight
1.5. Standard darkroom processing technique
2. Departmental standards for radiographic image
quality

3. Conduct of film analysis

3.1. Repeat analysis

3.2. Analysis of rejected versus repeated film
3.3. Determination of rejection rate
3.4. Distribution of rejection rate
3.5. Guide to good practice
4. Viewing conditions ( view boxes )

5. Intensifying Screen and Cassette

5.1. Efficiency
5.2. Screen contact
5.3. Cassette design
6. Radiographic equipment quality control tests

6.1. Peak kilovolt accuracy

6.2. Exposure time and milliamperage-second test tool
6.3. Focal spot size
6.4. X-ray output/half-value layer
6.5. Collimator alignment
6.6. Automatic exposure termination
6.7. Beam alignment
6.8. Focus of optical system
6.9. Automatic brightness system
6.10. Aluminum step wedge

7. Standard radiographic technique chart

Introduction :
In a medical diagnostic radiographic imaging system
there are numerous sources of variability. These
sources can produce sub-quality images if they are
not controlled. Most sub quality radiographs often
require repeat examinations resulting in additional
radiation exposure to the patient and an increased
cost to the department.
Quality assurance is the organized effort of a facility
to ensure the high standard of quality of its product.
For x-ray diagnosis, the facility is a medical x-ray
facility or x-ray department while the final product is
a radiograph.
The radiographic image quality provides the
information about the medical condition of the
patient required for his/her diagnosis.
 The Consumer-Patient
Radiation Health and
Safety Act of 1981
 established guidelines for further reducing
unnecessary patient exposure.
 this act addressed issues such as unnecessary
repeat examinations, quality assurance, techniques,
radiation exposure, referral criteria, and unnecessary
mass screening programs.
 in addition, the act established minimum standards
for accreditation of educational programs in the
radiologic sciences and for the certification of
radiographic equipment operators.
actors Affecting Image Quality
1. Processing Condition:
chemistry processor condition
time temperature
2. Patient
anatomy
pathology ( what is to be
physiology image)
3. Image Receptor

film
screen
screen film contact
4. Geometric Variables

target film
distance / object geometric distortion object distortion
film distance
5. Technique Variables

kVp mA / time focal spot size exposure

6. Motion
tube image receptor
patient
7. View Conditions
room light View box light
8. Observer/ Interpreter
Quality Assurance Versus Quality
Control
Radiographic quality assurance and radiographic
quality control are terms that are often used
synonymously. Both terms are concepts that define
a mechanism used to enhance the quality of the
services and products rendered. Their main
Radiographic
difference quality
is the scopeassurance encompasses the
of their intent.
total picture of radiographic care delivery with its
primary objective being the enhancement of
patient care.
The Joint Commission for Accreditation of
Healthcare Organization (JCAHO) uses this quality
assurance concept in their hospital accreditation
process.
uality Assurance / Quality Control Program
 Quality assurance as applied to medical
radiography is the organized effort of the staff to
ensure that the diagnostic images produced are
of
itshigh quality.
purpose is to provide adequate diagnostic
information with the least possible cost and the
least possible radiation exposure to the patient
and staff.
 Quality control refers to the sets of controls on
the physical aspects of providing radiology
services.
A quality control program monitors the factors
that control the production of a radiograph to
detect any changes that may adversely affect
 A good quality control program is
concerned with the following
1. minimizing the patient's radiation exposure

2. maximizing film quality

3. reducing repeat exposure

4. optimizing the use of staff time

Benefits
The benefits of having a well-administered
radiographic quality assurance program are
numerous.

The use of such program in diagnostic radiology

facilities is one of the methods that can minimize
The radiologyradiation
unnecessary facility isto
also the beneficiary of
patient
quality assurance. Improvement of radiographic
image quality is achievable, as is increased
consistency of image production.

Quality control procedures can increase the

reliability, efficiency, and cost effectiveness of the
These are important gains, considering the current
emphasis on cost containment in health care
delivery. Although increased overall department
efficiency in itself is a major advantage, the
betterment of personnel morale resulting from such
improvements may be the most important benefit
The goal
in the is run.
long to provide a more effective and efficient
delivery of radiologic services along with a
reduction in unnecessary radiation to the patient.

With the proper planning, design, and management

of a quality assurance program, these benefits are
easily achievable.
10 Elements of Quality Assurance Program
1. Responsibility
 quality assurance is the responsibility of the
entire staff of the diagnostic radiographic
facility
 an efficient and effective quality assurance
program requires accountability.

 distinct and documented assignments of

responsibility for the program and its
components are essential for success,
 the size of the facility, scope of
program and available resources
are some of the factors that
dictate the levels to which these
responsibilities are assigned
(i.e., physicist, chief
technologist, supervisory
personnel, staff technologist,
and consultant.)

 regardless of facility size, the

primary responsibility for quality
assurance is that of the owner or
practitioner in charge.
2. Evaluation
the element of evaluation within a quality assurance program should
be addressed at different levels.
- the performance of the facility should be evaluated.
- this information can be used to determine the scope and design of
a quality assurance program for the facility and/or provide data
generated at future points in time.
- these comparison evaluations demonstrate the effectiveness of the
quality assurance program.
- the most popular procedure used to evaluate facility performance
is the analysis of rejected radiographs, commonly known as reject
analysis.
- on other level, equipment monitoring results should be evaluated
to assess the need for corrective action or to determine trends that
may indicate that preventive maintenance is required.
3. Purchase Specification

- when new equipment is

purchased, the facility should
determine the desired performance
criteria for the equipment.
- these performance criteria are
then reflected in the purchase
specifications.
- before final acceptance of the
equipment, it should be tested to
ensure that the actual performance
meets the criteria requested in the
purchase specifications.
- the future monitoring and testing of
the equipment can be compared to the
equipment performance criteria to
determine if the equipment is
continuing to perform at the acceptable
level.
4. Standards for image quality
- standards for image quality should
be established for the performance
parameters of the x-ray system that
are of interest to the facility.
- the creation of these standards
should, when possible, objectively
indicate the amount of performance
variation that can be accepted before
the quality of the image is affected.
- a subjective determination of the
standards is often used when objective
standards cannot be defined.

- if the equipment monitoring

results show the equipment does
not meet the acceptance limits of
the standard, then corrective
actions are needed and should be
taken.
5. Monitoring and maintenance

- this element is sometimes referred

to as the quality control portion of the
program.
- equipment monitoring and
maintenance is the center of a quality
assurance program.
- the NCDRH suggests that every facility
should consider monitoring the following
system components:
1. film processing
2. performance of
radiographic/fluoroscopic units
3. cassettes and grids
4. Illuminators
5. darkroom
- the system component parameters
that should be monitored vary from
facility to facility, depending on such
factors as program goals, available
resources, and cost.
- a maintenance program including
both the preventive and corrective
aspects of equipment maintenance is
an important aspect of any quality
assurance program.
6. Training
- a plan for the training of personnel with
quality assurance responsibilities is
recommended
- a mechanism for the continuing education
of these individuals should also be included.
- a subtle but important aspect of this
element is educating the facilities staff to
the importance, design, and goals of the
quality assurance program
- the real strength of a quality assurance
program is based on the support and
7. Committee
- this element might better be described as
communication.
- large facility may require a QA committee
structure for planning, review, and evaluation
purposes.
- smaller facilities may not require a formal
committee but instead rely on input
directly from the staff.
- the intent of this element is to emphasize
the importance of maintaining open
communication among all participants in
8. Records
- the documentation of equipment
monitoring results, maintenance
actions, and other such activities
should be included in a QA program.

- a regular and systematic method of

collecting and recording data is the
foundation on which the review and
evaluation elements of the program are
based.
9. Manual
- a QA program should develop and maintain
a complete, comprehensive, and up-to-date
manual.
- the manual should serve as a source
document or guide for all the elements of
the program.
- the manual should include items such as
quality assurance personnel, monitoring
procedures, monitoring schedules,
monitoring evaluations, corrective actions,
and service records.
10. Review
- periodic review is necessary to determine
the status of the QA program
- a look at the entire program will determine
if it is operating at its maximum
effectiveness or if changes have to be made.
- inspection of the important program
elements will reveal their currentness,
appropriateness, consistency, regularity, and
effectiveness in achieving the
Quality assurance consists of
Quality Administration and Quality
Control.
• Quality administration procedures should
are the managerial functions initiated to
ensure that quality control measures are
performed according to predetermined
criteria.
• Results of such procedures should be
critically reviewed and corrective action
implemented when appropriate.
• Quality control refers to the sets of
controls on the physical aspects of providing
radiology services. A quality control program
monitors the factors that control the
production of a radiograph to detect any
changes that may adversely affect
radiographic quality.
A good quality control program is concerned
with minimizing the patient's radiation
exposure, maximizing film quality, reducing
repeat exposures, and optimizing the use of
staff time.
The program serves to control the
technical quality of the radiograph while
at the same time keeping radiation
exposure at the minimum. It involves
routine testing that ensures the proper
functioning of film processors, x-ray
generators and other devices associated
with recording or displaying an x-ray
image.
Requirements of a QA/QC Program
The QA/QC program requires the combined
efforts of the whole radiology staff. Every
staff member must therefore be motivated
and interested in the establishment and
maintenance of an effective QA/QC program.

A hospital QA/QC committee and a QA/QC

team must be created to institutionalize the
program. The roles and responsibilities of
each person in the committee must be
clearly defined.
• The persons included are the following:

For the hospital QA/QC team

1. hospital chief radiologist - head of the x-

ray section/department
2. chief x-ray/radiologic technologist
3. hospital physicist
4. other radiologist and radiology resident physicians
5. other x-ray/ radiologic technologist
For the hospital QA/QC committee
1. chief of hospital
2. administrative officer
3. chief radiologist
4. chief x-ray/radiologic technologist
5. chief physicist
6. hospital maintenance engineer/technician
7. others
• The responsibilities of these
groups are as follow:
Hospital QA/QC team
1. do periodic film analysis and prepare
monthly film analysis report for
presentation to the QA/QC Committee.

2. Establish additional radiographic

technique charts when needed, or revise
existing technique charts when
appropriate.
3. Establish additional darkroom processing
charts or revise existing ones when necessary.

4. do periodic quality control tests of x-ray

equipment, accessories, and darkroom equipment
and accessories.
5. keep a room logbook which contains all test
data on equipment, accessories and all
changes/repairs done to all
equipment/accessories in the room, sample
images, procedures for QC tests,etc.
6. keep all brochures and technical manuals
pertaining to equipment and accessories.
 Hospital QA/QC Committee
1. meet regularly to discuss film analysis report, QC
test results, other reports and problems of the x-ray
department/section.
2. decide on corrective action to be implemented and
on other matters related to the program.
3. keep a record of minutes of meetings.

- The creation of these groups within the hospital

should be formalized with the issuance of a hospital
order signed by the hospital chief.
 The following should be considered in
planning and establishing a QA/QC
program in medical radiography.
1. commitment and support of radiology personnel
to sustain the program.
2. establishment pf standards of image quality to
categorize radiographs as good, poor, or reject.
3. conduct of film analysis every month to identify
causes or problems of radiographic quality.
4. establishment of standard darkroom techniques and
conduct of darkroom quality control checks to
standardize film processing techniques and maintain
5. conduct of preventive maintenance and
quality control checks/tests.

6. establishment of protocols in performing

different examinations to standardize
radiographic techniques.
7. establishment of a radiation safety program
for personnel and patient.

8. conduct of continuous education and

training.
IMAGE QUALITY, FILM ANALYSIS
AND DARKROOM QUALITY
CONTROL
A. Departmental Standards for
Radiographic Image Quality
In order to produce high quality radiographs,
standards of quality should be set against which the
results of a given radiological study may judge as
GOOD or REPEAT/REJECT. For developing countries
with scarce resources, such as the Philippines, some
facilities/departments may include a third category in
their standards, which are POOR quality images.
These are radiographs with inferior quality images
but which may still contain certain information that is
The x-ray/radiologic technologists
who will perform the study should be
familiar with the criteria/standards of
image quality set by radiologists.
• Some of the things to be considered in
setting up standards:
1. Evidence of proper collimation on all sides
of the radiograph.

2. Evidence of the use of gonadal shield,

where appropriate.
3. Image density and contrast appropriate for the
visualization of the anatomy of interest.

4. Absence of image degradation due to patient motion

or artifacts due to poor film processing, old screens,
etc.

5. Adequate display of anatomy of interest for the

examination.

6. Evidence of markers to properly identify the

patient’s left and right anatomy, hospital name, patient
number, date, etc. It would be a good practice to have
• Specific standards for image quality may
also be made available for the following:
1. Chest x-ray examination
2. General radiographic examination
3. Orthopedics
4. Emergency/trauma cases
5. Gastro intestinal studies
6. Urography
7. Pediatrics examination
8. General special procedures
9. Mobile x-ray examination
10. Other special x-ray examinations
b. Conduct of Film Analysis

One of the main goals of a quality control

program is to reduce the number of poor and
rejected radiographs. Periodic film analysis
determines the problems and analyzes the
cause leading to poor and rejected
radiographs.
Film analysis is the subjective evaluation of
image quality based on the
standards/general requirements for good
and rejected radiographs set by the x-ray
department.
- To evaluate the problems leading to poor
image quality and film rejects;
- To serve as a self-improvement tool for the x-
ray facility staff; and
- To establish a management data base.
Film analysis should be done regularly (weekly
or monthly). It is done by the radiologic
technologist or the radiologist following these
procedures:
1. Collect all radiographs for the desired period and
determine the number of rejects, poor radiographs
and the actual number of radiographs used during
this period.

2. Together with a radiologist, analyze all of the films

and determine the single contributing/major problem
for each radiograph. Record the number of these
radiographs on the film analysis form.
3. As the radiologist reads the radiographs for
clinical diagnosis, he can also note down the
problem. The radiologic technologist will collate
and record these problem in the form.

4. Determine the overall reject rate while reviewing

the film by making use of the following formulas:

% 𝒓𝒆𝒋𝒆𝒄𝒕 𝒇𝒊𝒍𝒎=𝒕𝒐𝒕𝒂𝒍¿𝒐𝒇 𝒓𝒆𝒋𝒆𝒄𝒕𝒔 ¿ 𝒐𝒇 𝒇𝒊𝒍𝒎𝒔𝒖𝒔𝒆𝒅¿

𝒕𝒐𝒕𝒂𝒍¿

% 𝒑𝒐𝒐𝒓 𝒇𝒊𝒍𝒎=𝒕𝒐𝒕𝒂𝒍¿ 𝒐𝒇 𝒑𝒐𝒐𝒓 𝒒𝒖𝒂𝒍𝒊𝒕𝒚 𝒇𝒊𝒍𝒎𝒔 ¿ 𝒐𝒇 𝒇𝒊𝒍𝒎𝒔𝒖𝒔𝒆𝒅¿

𝒕𝒐𝒕𝒂𝒍¿

% 𝒈𝒐𝒐𝒅 𝒒𝒖𝒂𝒍𝒊𝒕𝒚 𝒇𝒊𝒍𝒎=𝒕𝒐𝒕𝒂𝒍¿𝒐𝒇𝒈𝒐𝒐𝒅 𝒒𝒖𝒂𝒍𝒊𝒕𝒚 𝒇𝒊𝒍𝒎𝒔 ¿ 𝒐𝒇 𝒇𝒊𝒍𝒎𝒔𝒖𝒔𝒆𝒅 ¿

𝒕𝒐𝒕𝒂𝒍¿
After the department standards on
radiographic quality have been established,
film analysis must be done to have baseline
data before starting the QA/QC program.
The result of the film analysis will
determine what problems affect the
technical quality of the film.
c. Darkroom Quality Control and
Standard Darkroom Processing
Techniques
The entry point for quality control monitoring is the
darkroom where the latent image is converted into
permanent image of a radiograph.

Most of the problems identified in film analysis is

mishandling of films during storage, loading/
unloading, and processing. Since these problems
take place in the darkroom, corrective actions
should be undertaken.
O Basic Test for Darkroom Facility
1. CLEANLINESS
a. Keep the room clean. Loading bench tops
and other darkroom accessories must be
used only for specific purposes.

b. Promptly wipe off chemical spills on the

loading bench, cassettes, floor and walls.

c. Store fresh films, cassettes, hangers

and other accessories in a proper place.
Arrange and organize them systematically.
d. Provide a separate box for spoiled films

e. Provide a waste basket inside the

darkroom.

f. Clean the master and insert tanks

properly before mixing processing
chemicals.
2. LIGHT LEAKAGE

a. Check for the presence of light leaks

inside the darkroom, paying particular
attention to the
surrounding doors, windows and exhaust
fans where pipes enter and leave the
darkroom.

b. Inspect the doors and windows, etc., from

the position where films are handled.

c. Correct light leaks immediately. Seal

3. WATER SUPPLY

a. Check for the adequate supply of fresh

water.

b. Provide running water for rinsing and

washing films.

c. Check for drainage clogging especially in

processing tanks.
4. VENTILATION

a. Have proper darkroom ventilation. An

electric fan or air-conditioning unit must
be installed and cleaned periodically.

b. Install an exhaust fan with a light tight

cover. This must be cleaned periodically.
5. PROCESSING SOLUTION

a. Stir processing chemicals at the start of the day.

b. Paddles must be clearly identified. Use the fixer

paddle only for the fixer and the developer paddle
only for the developer.

c. Cover each processing tank when not in use.

d. Check for the level of the processing solution on

each tank. If the solution level is low, never add
water to bring solution to desired level. Use a
replenisher solution, when available.
o Darkroom Quality Control

1. FILM HANGERS
Equipment needed:
Hand brush

To keep the hangers clean and in good shape, follow

these procedures:
a. Scrub film hangers with a hand brush using hot
water to remove chemicals.
b. Rinse and dry
c. Check for any damage to clips, distorted shape or
broken corners.
2. FILM VIEWER
Equipment needed:
Mild soap and soft cloth

For better viewing of radiographs follow these procedures:

a. Unplug the film viewer.
b. Clean the viewer (front) with damp cloth. Dry the viewer
completely with a clean soft cloth.
c. Make sure that all the fluorescent tubes are operating
correctly and provide an even overall illumination. Fluorescent
tubes should always be checked and cleaned.
d. The inside of the film viewer box and the back of the glass
front should be cleaned by an electrician or any other
authorized person every six (6) months.
3. DARKROOM LUMINOUS INTERVAL TIMER
Equipment needed:
Darkroom interval timer
A watch or another clock

This should be checked weekly to make sure that it measures

the time accurately and indicates clearly when the selected
time is over.

Procedure:
a. Under white light illumination, set the interval timer to be
checked to the usual developing time. Look at the clock as
soon as the starting lever or button of the interval timer is
operated. The interval timer clock will continue for the set time
and will sound the alarm when the time is complete.