QAQC

Quality Management To control or minimize the variables that affect the quality of
Program radiographic images
quality care providing patients in a technically competent manner, with good
communication, shared decision-making, and cultural sensitivity
3 Levels of quality:
Expected Quality - Level of quality of product or service that is expected by the
customer.
- Least amount of impact for Radiologic Technologists
Perceived Quality - Based on the customer’s perception of the product or service
- How long the patients had to wait, How the patients were treated,
How well the radiologic technologists performed his or her
responsibilities
Actual Quality - Measures outcome and considers all factors that can influence the
final outcome
- Quality of Image, Accuracy of diagnosis
In the diagnostic imaging department, we can ultimately define quality as the extent to which the
right procedure is done in the right way and at the right time
History:
FLORENCE NIGHTINGALE • Earliest known methods of evaluating
(1980) the quality of clinical healthcare by
assessing patient outcomes
• First to use systematic approach to collecting
and analyzing mortality rates in hospitals.
FREDERICK WINSLOW • Early 1900s – 1980s
TAYLOR (1900s – 1980s) • Origins of modern quality management
• “Father of Scientific Management”
• Planning and execution stage must be separated
• Assigning of specific tasks to numerous individuals to minimize the
complexity of the task to maximize the efficiency.
• Used in the US
W. Edwards Deming and • Quality Improvement began to gradually replace the concept of
Joseph Juran (1980s) scientific management.
• Used the quality improvement philosophy to revitalize the economy
of Japan after the World War II

1930s • Start of systematic monitoring equipment of diagnostic imaging

departments, independent of any government regulation or
accreditation agency.
• Main motivations were to save money and increase efficiency and
quality of care
1992 • Accreditation Manual for Hospitals by TJC
• Began a multiyear transition to standards
that emphasize performance improvement
 concepts inspired by the work DEMING and
JURAN
LATE 1990s • NATIONAL ACADEMY OF SCIENCES-INSTITUTE OF MEDICINE (IOM)
• Began researching how healthcare is delivered in the US
• MARCH 2016: change of name into: NATIONAL
ACADEMY OF SCIENCES-HEALTH AND MEDICINE
DIVISION (NAS/HMD)
• A non-profit agency based in WASHINGTON DC; not connected with
the government, business, educators, and healthcare professional
Quality Assurance - An all-encompassing management program used to ensure
excellence in healthcare through systematic collection and evaluation
of data
- Enhance patient care
- Patient selection parameter
- Scheduling
- Management technique
- Departmental policies and procedures
Quality Control - Is part of the QA program that deals with techniques used in
monitoring and maintaining the technical elements of the systems that
affect the quality of the image.
- Deals with instrumentation and equipment
3 levels of testing;
Level I: Noninvasive and • Can be performed by any technologist and include tests such as the
Simple wire mesh test for screen contact and spinning top for timer accuracy.
Level II: Noninvasive and • Should be performed by technologist who has been specifically
Complex trained in QC procedures.
• More sophisticated equipment, such as special test tools, meters or
the Noninvasive Evaluation of Radiation Output (NERO) computerized
multiple function unit, is used.
Level III: Invasive and • Involve some disassembly of the equipment and are normally
Complex performed by engineers or physicists.
3 TYPES OF QUALITY CONTROL TESTS ON VARIOUS LEVELS
ACCEPTANCE TESTING • Performed on a new equipment or equipment that has undergone
major repair to demonstrate that it is performing within the
manufacturer’s specification and criteria.
• It also can detect any defects that may exist in the equipment.
• Results from this test are used to establish the baseline
performance. And may be used as a reference point in future quality
control testing.
• Must be done by someone other than manufacturer’s
representative.
ROUTINE PERFORAMCE • Special tests performed on the equipment in use after a certain
amount of time has elapsed.
• These evaluations can verify that the equipment is performing within
previously accepted standards and can be used to diagnose any
changes in performance before becoming radiographically apparent.
ERROR CORRECTION TESTS • Evaluate equipment that is malfunctioning or not performing at the
manufacturer’s specifications and also are used to verify the correct
cause of the malfunction so that the proper repair can be made.
DIAGNOSTIC PROCEDURE • Are series of steps which would result into a an end product
CHAIN (RADIOGRAPH)
• This may vary per institution meaning no institution has the same
procedure chain
Standards, Regulations, and Quality Management
DOH-FDA • Radiation Safety Standards and Requirements on the Operation of
Diagnostic and Interventional X-ray Facilities
• The requirements and guidelines needed for putting up an X-ray
Facility
• ONE of the objectives: Provide the guidelines in fulfilling a Quality
Assurance Program
• GENERAL GUIDELINES: 6. Every x-ray facility shall have an x-ray
device that is tested to perform safely. A preventive maintenance
program shall be provided to ensure that the x-ray equipment is
functioning properly.
• ADMINISTRATIVE REQUIREMENTS: establishment of QA committee
to provide periodic review and evaluation of the facility’s QA program.
• MANPOWER REQUIREMENTS:
• For Level three x-ray facilities, the licensee shall designate a QUALITY
CONTROL TECHNOLOGIST
• QUALITY ASSURANCE PROGRAM must contain: • A QUALITY
MANUAL has to be prepared which shall be realistic and regularly 5
reviewed for relevance to existing practices. This shall be made
available during the conduct of Radiation Protection Survey and
Evaluation and Facility Compliance Monitoring.
DUTIES AND RESPONSIBILITIES OF A QUALITY CONTROL TECHNOLOGIST
• All staff in the radiology department should be involved in quality control. However, specific tests
are usually performed more effectively by specially trained technologists. The amount of time spent
on QC should be adequate to perform the functions required for an effective quality control program.
QC technologists should be allowed to devote at least 50 per cent of their time to a QC program in
small institutions (200 beds or less) and full time in larger institutions. Institutions with more than 500
beds may require additional help. Among the activities of the QC technologist(s) should be to:

1. Carry out the day-to-day QC tests on the department's photographic, radiographic and fluoroscopic
imaging equipment as prescribed by the QC test schedule;
2. Record and/or chart the QC test measurement data;
3. Evaluate the test results;
4. Report any deterioration or trends in equipment performance to the radiology manager and staff
using the equipment;
5. Initiate prompt corrective action and/or preventive measures when necessary;
6. Oversee the repair of defective equipment performed by the hospital biomedical or electronic
maintenance staff or by private service companies;
7. Perform the required tests to confirm that defective equipment was repaired and restored to the
original level of performance;
8. Maintain equipment performance records;
9. Provide monthly reports on QC activities to the radiology manager; and
10. Develop new QC monitoring and maintenance procedures as required
Components of a Quality Management Program in Diagnostic Imaging
EQUIPMENT QUALITY Aspect of quality management program which involves evaluation of
CONTROL equipment performance to ensure proper image quality
ADMINISTRATIVE Involves the establishment of various processes to accomplish the
RESPONSIBILITIES specific departmental tasks that are required
THRESHOLD OF Includes levels of accuracy, sensitivity and specificity of diagnosis
ACCEPTABILITY
COMMUNICATION  Deals on how to communicate proper with other departments
NETWORK staff (other members of the healthcare team)
 Report dictation, transcription and distribution to the ordering
physician
PATIENT COMFORT  Including their convenience and privacy should be provided
within the imaging department

 Factors which affect PATIENT COMFORT should be monitored

regularly such as:

 Patient scheduling, preparation, waiting time, ambient room,

temperature and politeness and consideration of personnel

 Patient satisfaction survey is method on how to monitor

patient comfort
PERSONNEL PERFORMANCE  Deals with if imaging staff are performing their duties within
accepted professional standards for areas such as proper
equipment operation critical thinking and interaction with
other patients and other personnel
 Other forms of assessing personnel performance is REPEAT
ANALYSIS
 Personnel education programs may also be included and
documented to improve performance and maintain staff
competency
RECORD-KEEPING SYSTEM Necessary to document that quality management and quality control
procedures are being implemented and that they are in compliance
with accepted norms
CORRECTIVE ACTION  Performed on equipment or personnel which are not
performing to accepted standards
 Proper documentation of equipment downtime and failure
 Education for staff for corrective action procedures
RISK MANAGEMENT Ability to identify potential risks to patients, employees and visitors at
the healthcare institution and establish processes that would minimize
these risks is extremely important to healthcare organizations
Quality Improvement  Also known as STRATEGIC PLAN is an organizational plan that
Planning describes the goals and proposed activities of a particular
quality improvement program
  Serves as a roadmap for all other quality improvement
program activities and will require a structure to support its
function
 Should address performance measures, performance
measurement, and performance management, focusing on
core areas of clinical care, operations, and finance.
QUALITY IMPROVEMENT  A systematic process with identified leadership, accountability,
PLAN and dedicated resources
 Use of data and measureable outcomes to determine progress
toward relevant, evidence based benchmarks
 It should include:
1. A systematic process with identified leadership,
accountability, and dedicated resources
2. Use of data and measureable outcomes to determine
progress toward relevant, evidence-based benchmarks
 Focus on linkages, efficiencies, and provider and patient
expectations in addressing outcome improvement the
framework of other programmatic quality and quality
improvement activities
 Assurance that goals are accomplished and are concurrent
with improved outcomes based on the data that are collected
PERFORMANCE MEASURES Designed to measure systems of care and derived from clinical or
practice guidelines; serves as meter to measure of the quality of care
of an institution
PERFORMANCE Process by which healthcare organization monitors important aspects
MEASUREMENT of its programs, systems, and processes. Includes: operation processes
PERFORMANCE A forward looking process that is used to set goals and regularly check
MANAGEMENT progress toward achieving these goals
Quality Management Technologist Duties
1. Coordinating, performing, and
monitoring quality control procedures
for all types of equipment
2. Determining and monitoring exposure
factors and/or procedural protocols in
accordance with ALARA principles and
age-specific considerations
3. Ensuring adherence to federal, state,
and local regulatory requirements
4. Ensuring adherence to accreditation
requirements
5. Providing input for equipment and
software purchase and supply decisions
when appropriate or requested
6. Facilitating performance improvement
processes
7. Providing practical information
regarding quality management topics
8. Facilitating the department’s quality assessment and improvement plan
9. Facilitating change through appropriate management processes
10. Performing physics surveys independently on general radiographic and fluoroscopic
equipment (medical physicist oversight is required)
11. Supporting and assisting a medical physicist with modality physics surveys
12. Providing assistance to staff for image optimization, including patient positioning, proper
equipment use, and image critique
13. Creating policies and procedures to meet regulatory, accreditation, and fiscal
requirements
14. Serving as a resource regarding regulatory, accreditation and fiscal requirements
RADIATION SAFETY PROGRAM

 To ensure that all employees who administer ionizing radiation to patients are aware of this
responsibility
 Implementation of proper radiation safety protocols are mandated by the government
 Ensure that patient exposure is kept as ALARA
 Use of high kVp and low mAs
 Use of high-speed image receptor systems u Use of proper filtration
 Use of the smallest field size possible, along with proper collimation
 Use of optimum processing conditions u Avoidance of repeat examination
 Use of PA instead of AP projection for scoliosis series for young female patients
 Use of gonadal shielding
Fluoroscopic Examinations
Potential to deliver a considerable amount dose of radiation to the patient.
1. Ensure that the fluoroscopic system does not exceed maximum entrance exposure or air kerma
rates
2. Keep fluoroscopic milliampere and time
3. Use high kilovolt peak as possible
4. Limit field size as much as possible
5. Use intermittent fluoroscopy rather than continuous activation
6. Use the last-image-hold feature
7. Avoid magnification mode
8. Keep the patient-to-image intensifier distance as short as possible
9. Reduce the number of spot images
Visitor Protection
Persons other than patients or radiology department staff
1. Keep the x-ray door closed
2. Move at least 8ft away from the source Remain behind the protective barrier Wear protective
apparel
 Personnel Protection
1. Personnel who perform diagnostic procedures using ionizing radiation can potentially receive
significant amounts of radiation and must therefore follow proper radiation practices
2. Occupational radiation dosage should be monitored with a dosimeter obtained from a
licensed provider

Pregnancy of Radiation Personnel

 Declare pregnancy to the employer
 Second dosimeter should be issued
to act as fetal dose monitor
 Should not work with patients who have been treated with radionuclides
Cardinal Principles of TIME
Radiation Protection DISTANCE
SHIELDING
Process Improvement Through Continuous Quality Improvement
TOTAL QUALITY  Aka Continuous Quality Improvement
MANAGEMENT  A philosophy developed by Dr. W. Edward Deming
 One of the hallmarks of Japanese Management systems
 Assumes that production and service focus on the
 individual and that quality can always be better
 Based on the premise that the individual is the focal element
on which production and service depend and that the quest
for quality is an ongoing process
Total Quality Management Principles
1. Create a constancy of purpose for the improvement of products and service.
2. Adopt a philosophy of continual improvement
3. Focus on improving processes, not inspection of product
4. End the practice of awarding business on price alone; instead, minimize total cost by working with a
single supplier
5. Constantly improve every process for planning, production, and service.
6. Institute job training and retraining.
7. Develop the leadership in the organization.
8. Drive out fear by encouraging employees to participate actively in the process.
9. Foster interdepartmental cooperation, and break down barriers between departments.
10. Eliminate slogans, exhortations, and targets for the workforce.
11. Focus on quality and not just quantity; eliminate quota systems if they are in place.
12. Promote teamwork rather than individual accomplishments. Eliminate the annual rating or merit
system.
13. Educate/train employees to maximize personal development.
14 .Charge all employees with carrying out the TQM package.
85/15 Rule  85% of the problems in our work lay within the process itself
and are under the control of management.
 15% (or less) of process problems are under the control of
employees,
 This rule helped managers to think in terms of process
problems and ask "how" it happened and not "who" did it.
80/20 Rule  also known as the Pareto Principle,
 80% of outcomes (or outputs) result from 20% of all causes (or
inputs) for any given event.
 a goal of the 80-20 rule is to identify inputs that are potentially
the most productive and make them the priority.
 In the 80-20 rule, you prioritize the 20% of factors that will
produce the best results.
 A principle of the 80-20 rule is to identify an entity's best
assets and use them efficiently to create maximum value.
Processes and System of an Organization
PROCESS is an ordered series of steps that help achieve a desired outcome or all
the tasks directed at accomplishing one particular outcome grouped in
a sequence.
SYSTEM is a group of related processes. Identifying, understanding, and
managing interrelated processes contribute to the healthcare
organization’s effectiveness and efficiency in achieving its objectives.
PARTS OF THE PROCESS
SUPPLIER is an individual or entity that furnishes input to a process (e.g., person,
department, organization) or one who provides the institution with
goods or services.
INPUT is information or knowledge necessary to achieve the desired outcome
or everything that is used (mostly as variables) to produce one or more
outputs from a process.
Action is the means or activity used to achieve the desired outcome or the
steps or activities carried out to convert inputs to one or more
outputs.
OUTPUT Refers to the desired outcome, result, product, or characteristics that
satisfy the customer or one or more outcomes or physical products
emerging from a process
INTERNAL VS EXTERNAL CUSTOMERS
INTERNAL  A person that is a part of the company or has direct contact
with the company and purchases products from it is known as
an internal customer.
 An internal customer has a direct relation or contact with the
company or organization
 Radiographers, other healthcare workers
EXTERNAL  A customer that uses and pays for the items, products, or
services that a company or an organization offers is known as
an external customer.
 An external customer is a customer that does not have any
direct contact with the organization.
  Clients/Significant Others
KEY QUALITY Qualities or aspects that have been identified as being most important
CHARACTERISTICS to the customer

Referred to as HEALTHCARE METRICS

TYPES OF HEALTHCARE METRICS
Financial Tracks the financial performance of the healthcare system from a
business perspective
Utilization Characterize the number and type of basic services rendered, the
resources that are used and availability of care
Cost/Productivity Used to reduce supply/labor costs and increase productivity
Clinical Performance Also known as patient outcome data, these measure the quality of
patient care, such as mortalitiy (deaths) rates and accuracy of
diagnosis
Patient Safety Metrics that characterize preventable medical mistakes that are made
Patient Satisfaction Measure satisfaction from a patient’s perspective
KEY INPUT VARIABLES  Process inputs that have a significant impact on the variation
found in a key process output variable and the most
importance input (s) to a process
 Components of the process that we can directly control to
deliver a quality product or service
KEY OUTPUT VARIABLE  Measurable on, within or about the product or service itself
and are the attributes seen by the customer
 Process outputs that are affected by KIVs and are known
collectively as quality
 Has big impact on efficiency and/or customer satisfaction
MANPOWER Refers to the personnel involved in the process
MACHINES Refers to the equipment used in the process
MATERIALS Refers to the type and quality of materials used in the process
ENVIRONMENT Refers to the physical and psychological aspects on people involved in
the process
POLICIES Refers to the steps in the procedure or policy manual that have been
used in the process
Group Dynamics
BRAINSTORMING  is a group process used to develop a large collection of ideas
without regard to their merit or validity.
 leader of this session should encourage participation by
everyone, not criticize any contribution made, and record all
ideas for future assessment.
FOCUS GROUPS  a small group that focuses on a particular problem and then
hopefully derives a solution.
 the applicable ideas on a particular problem obtained from
brainstorming are considered in this smaller group, which can
come to a consensus.
 A focus group must have a skilled facilitator to be successful.
QUALITY IMPROVEMENT  a group of individuals who implement the solutions that were
TEAM derived by the focus group.
 MAY OR MAY NOT include members of the focus group
 Should have 6 to 7 members who are key customers or
suppliers or both
QUALITY CIRCLES  Normally composed of supervisors and workers who are from
the same department or who may have the same function in
the same department
 Scheduled to meet regularly and have the specific function to
identify potential problems
MULTIVOTING Used after a brainstorming to dismiss nonessential or norealistic ideas
and then concentrate on those that can realistically solve a problem
CONSENSUS  Another method that can follow a successful brainstorming
session
 After the initial ideas are formulated during the brainstorming
session, the group members, through discussion and
teamwork, come to an agreement on the most important idea
to be addressed.
WORK TEAMS  Teams focus on solving a complete problem or completing an
entire task, rather than focusing on any one particular step in
a process. Some work teams, known as self-managed teams (
SMTs )
 And composed of 6 to 18 persons and are empowered by
management to take any corrective action necessary to solve
the assigned problem or task.
PROBLEM-SOLVING TEAMS PROBLEM – defined as a gap between the current condition and the
target condition
Problem-solving teams should have a knowledgeable facilitator who is
responsible for teaching team members the appropriate problem-
solving tools for guiding them through process
Common RCA tools
5 WHYS This is a question-asking method developed by the Toyota Corporation
that is used to explore the cause-and-effect relationships that may
underlie a particular problem. Its ultimate goal is to determine the
root cause of a problem.
THOUGHT PROCESS MAP This is a question-asking method developed by the Toyota Corporation
that is used to explore the cause-and-effect relationships that may
underlie a particular problem. Its ultimate goal is to determine the
root cause of a problem.
Five Basic Steps of Thought Process Map
STEP 1: Define the project’s goal(s).

The project improvement team needs to clearly define what needs to be accomplished or what
problem needs to be solved. Brainstorming among the group is a good way to define the goal.

STEP 2: List the knowns and unknowns.

The team leader should use a large poster board or easel pad and make two columns one for what
the team knows and one for what the team does not know this can identify the amount and type of
data necessary to complete the project

STEP 3: Ask the group

Ask grouped questions or questions that define, measure, analyze, improve, and control (DMAIC).
Focusing on the unknowns from step 2, create questions from the categorical perspectives of DMAIC.

STEP 4: Sequence and Link the Questions

Link the questions using FLOWCHARTS

STEP 5: Identify Possible Tools to be used

This step involves identifying potential tools that can be used to answer questions posed in step 3
TJC 10 STEP PROCESS

Design  Systematic planning and implementation are key to the design

of any function or process
 When new functions and processes are being designed the
following should be take into consider
Measure  Collection of valid and reliable data to demonstrate
effectiveness and efficiency of care and performance
improvement
Assess Translating data collected during measurement into information that
can be used to change processes and improve performance. This is the
process of assigning meaning or determining the significance,
implications, and conclusions of data that have been collected
IMPROVE