Download CT Technical Quality Assessment Policy

XXXX Facility
CT Technical Quality Assessment
EFFECTIVE DATE: May 29, 2012
PURPOSE: To outline the processes that are internally reviewed on a quarterly basis via establishing thresholds for
compliance and implementing corrective action plans when necessary.
Clinical Image Quality
PROCEDURE:
1.
Our Quality Improvement (QI) Committee will conduct a random, quarterly review of 1% of the cases that were
performed for that given period. At a minimum we will examine the image quality (clinical image quality, not
the QC phantom images) and assess for proper protocol selection for the given clinical indication;
a.
b.
c.
d.
e.
f.
g.
h.
2.
thorough coverage of the anatomy of interest;
proper positioning of the anatomy of interest;
presence of patient motion on the images or any other artifacts;
correct bolus timing (if applicable);
images being properly labeled as post contrast (if applicable);
appropriate field of view;
proper adjustment of technical parameters (kVp, mAs, etc.) for the body habitus of the patient being
imaged; and
appropriate post processing and multi-planar reconstruction images (if performed) and correct transfer of
all images to PACS/film.
If it is determined that 10% of the cases are not of acceptable quality, corrective action will be taken. This may
include technologist training, imaging protocol modification or a consultation with the manufacturer’s
application specialist.
The documentation of adverse effects (incident reports) are reviewed and assessed for proper resolution.
3.
Patient Dose Tracking
PROCEDURE:
1.
Along with review of clinical image quality described above, patient dose will be assessed. This will include:
a.
b.
2.
Calculation of the average dose for each protocol utilized. This will be done by adding the doses for a given
number of cases for each protocol separately and then dividing by the number of the cases added for each
specific protocol.
Reviewing the documentation of repeat exams and technique adjustments for body habitus (if applicable)
that is recorded on the examination log for each case reviewed.
If it is determined that 10% of the cases demonstrate deviation from the average dose calculated, corrective
action will be taken. This might include technologist training, imaging protocol modification, consultation
with the manufacturer’s application specialist or medical physicist.
Appropriate Use Criteria
PROCEDURE:
1.
Measurement of the appropriate use of the diagnostic imaging examination based on the criteria published
and/or endorsed by professional medical organizations is conducted for the cases that are reviewed.
CT Interpretive Quality Assessment Policy (SAMPLE)
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Equipment Quality
PROCEDURE:
1.
2.
The daily, weekly, and monthly quality control documentation will be reviewed for inconsistencies. If any
inconsistencies are noted, the service engineer will be contacted to evaluate the equipment.
The annual physicist’s dose assessment and image quality assessment will be reviewed at the meeting following
the date of the annual testing. The service engineer’s preventative maintenance (PM) report will be reviewed at
the meeting following the date of the PM. Any issues or suggestions noted by either the service engineer or the
medical physicist will be discussed and addressed.
Administrative Quality
PROCEDURE:
1.
2.
3.
Scheduling backlogs and excessive patient wait times will be reviewed. If it is noted that our pre-established
thresholds have been exceeded, a corrective action plan will be implemented.
A given number of final reports will be reviewed to assess for compliance with our four business day
turnaround requirement. If it is noted that our pre-established thresholds have been exceeded, a corrective action
plan will be implemented.
The results of the patient satisfaction surveys and any patient complaints will be reviewed.
Documentation of the reviews described above along with the meeting minutes will be maintained and made
available to all staff for review.
Written by:
Revised by:
Reviewed by:
Reviewed by:
CT Interpretive Quality Assessment Policy (SAMPLE)
Date:
Date:
Date:
Date:
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