FRCR: Physics Lectures

Diagnostic Radiology
Lecture 9
Quality Assurance (QA) of radiographic
systems
Dr Tim Wood
Clinical Scientist

Overview
What is QA?
The life cycle of X-ray imaging systems

The critical examination

Acceptance testing
Commissioning
Routine performance testing

IPEM Report 91
Recommended tests by modality a whistle stop tour

The role of Medical Physics in Diagnostic

Radiology

What is QA?
Qualityassurance
A programme for the systematic
monitoring and evaluation of the various
aspects of a project, service or facility to
ensure that standards of quality are being
met
Merriam-Webster's Medical Dictionary, 2007 Merriam-Webster, Inc.

What is QA?
It is a requirement under the Ionising Radiations
Regulations 1999 (Reg. 32(3)-(4)) to
make arrangements for a suitable quality
assurance programme to be provided in respect of
the equipment or apparatus for the purpose of
ensuring that it remains capable of restricting so far
as is reasonably practicable exposure to the extent
that this is compatible with the intended clinical
purpose or research objective.

What is QA?
Regulation 32 also requires;
Adequate testing before entering clinical service
(commissioning)
Adequate testing at appropriate intervals and after
any major maintenance procedure (routine)
Measurements at suitable intervals to enable
assessment of representative doses to persons
undergoing medical exposures

What is QA?
The regulations use lots of vague terms like
suitable, adequate and appropriate
Deliberate due to range of equipment the regulations
have to cover

The Approved Code of Practice gives slightly

more detail
Depends on the nature and range of equipment in use
The QA programme should specify the frequency of
any testing and appropriate actions levels
Inestablishingtheselevelstheemployershould
takeintoaccountguidanceestablishedby
relevantprofessionalbodiesaboutcriteriaof
acceptability

What is QA?
In devising the QA programme, pay special
attention to equipment for;
Children
Health screening programmes
High dose procedures, such as interventional
radiology, CT or radiotherapy

The employer should consult their RPA when

devising the QA programme
Note QA, does not just cover the equipment, but
also procedures, etc (as required under
IR(ME)R)

The life cycle of X-ray imaging

systems
There are essentially four stages of checks
applicable to X-ray imaging systems;

Critical examination
Acceptance
Commissioning
Routine performance testing

Maintenance is vital throughout

The life cycle of X-ray imaging

systems

The Critical Examination

Under IRR 99 Reg 31(2), the installer is
required to perform a criticalexamination of
any new installation
The purpose of the critex is to ensure all safety
features and warning devices work correctly
Also includes tube leakage, total filtration, etc

Primarily related to radiation protection features

that affect staff and visitors, but some impact on
patient safety too
Employer must not allow the equipment to go
into clinical service until the results of the critex
are satisfactory

Acceptance testing
Verify that the contractor has supplied all the
equipment specified and has performed
adequate tests to demonstrate specified
requirements are met
May be a simple check list
Mechanical and electrical safety checks also
required

Commissioning
Set of tests performed by a representative of the
employer (usually Medical Physics), to ensure
the equipment is ready for clinical use, and to
establish baseline values against which routine
QA can be compared
Commissioning tests may need to be repeated
during the life of the system if any major
maintenance is undertaken e.g. new X-ray tube
New baselines may need to be established

Routine testing
Regular tests throughout the lifetime of the
equipment
Looking for changes in performance that
indicates remedial action required
Generally, routine are a subset of the
commissioning tests

IPEM Report 91
The Institute of Physics and
Engineering in Medicine (IPEM)
produce a series of reports related
to medical equipment QA
The most useful for Diagnostic
Radiology is IPEM Report 91
Recommended standards for the
routine performance testing of
diagnostic X-ray imaging systems
(2005)

Relates primarily to imaging

performance and radiation safety
checks

IPEM Report 91
The report is split into chapters on different
modalities
Each chapter starts with a summary table of;
Thephysicalparametertobetested
Frequency varies from daily to three yearly
Priority level 1 is essential for good practice; level
2 is not essential, but considered best practice
Levelofexpertiserequired level A applies to
frequent and relatively basic tests performed by
Radiographers; level B tests are less frequent, but
require greater expertise and more complex
equipment (Medical Physics tests)
Actionlevels split into Remedial and Suspension
(see later)

IPEM Report 91
Each test is then described briefly,
with appropriate references to other
documents, such as the IPEM Report
32 series
These are a series of reports that give
much greater detail on the method for
testing systems e.g. X-ray tubes and
generators, fluoroscopy, CT, etc

IPEM Report 91
RemedialLevel:
A level of performance at which remedial
action is required, but the unit may continue to
be used in the mean-time
The action will be based on a risk assessment
of the equipments performance and the risk
arising should it continue to be used
Following assessment, a timescale must be
agreed and restrictions on its use followed

IPEM Report 91
SuspensionLevel:
A level of performance at which it is
recommended the equipment is removed from
clinical use immediately
Not all tests have suspension levels set due
to the subjective nature of the test e.g. image
quality

IPEM Report 91
IPEM 91 also emphasises that;
A senior radiography or other suitable person should
be appointed to supervise the QA programme
Time should be allocated to staff and equipment for
testing
AllQAtestsshouldbedocumentedaspartofthe
QAprogramme may be required as evidence
presented to the HSE inspectors
Results and remedial actions must be followed up
promptly
Test equipment should be available and within
calibration (annual recalibration usually required for
dosemeters)

A whistle stop tour of IPEM 91

X-ray tubes and generators

(Chapter 3)

LevelA
X-ray/light beam alignment and centring
Light beam/bucky centring
Field size calibration
Distances and scales
Radiation output repeatability and
reproducibility (small range of settings)

X-ray tubes and generators

(Chapter 3)

LevelB
Radiation output repeatability and
reproducibility (larger range of settings)
Exposure time
Tube potential

Film/screen radiography,
processors and AECs
(Chapter 4)

LevelA
Developer temperature, fog, film speed,
contrast index, replenishment, pH, silver
content
Intensifying screens and darkroom checks
AEC guard timer and resulting film OD

Film/screen radiography,
processors and AECs
(Chapter 4)

LevelB
Only AEC tests
Consistency between chambers
Repeatability and reproducibility
Receptor dose

CR and DR
(Chapters 5 and 6)

LevelA:
Detector dose indicator monitoring
Uniformity
Condition of image plates (CR only)
Low contrast sensitivity
Limiting spatial resolution

CR and DR
(Chapters 5 and 6)

LevelB:(in conjunction with IPEM 32 Part VII)

DDI repeatability and reproducibility

Measured uniformity
Threshold contrast detail detectability
Erasure cycle efficiency (CR only)
Limiting spatial resolution
Scaling errors
Dark noise
Modulation transfer function (MTF)
Normalised noise power spectrum (NNPS)
AEC tests

Image display
(Chapter 7)
Filmviewers
LevelA general condition
LevelB luminance, uniformity,
variation between viewers, room
illumination

Monitors
LevelA general condition,
greyscale and resolution with test
patterns
LevelB DICOM greyscale
calibration, test patterns, uniformity,
variation between monitors, room
illumination

Mammography
(Chapter 8)
See also IPEM Report 89 The commissioning
and routine testing of mammographic X-ray
systems and the latest NHSBSP reports
NHSBSP Equipment Report 0604 for full field
digital testing
Lots of testing required!
Radiographer testing daily, weekly, monthly
Physics testing every 6 months

Mammography
(Chapter 8)
Example tests include;

Processing, where applicable

AEC
Limiting spatial resolution
Image quality with test phantoms
MGD to standard breast
X-ray beam alignment
Compression force
kV accuracy (specific calibrations)
Uniformity
Radiation output repeatability/reproducibility
And much more

Dental Radiography
(Chapter 9)
Processing tests
Temperature, solutions, stepwedge, light proofing

X-ray/detectortests
Tube voltage, exposure time,
collimation, dose at collimator tip
for IO, DAP for OPG, detector
condition, clinical image quality
compared with reference

Fluoroscopy
(Chapter 10)

LevelA
Dose rate reproducibility under ABC/AEC
Display monitor setup
Limiting spatial resolution
Threshold contrast
Radiation/image field size

Fluoroscopy
(Chapter 10)

LevelB
Dose rate at the entrance surface of a
phantom under ABC/AEC
Dose rate at the input face of the detector
under ABC/AEC
Limiting spatial resolution
Threshold contrast

Fluorography
(Chapter 11)

LevelA
Dose per image under AEC
Limiting spatial resolution
Threshold contrast

Fluorography
(Chapter 11)

LevelB
Dose per image at the input face of the
detector under AEC
Limiting spatial resolution
Threshold contrast
Dynamic range

Patient dose measurements

(Chapter 13)
Performdoseauditsand/orQAmeasurements
Individual radiographic exposures
Entrance surface dose or DAP > Diagnostic Reference Levels (DRLs)

Complete examinations
DAP > DRLs

Mammography
MGD to standard breast >2.5 mGy per film
MGD to patients >3.5 mGy per film

Dental Radiography
IO dose at collimator tip > DRL
OPG dose > DRL

Fluoroscopy
Dose at entrance surface of phantom > 50 mGy/min
DAP > DRL

CT
(Chapter 12)
Craig to cover

QA is important because
QA is important because

Can identify equipment deterioration

Can be used to achieve ALARP
Ensures patient (and staff) safety
Ensures legislative compliance

Final thought
Although its not your responsibility to check
equipment, you should ensure that the X-ray sets you
use have been checked for your own safety, as well
as the patients

The role of Medical Physics in

Diagnostic Radiology
QA
Level B tests
Advising on QA programme and monitoring performance

Radiationprotectionandphysicsadvice
(RPA/MPE)
Ensuring compliance with relevant regulations e.g. risk
assessments, controlled areas, dose monitoring, etc
IRR and IR(ME)R audits make sure were ready if the
inspector calls!
New installations shielding, testing, etc
Notification of incidents to the CQC, HSE, EA, Police, etc

Education
FRCR, Update Training, etc

The role of Medical Physics in

Diagnostic Radiology
Optimisation
We arent just here to interfere and police the
regulations!
Significant part of the Radiation Physics groups work
is looking at how we can get the most out of our X-ray
imaging systems
Rely on feedback and co-operation from Radiology to
ensure we are optimising exposures
Were here to help

Recent publications

ABeavis, JSaunderson, J Ward ,

WE-G-BRA-06: Calibrating an Ionisation Chamber: Gaining Experience Using
a Dosimetry flight Simulator
, Med. Phys. 39, 3970 (2012)
CSMoore, G Avery, S Balcam, L Needler, A Swift,AWBeavis,JR
Saunderson, Use of a digitally reconstructed radiograph based computer
simulation for the optimisation of chest radiographic techniques for
computed radiography imaging systems , Br J Radiol 2012;85 e630-e639
TJWood,AWDavis,CSMoore,AWBeavis&JRSaunderson,
Validation of a Large-Scale Audit Technique for CT Dose Optimisation ,
Radiat Prot Dosimetry (2012) 150(4): 427-433
CSMoore,GPLiney,AWBeavis,JRSaunderson, A method to produce
and validate a digitally reconstructed radiograph-based computer simulation
for optimisation of chest radiographs acquired with a computed radiography
imaging system, British Journal of Radiology, 84 (2011), 890-902
MLWilson,WPColley&AWBeavis, The effect of the carbon fibre insert
for the Varian Exact couch on the attenuation and build-up of high energy
photon beams, Journal of Radiotherapy in Practice (2011) 10, 77-83

Current Projects
Further development of our dose audit software
CT AEC optimisation with a custom built phantom
Development of a high skin dose reporting system
for interventional procedures
Development of a new test object for routine
image quality assessment in digital
mammography
And many more www.hullrad.org.uk