Continuous Quality Improvement for Digital Radiography

  • Euclid Seeram


Continuous quality improvement is a process to ensure that every employee plays a role in ensuring a quality product, and it includes two major elements, quality assurance (QA) and quality control (QC). While QA primarily deals with the administrative aspects of patient care and quality outcomes, QC addresses the more technical aspects of equipment performance. Both QA and QC play major roles in dose optimization that is a radiation protection principle to keep the dose as low as reasonably achievable (ALARA) without affecting the diagnostic quality of the image. QC is a common activity of technologists, medical physicists, and radiologists working in a medical imaging department, and it involves at least three essential tasks: that of acceptance testing, routine performance, and error correction. Furthermore acceptance criteria or tolerance limits for the recommended digital radiography QC tests, in which both qualitative and quantitative criteria may be used to assess image quality are provided.

A quality image is one that makes accurate diagnosis possible. This is known as “diagnostic quality.” The quality of any image can be described in terms of spatial resolution, contrast resolution, noise, detective quantum efficiency (DQE), and artifacts. QA and QC activities demand an understanding of the processes and errors in digital radiography. A process map which is a flowchart of the steps involved in performing a DR exam can be created as a way to understand the interrelationships between activities within the imaging operation. There are at least 16 steps that begin with the arrival of the patient in the imaging department to the step (step 16) where the images are released to the picture archiving and communication system (PACS). The process map draws attention to errors in the association of demographic and exam information, errors that can be avoided by periodic testing, errors in performing the examination, and errors in the delivery of the images. Additionally, reject analysis is an essential element of QC activities, and it is a time-honored method for assessing and improving quality of imaging operations.

Examples of several QC tests that employ qualitative criteria for acceptance limits have been described briefly and include tests for dark noise, computed radiography imaging plate test for uniformity and spatial accuracy, and erasure thoroughness. Furthermore, ongoing QC is an essential element and process of any digital imaging department, and as such the American Association of Physicists in Medicine (AAPM) has provided guidance details of such activities such as reject image analysis, exposure analysis, and artifact identification. The AAPM, the American College of Radiology (ACR), and the Society for Imaging Informatics in Medicine (SIIM) identify and describe at least five individuals who should play a significant role in QA/QA programs including the physician, a qualified medical physicist (QMP), registered radiologist assistant, radiologic technologist, and the imaging informatics professional.

Digital mammography is now an acceptable modality in most imaging departments, and the ACR provides recommendations for full-field digital mammography quality control in which they provide a list of 13 QC tests specifically for the technologist and 17 QC tests to be carried out specifically by the qualified medical physicist.


  1. 1.
    Bushong S. Radiologic science for technologists. 11th ed. St Louis, MO: Elsevier; 2017.Google Scholar
  2. 2.
    Katzman GL, Paushter DM. Building a culture of continuous quality improvement in an academic radiology department. J Am Coll Radiol. 2016;13(4):453–60.CrossRefGoogle Scholar
  3. 3.
    Seeram E, Brennan P. Radiation protection in diagnostic imaging. Burlington, MA: Jones and Bartlett Learning; 2017.Google Scholar
  4. 4.
    AAPM. Report no. 93 acceptance testing and quality control of photostimulable storage phosphor imaging systems report of AAPM task group 10. College Park, MD: AAPM; 2006.Google Scholar
  5. 5.
    Zarb F, Rainford L, McEntee MF. Image quality assessment tools for optimization of CT images. Radiography. 2010;16(2):147–53.CrossRefGoogle Scholar
  6. 6.
    Körner M, Weber CH, Wirth S, Pfeifer KJ, Reiser F, Treitl M. Advances in digital radiography: physical principles and system overview. Radiographics. 2007;27(3):675–86.CrossRefGoogle Scholar
  7. 7.
    Seibert JA. Computed radiography/digital radiography: adult. In: Frush DP, Huda W, editors. RSNA categorical course in diagnostic radiology physics: from invisible to visible—the science and practice of x-ray imaging and radiation dose optimization. Chicago, IL: Radiological Society of North America; 2006. p. 57–71.Google Scholar
  8. 8.
    Rowlands JA. The physics of computed radiography. Phys Med Biol. 2002;47(23):R123–6.CrossRefGoogle Scholar
  9. 9.
    Willis CE, Weiser JC, Leckie RG, Romlein J, Norton G. Optimization and quality control of computed radiography. PACS design and evaluation. Proc. SPIE. 1994;2164:178–85.CrossRefGoogle Scholar
  10. 10.
    Willis CE. Computed radiography, QA/QC. In: Practical digital imaging and PACS. Medical physics monograph no. 28. Madison: Medical Physics; 1999. p. 157–75.Google Scholar
  11. 11.
    Willis CE. Quality assurance: an overview of quality assurance and quality control in the Digital Imaging Department. In: Reiner BI, Seigel EL, Carrino JA, editors. Quality assurance, meeting the challenge in the digital medical enterprise. Great Falls: Society for Computer Applications in Radiology; 2002. p. 1–8.Google Scholar
  12. 12.
    Willis CE, Thompson SK, Shepard SJ. Artifacts and misadventures in digital radiography. Appl Radiol. 2004;33(1):11–20.Google Scholar
  13. 13.
    Bjorn H, Rosanowshy TB, Jnesen C, Wah KHC. Image rejects in general direct digital radiography. Acta Radiol. 2015;4(10):1–6. OpenGoogle Scholar
  14. 14.
    Khafaji MA, Hagi SK. Direct digital radiograph: technicians role in obtaining good images. Saudi Med J. 2014;35(8):879–81.PubMedGoogle Scholar
  15. 15.
    Andersen ER, Jorde J, Yaousse N, Yaqoob SH, Konst B, Seierstad T. Reject analysis in direct digital radiography. Acta Radiol. 2012;53(2):174–8.CrossRefGoogle Scholar
  16. 16.
    Jones AK, Heintz P, Geiser W, Goldman L, Jerjian K, Martin M, et al. Ongoing quality control in digital radiography: report of AAPM Imaging Physics Committee Task Group 151. Med Phys. 2015;42(11):6658–70.CrossRefGoogle Scholar
  17. 17.
    Seeram E, Davidson R, Bushong S, Swan H. Optimizing the exposure indicator as a dose management strategy in computed radiography. Radiol Technol. 2016;87(4):380–91.PubMedPubMedCentralGoogle Scholar
  18. 18.
    ACR-AAPM-SIIM. Technical standard for electronic practice of medical imaging, revised 2017. Accessed Mar 2018.
  19. 19.
    Willis C. Quality control for digital radiography. In: Seeram E, editor. Digital radiography: an introduction. Clifton Park, NY: Delmar, Cengage Learning; 2011.Google Scholar
  20. 20.
    FDA. FDA approves new ACR digital mammography quality control manual. Accessed Mar 2018.
  21. 21.
  22. 22.
    ACR. The American College of Radiology. Recommendations for full-field digital mammography quality control. Accessed Mar 2018.
  23. 23.
    Heggie JCP, Barnes P, Cartwright L, Diffey J, Tse J, Herley JMcLean ID, et al. Position paper: recommendations for a digital mammography quality assurance program V4.0. Australas Phys Eng Sci Med. 2017;40(3):491–543.CrossRefGoogle Scholar

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© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Euclid Seeram
    • 1
    • 2
    • 3
    • 4
    • 5
  1. 1.Medical Radiation Sciences University of SydneySydneyAustralia
  2. 2.Medical Radiation Sciences, Faculty of Health SciencesUniversity of SydneySydneyAustralia
  3. 3.Adjunct Associate Professor, Medical Imaging and Radiation SciencesMonash UniversityClaytonAustralia
  4. 4.Adjunct Professor, Faculty of ScienceCharles Sturt UniversityWagga WaggaAustralia
  5. 5.Adjunct Associate Professor, Medical Radiation Sciences, Faculty of HealthUniversity of CanberraBruceAustralia

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