6. Collect and organize data.

CHAPTER 20: SCREEN - 7. Evaluate care when outcomes are

FILM RADIOGRAPHIC reached.
8. Take action to improve care.
CONTROL 9. Assess and document actions.
10. Communicate information to
Quality Assurance organization-wide quality assurance
programs.
• Health care organizations often
adopt formal, structured QA models. Quality Control
• The Joint Commission (TJC)
promotes “The Ten-Step Monitoring • Quality control is more tangible and
and Evaluation Process.” obvious than QA.
• This QA program uses a 10-step • A program of QC is designed to
process to resolve identified patient ensure that the radiologist is
care problems. provided with an optimal image
• To ensure that health care produced through good imaging
organizations are committed to system performance and resulting in
providing high-quality services and minimal patient radiation dose.
care, accrediting agencies • Quality control (QC) consists of a
encourage the adoption of QA series of standardized tests
models such as that recommended developed to detect changes in x-ray
by TJC equipment function from its original
• The primary goal of a radiology level of performance.
quality assurance program is to • The objective of such tests, when
ensure the consistent provision of carried out routinely, allows prompt
prompt and accurate diagnosis of corrective action to maintain x-ray
patients. image quality.
• This goal will be adequately met by • It is important to note that the
a QA program having the following ultimate responsibility for quality
three secondary objectives: control rests with the physician in
- to maintain the quality of diagnostic charge of the x-ray facility, not with
images; the regulatory agency.
- to minimize the radiation exposure
- to patient and staff; and
- to be cost effective. As with QA, QC requires a team effort, but
QC is principally the responsibility of the
medical physicist.
The Joint Commission’s 10-Step Medical Physicist establishes the QC
Quality Assurance Program program and oversees its implementation at
a frequency determined by the activity of the
1. Assign responsibility.
institution.
2. Delineate scope of care.
3. Identify aspects of care. In addition to ensuring quality patient care, a
4. Identify outcomes that affect aspects QC program in radiology is conducted for
of care. other reasons.
5. Establish limits of the scope of
assessment.
Quality Assurance Program in
radiology facility is determined
by an analysis of the facility's
objectives and resources and
should include the following
major constituents:
1. Responsibilities
2. Purchase specifications
3. Standards for Image Quality
4. Monitoring and Maintenance
programs
5. Installation/Operational/
Performance qualifications of
equipment
6. Records
7. Quality Assurance Manual
8. Training
Thus, a QA program should include periodic
reviews of referral patterns, clinical SCREEN - FILM
protocols, continuing education RADIOGRAPHIC QUALITY
opportunities for staff, facility inspections,
CONTROL
equipment testing, and administrative
procedures related to the purchase of Organizations such as the American College of
supplies and billing. Radiology and the American Association of
Physicists in Medicine have developed
The ultimate goal of QA is to improve guidelines for QC programs in radiography, as
patient care. well as other diagnostic imaging modalities.

Filtration
Filtration of the primary beam is achieved
using metal filters that remove low-energy
photons. These photons lack the energy to
penetrate the body and would be absorbed
in the first few millimeters of tissue. By Radiologic technologists carefully select
absorbing these low-energy photons, the kilovolt peak (kVp) for screen-film
filter reduces unnecessary radiation radiographic examinations, making proper
exposure to the patient, improving the calibration of the x-ray generator essential.
overall quality of the x-ray image. The The accuracy of kVp is typically evaluated
primary function of the filter is to decrease using devices based on filtered ion
the amount of low-energy radiation reaching chambers or photodiodes, which are widely
the patient. used for their efficiency. While methods
involving voltage diodes and oscilloscopes
Collimation are more accurate, they are time-consuming
and less commonly employed. To ensure
The x-ray field must align with the light field
reliable imaging, the measured kVp should
of the collimator to ensure accurate
be within 10% of the indicated value.
targeting and avoid unnecessary irradiation.
Misalignment can result in missed anatomy kVp calibration should be assessed
or unintended exposure, which can be annually or after significant changes to high-
verified using appropriate test tools. Modern voltage generator components. Variations in
systems often feature positive beam-limiting kVp within the diagnostic range impact
(PBL) collimators, which automatically patient radiation dose. A 4% change in kVp
adjust to the size of the image receptor. To is required to noticeably affect image optical
ensure proper functionality, the PBL must be density and radiographic contrast.
evaluated for all receptor sizes. The x-ray
beam should not exceed the receptor size
unless the system is in override mode.
Exposure Timer Accuracy
Exposure time is operator selectable on
Focal-Spot Size most radiographic consoles. Although many
radiographic systems are photo time or
The spatial resolution of a radiographic controlled by milliampere seconds (mAs),
imaging system primarily depends on the exposure time is still the responsibility of
focal-spot size of the x-ray tube, which must radiologic technologists. This parameter is
be measured when new or replacement particularly responsible for patient radiation
equipment is installed. Measurement tools dose and image optical density.Exposure
include the pinhole camera, star pattern, timer accuracy is typically evaluated using
and slit camera, with the slit camera being commercially available devices that
the standard due to its accuracy. Focal-spot measure irradiation time through an ion
size specification involves complex x-ray chamber or photodiode assembly, a method
tube fabrication and electron beam commonly employed by medical physicists.
focusing, allowing vendors some variance
from advertised sizes.
Focal-spot size should be evaluated Exposure timer accuracy should be within
annually or whenever an x-ray tube is 5% of the indicated time for exposure times
replaced. greater than 10 ms.

Kilovolt Peak Calibration

Exposure Linearity same technique factors, changing the
controls between each exposure. Non-
Many combinations of mA and exposure reproducibility often indicates an error in the
time produce the same mAs value. The kVp control. The second method involves
ability of a radiographic unit to produce a holding technique factors constant across
constant radiation output for various 10 exposures. In both cases, mathematical
combinations of mA and exposure time is formulas are used to ensure that radiation
called exposure linearity. output intensity does not vary by more than
±5%.

Exposure linearity must be within 10% for

adjacent mA stations. Radiographic Intensifying
Screens
Intensifying screens should be cleaned
periodically to prevent artifacts. Cleaning
involves using a soft, lint-free cloth and a
manufacturer-recommended cleaning
solution. The frequency of cleaning depends
on departmental workload but should occur
at least quarterly.

Protective Apparel
Protective aprons, gloves, and gonadal
shields should be inspected annually using
Exposure Reproducibility radiography or fluoroscopy to check for
defects such as cracks, tears, or holes.
Damaged items may need replacement.
Radiologic technologists expect optimal
image optical density and contrast when
selecting kVp, mA, and exposure time. If Film Illuminators
these settings are adjusted and then
Viewbox illumination should be tested
restored, radiation exposure should remain
annually using a luminance meter to
consistent. Reproducibility of radiation
measure light intensity across the surface.
exposure is essential for accurate and
Intensity must be at least 1500 cd/m² with a
reliable imaging.Sequential radiation
variation of no more than ±10%. If one bulb
exposures should be reproducible to within
is replaced, all bulbs in the illuminator
±5%.
should be replaced and matched to
adjacent units.

Exposure reproducibility can be evaluated

using a precision radiation dosimeter
through two methods. The first involves Tomography Quality Control
making at least three exposures with the
In addition to the standard quality control high-concentration processing chemistry, a
(QC) measures for screen-film radiographic development temperature of 35°C (95°F),
systems, additional measurements are and a developer immersion time of 22
needed for systems capable of conventional seconds. The wash water temperature
tomography. Since precise performance should be maintained at 31°C (87°F), with
standards for conventional tomography do current processors using only cold water
not exist, QC measurements are focused on and a thermostatically controlled heater to
ensuring consistency in the system's regulate temperature.
characteristics.

Patient radiation dose should be measured

for the most common types of tomographic
examinations. The geometric characteristics
of tomograms are assessed using test
objects, ensuring that the indicated and
measured section levels are within ±5 mm,
with section increments accurate to within
±2 mm and consistency of ±1 mm between
evaluations. Section uniformity is checked
by imaging a hole in a lead sheet, where the
optical density of the image should be
uniform, without noticeable variations, gaps,
or overlaps.

Processor Quality Control

Quality control (QC) in any activity involves
routine and special procedures to ensure
consistently high-quality results. In screen-
film radiography, QC requires a continuous,
planned program for evaluating and
monitoring radiologic equipment and
procedures.

Processor Cleaning
The first automatic processor had a dry-to-
drop time of 7 minutes, which was later
reduced to 3 minutes with double capacity
processors. The processing time was further
shortened with the fast-access system,
resulting in the current 90-second
processor, capable of handling up to 500
films per hour. To achieve this speed, it uses
Processor Maintenance
Proper maintenance of the film processor is
essential to prevent unexpected failures,
especially during heavy workloads. There
are three types of maintenance in the QC
program for an automatic film processor:

1. Scheduled Maintenance: Routine tasks

performed weekly or monthly, such as
checking moving parts for wear, adjusting
belts, pulleys, and gears, and lubricating
parts to minimize wear. Lubricant should not
come into contact with hands, film, rollers,
or processor chemistry.

2. Preventive Maintenance: A planned

program for replacing parts at regular
intervals before they fail, reducing the risk of
unexpected downtime.

3. Nonscheduled Maintenance:
Unplanned repairs due to system failures. A
good scheduled and preventive
maintenance program minimizes the need
for this type of maintenance.

Processor Monitoring
Processor operation should be observed
daily, ideally at the same time each day,
with specific measurements recorded. This
includes noting the temperature of the
developer and wash water, monitoring
replenishment rates, and checking if the
floating lids on replenishment tanks are
correctly positioned. Fresh chemistry levels
should also be assessed, and the pH and
specific gravity of the developer and fixer
solutions should be checked. Residual hypo
should be measured. A sensitometric strip
should be processed, and fog, speed, and
contrast should be recorded. Many film
suppliers provide forms and support for
setting up a monitoring program. A written
record of these results is essential. The
monitoring procedures used for
mammography processors can be applied
to all processors in the facility.