Radiology QA

03. Radiology QA Framework

A. Clinical Quality & Reporting (Diagnostic Accuracy)

Focuses on the quality of the interpretation.

1. Peer Review / Inter-Observer Variability:

   • Indicator: Random selection of 2-5% of reported cases (CT/MRI) re-read by a second radiologist or Department Head.

   • Metric: Discrepancy Rate (Major vs. Minor discrepancies).

2. Resident-Faculty Correlation (Academic QA):

   • Indicator: Comparison of the "Provisional Report" (issued by the Resident on night duty) vs. "Final Report" (countersigned by Faculty).

   • Target: > 95% concordance.

3. Clinico-Radiological Correlation:

   • Indicator: Correlation of Radiological diagnosis with Surgical findings (intra-op) or Histopathology results.

   • Example: USG diagnosis of Appendicitis vs. Surgical finding of inflamed appendix.

4. Critical Finding Notification Rate:

   • Indicator: Time taken to alert the referring clinician about life-threatening findings.

   • Examples: Tension Pneumothorax, Ectopic Pregnancy, Acute Stroke, Aortic Dissection.

   • Benchmark: Alert within 15-30 minutes of scan completion.

5. Report Turnaround Time (TAT):

   • Emergency (Trauma/Stroke): Reporting < 30-60 mins.

   • In-patient Routine: < 6-12 hours.

   • Out-patient (OPD): < 24 hours.

B. Technical Quality (Image & Equipment)

Focuses on the quality of the image produced.

1. Reject Analysis (Repeat Rate):

   • Indicator: % of X-ray films/scans rejected and repeated.

   • Breakdown: Motion artifact, Positioning error, Exposure error (Over/Under), Equipment artifact.

   • Target: < 5% (Higher rates imply excess radiation exposure to patients).

2. Equipment Downtime:

   • Indicator: % of time heavy equipment (MRI/CT) is non-functional.

   • Impact: Delays in diagnosis and revenue loss.

3. Image Quality Audit:

   • Audit: Check for proper anatomical markers (L/R), patient details on film, and artifact-free images.

C. Patient Safety Indicators

1. Contrast Induced Nephropathy (CIN):

   • Indicator: Patients developing Acute Kidney Injury (AKI) within 48-72 hours of contrast administration.

   • Process: Mandatory Serum Creatinine check before contrast CT/MRI.

2. Contrast Extravasation Rate:

   • Indicator: Incidence of contrast media leaking into tissue during high-pressure injection (CT Angio).

3. Adverse Drug Reactions (ADR) to Contrast:

   • Indicator: Rate of allergic reactions (Mild: Urticaria vs. Severe: Anaphylaxis).

4. MRI Safety Incidents:

   • Indicator: Near-misses regarding ferromagnetic objects (oxygen cylinders, keys, wheelchair) entering Zone IV (Magnet room).

5. Radiation Safety (ALARA Principle):

   • Indicator: Adherence to "As Low As Reasonably Achievable."

   • Audit: Documented exposure factors (kVp, mAs) in the DICOM header.

D. Statutory & Legal Compliance (Strict for India)

1. PCPNDT Act Compliance (Ultrasound):

   • Indicator: 100% "F-Form" completion for all pregnant patients.

   • Audit: Verify that ID proof is attached and the indication for scan is valid. No sex determination.

2. AERB Compliance:

   • Audit:

     • Valid License (ELORA registration) for all X-ray/CT units.

     • TLD Badges (Dosimeters) worn by all staff (Red/Chest/Thyroid levels).

     • Lead Apron integrity check (Annual Fluoroscopy screening of aprons for cracks).

3. Consent Compliance:

   • Audit: Written informed consent for:

     • Contrast administration.

     • Interventional procedures (Biopsy, Drainage).

     • Trans-vaginal USG (TVS).

E. Staff Safety

1. Staff Radiation Exposure:

   • Indicator: Quarterly review of TLD badge reports from the agency (e.g., Avanttec/BARC).

   • Action: Any staff exceeding limits must be taken off radiation duty immediately.

2. Pregnancy Declaration:

   • Policy: Female staff must declare pregnancy immediately to be rotated out of radiation zones (CT/Fluoro) to MRI/USG.

Implementation Checklist for Radiology HOD/Manager

• Daily Checks:

  • Crash Cart in CT/MRI: Check Adrenaline and Hydrocortisone (for contrast reaction).
    Lead Apron Storage: Ensure aprons are hung on racks (not folded, which causes cracks).
    Review Workstation: Ensure PACS (Picture Archiving and Communication System) is online and transferring images.

• Monthly Audits:

  • Reject Analysis Meeting: Technicians must explain why X-ray repeats happened (training issue vs. machine issue).
    TAT Review: Analyze delays in MRI reporting (Is it backlog or slow typing?).
    PCPNDT Audit: Cross-check USG register with F-Forms and Referral slips (Zero tolerance for error).

• Quarterly/Annual:

  • QA Tests of Machines: Physicist to perform QA (kVp accuracy, Focal spot size, Output consistency).
    Lead Apron Fluoroscopy: Screen aprons under fluoro to check for internal cracks/leaks.
    Fire Drill in MRI: Specific training for non-magnetic fire extinguishers.