Quality Assurance: The Missing Link

Abstract

Listen

Translate article

Bruce I. Reiner, MD Eliot L. Siegel, MD Khan M. Siddiqui, MD Amy E. Musk, MD Throughout our professional and personal lives we encounter constant paeans to the importance of quality, as if this were the generally accepted and primary focus of attention in any endeavor. We hear advertisements and pronouncements that products are of “top quality” or that “quality is job number one.” But is quality really the primary incentive for those who produce goods and services in our economy? When government statistics are released, economic and productivity factors are often emphasized with little or no data on quality. If we were to ask a hospital administrator, chief technologist, and radiologist about their respective highest priorities, they would probably respond (if free to be entirely honest) that productivity is the most important measure of performance. If our outcomes are defined in quantitative rather than qualitative terms, what does this say about our priorities? The easy answer, of course, is that our first and foremost priority should be patient care, which is the true object of quality assurance (QA) and quality control. Some might argue that an occasional suboptimal-quality image is not really important in the overall scheme of quality health care. The response, of course, is that patient care is compromised by inferior image quality and that there is the potential for medical and legal ramifications that can amount to millions of dollars for a single missed diagnosis. But how can we, as busy practitioners and administrators, justify expensive QA and quality control programs that threaten to diminish operational efficiency within an already overworked and understaffed imaging department? In radiology, as in other areas of our lives, perceptions are formed from collective experience. Despite the inroads of the digital revolution, most radiologists and technologists still operate in a “filmlike” world. Even after the transition from screen-film to digital radiography, technologist workflow typically replicates the screen-film paradigm. Technologists are located in a centralized work area, which is used to transfer computed radiographic cassettes into a shared computed radiographic plate reader; technologists then review and manipulate images on a shared QA workstation. This centralized, shared workflow approach is often compounded by bottlenecks, errors, and delays. Many radiologists also work in a parallel fashion. They may take a relatively passive role when it comes to image display and optimization, preferring to review digital radiographs in a “single best, as is” presentation state. Rather than actively manipulate images by using the workstation tools and functions that are inherent to filmless operation, radiologists may elect to review and interpret each image in a static manner. The advantage of this approach is that it is quicker and therefore enhances productivity. The disadvantage is that it fails to take advantage of much of the image information that is available on a digital radiograph. By actively manipulating the image, applying advanced processing algorithms, or using decision support software such as computeraided detection, diagnostic interpretation can be enhanced, with measurable benefits in the quality of patient care. Because of their collective film-based experience, technologists and radiologists may tend to undervalue or even ignore QA. QA is commonly viewed as a wasteful endeavor that sidetracks valuable resources without noticeable gains. This “hands off” approach to QA actually seemed more justified to many after the transition to digital radiography because image quality is now automatically adjusted through the combination of wider dynamic range, wider exposure latitude, and computer image enhancement. The end result is that QA in Published online 10.1148/radiol.2381050357