Quality Assurance Program Research Articles

Quality and Safety Considerations in Image Guided Radiation Therapy: An ASTRO Safety White Paper Update

This updated report on image guided radiation therapy (IGRT) is based on a consensus-based white paper previously published by the American Society for Radiation Oncology (ASTRO) addressing patient safety. In the past decade, IGRT technology and procedures have progressed significantly and are now more commonly used. The use of IGRT has now extended beyond high-precision treatments, such as stereotactic radiosurgery and stereotactic body radiation therapy, and into routine clinical practice for many treatment techniques and anatomic sites. Therefore, quality and treatment planning and delivery considerations for these techniques are paramount for patient safety. In 2021, ASTRO convened an interdisciplinary task force to assess the original IGRT white paper and update content where appropriate. Recommendations were created using a consensus-building methodology, and task force members indicated their level of agreement based on a 5-point Likert scale from "strongly agree" to "strongly disagree." A prespecified threshold of ≥75% of raters who selected "strongly agree" or "agree" indicated consensus. The IGRT white paper was published (Pract Radiat Oncol. 2022 Dec) and endorsed by the American Association of Physicists in Medicine (AAPM), American Association of Medical Dosimetrists, and American Society of Radiologic Technologists. Since the first IGRT paper was published by ASTRO in 2013, significant technological advancement has taken place. New and updated considerations in personnel requirements, staffing, education and training, equipment and technological requirements, quality management and assurance, IGRT program management, and safety considerations were reported. A 17-point consensus was reached and recommended in 5 areas surrounding program development, quality assurance, quality management, treatment delivery, and vendor engagement (Table 5, Summary of key recommendations). This IGRT white paper builds on the previous version and uses other guidance documents to primarily focus on processes related to quality and safety. IGRT requires an interdisciplinary team-based approach, staffed by appropriately trained specialists, as well as significant personnel resources, specialized technology, and implementation time. A thorough feasibility analysis of resources is required and should be discussed with all personnel before undertaking new imaging techniques. A comprehensive quality-assurance program must be developed to ensure IGRT is performed safely and effectively. As IGRT technologies continue to improve or emerge, existing practice guidelines should be updated regularly according to the latest AAPM Task Group reports. Patient safety in the application of IGRT is everyone's responsibility, and professional organizations, regulators, vendors, and end-users must demonstrate strong commitments to ensure that the highest levels of safety are achieved.

A-361 Implementation of a Fit-for-purpose Point of Care Quality Assurance Program

Abstract Background All individuals should have equitable access to accurate and timely testing for infectious diseases. Point of care testing (PoCT) has been developed to support populations having limited access to laboratory-based testing. Unlike laboratory-based testing, PoCT is often performed by non-laboratory staff and outside the jurisdiction of regulatory frameworks. Under these conditions, quality assurance (QA) of PoCT is often lacking; inaccurate testing can go undetected, leading to poor patient outcomes. A fit-for-purpose QA program was developed to monitor the quality of PoCT for infectious disease testing, particularly in low-middle income countries and in testing outside the laboratory regulatory environment. Methods In collaboration with the World Health Organization (WHO), the National Serology Reference Laboratory (NRL) reviewed the barriers to participation in QA programs experienced by PoCT sites. Using this information, NRL developed a QA model specifically designed for PoCT for infectious disease. In collaboration with Foundation for Innovative and New Diagnostics (FIND, Geneva, Switzerland), Kirby Institute (Sydney, Australia) and Flinders University (Adelaide, Australia), NRL implemented the PoCT QA model across Africa, Asia, and remote regional Australia. The model consists of competency panels (CP - one positive and one negative sample) and external quality assessment (EQA) panels. The EQA panels contain five samples. Whereas the test site knows the reactivity of the CP samples, the EQA samples are tested blinded. Both panels use inactivated samples that are stable at ambient temperature. The model uses streamlined logistics channels, with data collection and analysis using smartphone technology and QR codes. NRL designed a method for randomizing the identity of EQA sample vials so test sites can test QA panels ad hoc, and not be limited to specific test event dates. A range of support material such as pictorial instructions for use, virtual training events and on-line videos were produced to support test sites. Results More than 100 test sites from 14 countries have participated in the NRL PoCT QA programs. The model is designed so data is collected by test sites scanning QR codes and entering results directly into a data entry screen. The NRL PoCT QA program removed barriers to participation by offering sample types that are inactivated and stable at ambient temperature for extended periods of time, removing the need for dry ice shipping. The program is cost effective making it accessible to low- and middle-income countries. Data is collected using novel smartphone technology, facilitating results to be entered into a central database for immediate analysis. Testing of the QA samples can be done at any time, avoiding set test events. Conclusion Implementation of a fit-for-purpose PoCT QA for infectious disease testing removes the barriers to participation and facilitates the monitoring of testing over time. Any deficiencies in testing can be detected and addressed rapidly, ensuring that accurate test results are reported, and the population protected.

A-106 Sigma Metric Performance of Chemistries on the Abbott Alinity c Analyzer

Abstract Background The analytical performance of the Abbott Alinity c (Abbott Park, IL) was compared to our current Abbott Architect analyzers using sigma metrics. Methods Sigma metrics of 28 chemistry analytes on our six Abbott Alinity analyzers was compared to three Abbott Architect 16 000 analyzers and one Architect 8000 analyzer using Bio-Rad Multiqual quality control (QC) (Hercules, CA). Method imprecision was estimated for each assay using the cumulative coefficient of variation (CV) of 12 months data for each analyzer at three QC concentrations and calculating the average sigma. Method bias was estimated by comparing each analyzer QC mean to peer group QC means. Sigma values were calculated for each method as (TEa—Bias%)/CV% using allowable total error (TEa) from three sources: the CLIA proficiency testing evaluation limits, Australasian Association of Clinical Biochemistry allowable limits of performance (RCPA quality assurance programs Pty limited, Adelaide, Australia) and desirable biological variation (Ricos C et al, Scand J Clin Lab Invest. 1999, 59(7):491–500). Average sigma values were generated for each analyte and graded as optimal >6 sigma; good 5–6 sigma; marginal 3–5 sigma; or poor <3 sigma. Results Assay sigmas varied across QC concentrations and between analyzers of the same platform. Na, Cl, and CO2 had the lowest sigma performance. Since the sigma calculations are dependent on TEa, tighter TEa limits (Ricos and RCPA) generated lower sigmas compared to the wider CLIA TEa limits especially for Ca, Cl, total bilirubin, CO2, Na, total protein, and HDL. Conclusion None of the chemistries met optimal six sigma performance for all analytes, concentrations of QC and sources of TEa. However, the assay performance between analyzer platforms was comparable.

Diamond detectors for dose and instantaneous dose-rate measurements for ultra-high dose-rate scanned helium ion beams.

The possible emergence of the FLASH effect-the sparing of normal tissue while maintaining tumor control-after irradiations at dose-rates exceeding several tens of Gy per second, has recently spurred a surge of studies attempting to characterize and rationalize the phenomenon. Investigating and reporting the dose and instantaneous dose-rate of ultra-high dose-rate (UHDR) particle radiotherapy beams is crucial for understanding and assessing the FLASH effect, towards pre-clinical application and quality assurance programs. The purpose of the present work is to investigate a novel diamond-based detector system for dose and instantaneous dose-rate measurements in UHDR particle beams. Two types of diamond detectors, a microDiamond (PTW 60019) and a diamond detector prototype specifically designed for operation in UHDR beams (flashDiamond), and two different readout electronic chains, were investigated for absorbed dose and instantaneous dose-rate measurements. The detectors were irradiated with a helium beam of 145.7 MeV/u under conventional and UHDR delivery. Dose-rate delivery records by the monitoring ionization chamber and diamond detectors were studied for single spot irradiations. Dose linearity at 5cm depth and in-depth dose response from 2 to 16cm were investigated for both measurement chains and both detectors in a water tank. Measurements with cylindrical and plane-parallel ionization chambers as well as Monte-Carlo simulations were performed for comparisons. Diamond detectors allowed for recording the temporal structure of the beam, in good agreement with the one obtained by the monitoring ionization chamber. A better time resolution of the order of few μs was observed as compared to the approximately 50 μs of the monitoring ionization chamber. Both diamonds detectors show an excellent linearity response in both delivery modalities. Dose values derived by integrating the measured instantaneous dose-rates are in very good agreement with the ones obtained by the standard electrometer readings. Bragg peak curves confirmed the consistency of the charge measurements by the two systems. The proposed novel dosimetric system allows for a detailed investigation of the temporal evolution of UHDR beams. As a result, reliable and accurate determinations of dose and instantaneous dose-rate are possible, both required for a comprehensive characterization of UHDR beams and relevant for FLASH effect assessment in clinical treatments.

Quality assurance programs for vitamin A and E in serum: are we doing enough to assess laboratory performance?

Monitoring serum vitamin A (retinol) and vitamin E (α-tocopherol) concentrations is common practice for assessing nutritional status. Measurement of these vitamins can be challenging due to several factors. Whilst the RCPAQAP Vitamins: Serum Program assists participating laboratories in harmonisation, the materials provided do not contain the analogues of retinol and α-tocopherol that may be present in real patient samples. We aimed to assess participants' capacity to accurately report retinol and α-tocopherol in the presence of the vitamin E analogues tocopherol acetate and γ-tocopherol. A supplementary series of a control sample andthree matched spiked samples were distributed to each laboratory participating in the Program. Retinol and α-tocopherol results for each spiked sample were compared to the results of the control sample submitted by each participant. Acceptability of retinol and α-tocopherol results was determined based on the RCPAQAP allowable performance specifications (APS). Thirteen participants returned results for the supplementary sample series. Interference from α-tocopherol acetate was observed with results below the APS in 30 % (n=4) of laboratories for retinol quantification and in 23 %(n=3) for α-tocopherol quantification. One laboratory returned results above the APS for α-tocopherol when γ-tocopherol was present. This supplementary sample series has shown that the presence of vitamin E analogues can lead to the over or under estimation of nutritional status by some participants. Affected laboratories are encouraged to review their analytical procedures. To further assess laboratory competence, EQA providers should consider using patient samples or spiked challenge samples.

Evaluation of Quality Control and quality assurance Program in Egyptian X-ray Mammogram Units: Achievements and Challenges

Evaluation of Quality Control and quality assurance Program in Egyptian X-ray Mammogram Units: Achievements and Challenges

Lessons learned: audit of the record-keeping quality of a tertiary hospital’s mammography service

Breast cancer is the most common cancer worldwide. In diagnostic centers offering mammography, periodic audit of medical archived procedures is an important component of a quality assurance program; this ensures optimal follow-up of positive cases and establishment of measures to combat any deficiencies. The study aimed to audit the record-keeping of the mammography service in a tertiary institution, with a view to improving its efficiency. A retrospective audit of request forms, questionnaires, mammograms, and reports of 1,098 women who had mammography at the radiology department of a public tertiary hospital between 2011 and 2018. An internal audit of records evaluated the completeness of clinical information on the request forms, questionnaires, accuracy of diagnosis, and state of stored mammographic films, years later. Microsoft Excel and SPSS version 23 were used for the analysis of descriptive and inferential statistics, respectively. Two hundred and thirty (21%) and 791 (72%) women had screening and diagnostic mammography, respectively; their ages ranged from 31 to 85 years. Indication of study was not stated on 73 (7%) request forms and 281 (26%) request forms were improperly filled. There were 52 (4.7%) women not clerked with the questionnaire, while 158 (14%) had no clinical breast examination prior to imaging. One hundred and thirty (12%) mammograms were damaged, while 2 were missing and not reviewed. Our study revealed a significant lapse in quality of our mammography record archival system. Evidence obtained helped institute necessary measures in place for digitization and quality control of mammography services.

Translation of AI into oncology clinical practice.

Artificial intelligence (AI) is a transformative technology that is capturing popular imagination and can revolutionize biomedicine. AI and machine learning (ML) algorithms have the potential to break through existing barriers in oncology research and practice such as automating workflow processes, personalizing care, and reducing healthcare disparities. Emerging applications of AI/ML in the literature include screening and early detection of cancer, disease diagnosis, response prediction, prognosis, and accelerated drug discovery. Despite this excitement, only few AI/ML models have been properly validated and fewer have become regulated products for routine clinical use. In this review, we highlight the main challenges impeding AI/ML clinical translation. We present different clinical use cases from the domains of radiology, radiation oncology, immunotherapy, and drug discovery in oncology. We dissect the unique challenges and opportunities associated with each of these cases. Finally, we summarize the general requirements for successful AI/ML implementation in the clinic, highlighting specific examples and points of emphasis including the importance of multidisciplinary collaboration of stakeholders, role of domain experts in AI augmentation, transparency of AI/ML models, and the establishment of a comprehensive quality assurance program to mitigate risks of training bias and data drifts, all culminating toward safer and more beneficial AI/ML applications in oncology labs and clinics.

Quality Control of Brachytherapy Equipment in Kazakhstan: Current Stage and Minimum Requirements.

Brachytherapy is used in 17 radiotherapy facilities In Kazakhstan. Each institution has an individual quality control (QC) program in place to ensure the safe and accurate delivery of the treatment dose to the patient. The main objective of this paper is to explore current approaches to quality control of brachytherapy in Kazakhstan and reduce potential discrepancies in testing frequency and tolerance limits by identifying a set of basic quality control requirements. A detailed brachytherapy quality control questionnaire was provided to 17 radiotherapy institutions for completion. A separate questionnaire was sent to two institutions associated with brachytherapy. Questions addressed safety aspects, radiation parameters, total time spent on quality control, and available imaging systems for dose determination. The results of the survey were compared with the recommendations set found in international brachytherapy quality control documents. The results of the questionnaires revealed significant differences in the frequency and methods of testing. For example, only two of the 17 centers have at least some kind of quality assurance program for brachytherapy treatment. Only five centers have equipment with the help of which dosimetric control can be performed, and only two centers have local medical physicists performing this control. One of the centers is checked quarterly, while the other is checked only once a year. In the remaining 15 centers, dosimetric control is performed by specialists who recharge the source without providing any document or protocol. There were also significant differences in the amount of time spent on quality control, mostly related to the variety of approaches to quality control and differences in the availability of resources. Almost all centers (15 of 17) rely only on inspections from the radionuclide source supplier and do not monitor the dosimetric and mechanical parameters of the facility at all. Based on the results of the survey and comparison with international recommendations, a set of basic requirements for brachytherapy quality control is needed.

135 External quality assurance program for diagnostic complement laboratories: Evaluation of the past six year[StQuote]s results

135 External quality assurance program for diagnostic complement laboratories: Evaluation of the past six year[StQuote]s results

Diagnostic proficiency test using digital cytopathology and comparative assessment of whole slide images of cytologic samples for quality assurance program in Korea.

The Korean Society for Cytopathology introduced a digital proficiency test (PT) in 2021. However, many doubtful opinions remain on whether digitally scanned images can satisfactorily present subtle differences in the nuclear features and chromatin patterns of cytological samples. We prepared 30 whole-slide images (WSIs) from the conventional PT archive by a selection process for digital PT. Digital and conventional PT were performed in parallel for volunteer institutes, and the results were compared using feedback. To assess the quality of cytological assessment WSIs, 12 slides were collected and scanned using five different scanners, with four cytopathologists evaluating image quality through a questionnaire. Among the 215 institutes, 108 and 107 participated in glass and digital PT, respectively. No significant difference was noted in category C (major discordance), although the number of discordant cases was slightly higher in the digital PT group. Leica, 3DHistech Pannoramic 250 Flash, and Hamamatsu NanoZoomer 360 systems showed comparable results in terms of image quality, feature presentation, and error rates for most cytological samples. Overall satisfaction was observed with the general convenience and image quality of digital PT. As three-dimensional clusters are common and nuclear/chromatin features are critical for cytological interpretation, careful selection of scanners and optimal conditions are mandatory for the successful establishment of digital quality assurance programs in cytology.

Slice by slice: An Australian state-by-state analysis of Mohs micrographic surgery over 5 years.

In November 2018, Mohs micrographic surgery (MMS) was restricted to fellows registered with the Australasian College of Dermatologists. Three new item numbers for the provision of MMS were also introduced. We examine the national and state usage of MMS item numbers based on Medicare claim statistics and Mohs surgeons' self-reported data, noting the impact of the pandemic and the usage of individual item numbers. Medicare item number data were obtained from the Medicare Benefits Schedule website for January 2017-December 2021. Self-reported data were collected on an annual basis by the Royal College of Pathologists of Australasia (RCPA) as part of the Quality Assurance Program (QAP) from 2019 onwards. Data were analysed with the Holt-Winters smoothing method for forecasting. An increasing number of MMS claims were processed each year, with a total of 89,183 for the study period. Since November 2018, 97.7% of procedures have been conducted on the head, neck, genitalia, hand, digits, leg (below the knee) or foot. The provision of services across the country was maintained during the pandemic years of 2020-2021, with an increase in services in Queensland. There were discrepancies between the states for procedures performed in greater than six sections; these constituted more than 35% of claims in Queensland and Western Australia compared to less than 15% in other states. The pandemic impacted certain states more than others, with Victoria and the Northern Territory having significantly fewer presentations than predicted (p < 0.05). Overall, the use of MMS in Australia is in keeping with peer-developed guidelines, despite discrepancies between states. Although certain states were more severely affected by the pandemic, MMS is increasingly used in Australia.

Ki67 assessment protocol as an integral biomarker for avoiding radiotherapy in the LUMINA breast cancer trial.

The LUMINA trial demonstrated a very low local recurrence rate in women ≥55 years with low-risk luminal A breast cancer (defined as grade I-II, T1N0, hormone receptor positive, HER2 negative and Ki67 index ≤13.25%) treated with breast-conserving surgery and endocrine therapy (but no other systemic therapy), supporting the safe omission of radiation in these women. Here we describe the protocol for Ki67 assessment, the companion diagnostic used to guide omission of adjuvant radiotherapy. Ki67 immunohistochemistry was performed on full-face sections at one of three regional labs. Pathologists trained in the International Ki67 in Breast Cancer Working Group (IKWG) method demarcated tumour areas on scanned slides and scored 100 nuclei from each of at least five randomly selected 1-mm fields. For cases with high Ki67 heterogeneity, further virtual cores were selected and scored in order to confidently assign a case as luminal A (≤13.25%) or B (>13.25%). Interlaboratory variability was assessed through an annual quality assurance programme during the study period. From the quality assurance programme, the mean Ki67 index across all cases/labs was 13%. The observed intraclass correlation coefficient (ICC) and kappa statistics were ≥0.9 and ≥0.7, respectively, indicating a substantial level of agreement. Median scoring time was 4 min per case. The IKWG-recommended scoring method, performed directly from slides, requiring up to four scored fields, is concordant with the LUMINA scoring method (ICC ≥ 0.9). Ki67 is a practical, reproducible, and inexpensive biomarker that can identify low-risk luminal A breast cancers as potential candidates for radiation de-escalation. ClinicalTrials.gov number, NCT01791829.

Corneal blindness and eye banking: Current strategies and best practices.

Corneal blindness (CB) is one of the leading causes of blindness in India and globally, affecting around 8 million population worldwide. Many of these corneal blind patients may be visually rehabilitated by corneal transplantation (CT). Eye banking plays a crucial role in facilitating CT and ocular research. Many countries have adopted regulatory frameworks, quality assurance programs, and technological advancements to enhance the efficacy and safety of CT. Various infrastructural and organizational frameworks of eye banks (EBs) in India, according to the Eye Bank Association of India (EBAI), aid in establishing guidelines and standards for EB practices. Initiatives such as the National Programme for Control of Blindness (NPCB) have significantly contributed to eye donation rates and improved access to donor corneas. This review article discusses the established eye banking networks in countries such as India, the United States (USA), and Europe, where dedicated EB organizations work collaboratively to ensure efficient procurement, processing, and distribution of corneal tissue. It also highlights specific strategies employed in India and global countries to address EBs' challenges. These challenges include the shortage of donor corneas, improving donor screening and tissue processing techniques, ensuring timely distribution of corneal tissue, and maintaining high-quality standards. Interestingly, the comparative analysis between India and other developed countries highlights the similarities and differences in eye banking strategies. By understanding the strategies employed by different regions, EBs can learn from each other's experiences and work toward achieving optimal outcomes in CT and ocular research worldwide. It underscores the importance of knowledge sharing and collaborative efforts in addressing common challenges and implementing best practices in eye banking.

Corrective and preventive actions (CAPAs) in eye bank.

This case series highlights the challenges in eye banking and the importance of a quality assurance program. Three cases triggered corrective and preventive actions (CAPAs) to improve the processes. Case 1 emphasized training to prevent retrieval failures. Case 2 stressed the need for blood samples and comprehensive documentation. In Case 3, mishandling led to policy revisions and staff training. CAPA involved identifying concerns, root cause analysis, action plans, implementation, checks, and closure. Errors can occur in man, machinery, process, and policies. Continuous CAPA ensures continuous quality improvement and safe corneal tissue transplantation, benefiting patients in need.

Contaminants of emerging concern in urine: a review of analytical methods for determining diisocyanates, benzotriazoles, benzothiazoles, 4-methylbenzylidene camphor, isothiazolinones, fragrances, and non-phthalate plasticizers.

Human biomonitoring (HBM)frameworks assess human exposure to hazardous chemicals. In this review, we discuss and summarize sample preparation procedures and analytical methodology for six groups of chemicals of emerging concern (CECs), namely diisocyanates, benzotriazoles, benzothiazoles, 4-methylbenzylidene camphor, isothiazolinones, fragrances, and non-phthalate plasticizers, which are increasingly detected in urine, however, are not yet widely included in HBM schemes, despite posing a risk to human health. The sample preparation procedures depend largely on the chemical group; however, solid-phase extraction (SPE) is most often used due to the minimized sample handling, lower sample volume, and generally achieving lower limits of quantification (LOQs) compared to other extraction techniques. In terms of sample analysis, LC-based methods generally achieve lower limits of quantification (LOQs) compared to GC-based methods for the selected six groups of chemicals owing to their broader chemical coverage. In conclusion, since these chemicals are expected to be more frequently included in future HBM studies, it becomes evident that there is a pressing need for rigorous quality assurance programs to ensure better comparability of data. These programs should include the reporting of measurement uncertainty and facilitate inter-laboratory comparisons among the reporting laboratories. In addition, high-resolution mass spectrometry should be more commonly employed to enhance the specificity and selectivity of the applied analytical methodology since it is underrepresented in HBM. Furthermore, due to the scarcity of data on the levels of these CECs in urine, large population HBM studies are necessary to gain a deeper understanding of the associated risks.

Laboratory Surveillance, Quality Management, and Its Role in Addressing Antimicrobial Resistance in Africa: A Narrative Review.

AMR is a major public health concern that calls for extensive work and a multidisciplinary team approach. The high prevalence of infectious diseases in African nations leads to widespread antibiotic usage and eventual antimicrobial resistance, which has significant negative effects on people's health, the economy, and society. Additionally, inadequate or nonexistent antimicrobial drug regulations, inappropriate prescription practices, and restrictions on public health prevention initiatives such as immunization, water and sanitation, and sexual health may all contribute to the emergence of AMR. Despite the need for laboratory quality assurance, many African laboratories confront substantial difficulties in implementing efficient quality assurance programs. AMR surveillance in Africa is hampered by a lack of laboratory capacity, insufficient data collection and analysis, and poor stakeholder collaboration. Several initiatives and programs, including the World Health Organization's Global Antimicrobial Resistance and Use Surveillance System (GLASS), the Africa Centres for Disease Control and Prevention (Africa CDC) Antimicrobial Resistance Surveillance Network (AMRSNET), and the Fleming Fund, a UK government initiative aimed at tackling AMR in low- and middle-income countries, have been established to strengthen AMR surveillance in Africa and globally.

Results of a multicenter 4D computed tomography quality assurance audit: Evaluating image accuracy and consistency

Background and purpose4D Computed Tomography (4DCT) technology captures the location and movement of tumors and nearby organs at risk over time. In this study, a multi-institutional multi-vendor 4DCT audit was initiated to assess the accuracy of current imaging protocols. Materials and methodsTwelve centers, including thirteen scanners performed a 4DCT acquisition of a dynamic thorax phantom using the institution’s own protocol with the in-house breathing monitoring system. Five regular and three irregular breathing patterns were used. Image acquisition and reconstruction were followed by automated image analysis with our in-house developed 4DCT QA program (QAMotion). CT number accuracy, volume deviation, amplitude deviation, and spatial integrity were assessed per pattern using both the segmented volumes and line profiles. ResultsRegular breathing curves showed relatively accurate results across all institutions, with mean volume and CT number deviations and median amplitude deviation below 2%, 5 HU and 2 mm, respectively. Results obtained for irregular patterns showed more variation across the institutions. Volume and CT number deviations co-occurred with a blurring of the sphere, interpolation, or double-structure artifacts that were confirmed through the line profiles. For some of the irregular patterns, amplitude deviations up to 6 mm were observed. Maximum Intensity Projection (MaxIP) correctly captured the applied motion amplitude with deviations across all institutions within 2 mm except for double amplitude pattern. ConclusionsAll centers invited to participate in the audit responded positively, highlighting the need for a comprehensive yet easy-to-execute 4DCT quality assurance program. The largest variances between the results from one institution to another confirmed that a standardized 4DCT audit is warranted.

Impacts of Ignition Furnace Correction Factor Errors on Quality Assurance of Asphalt Mixtures

The accurate determination of asphalt content has long been a key component of assessing the quality and characteristics of an asphalt mixture, with the ignition method (AASHTO T 308) being the most common. Despite previous research work recommending the use of unique correction factors for each mixture and oven, the practice of sharing correction factors is very prevalent. A unique dataset of correction factors and ignition furnace results generated by Maine Department of Transportation (MaineDOT) is analyzed to quantify the potential errors in a production environment induced by the practice of sharing correction factors and apply those errors to different quality assurance systems. The work is based largely on correction factors generated by MaineDOT for the same design in multiple ovens across two laboratories. The difference in mixture type was evident in the correction factor data and the difference in correction factors in the same design ranged from 0.0% to 0.43%, with most differences between 0.07% and 0.15%. Larger differences in correction factors were observed between different laboratories then when they were generated for different furnaces in the same laboratory. Analysis of acceptance data and percent-within-limits simulations showed that sharing of correction factors, even in cases when the differences are small, resulted in significant impacts on quality acceptance and payment. The added variability can result in errors in assessment of quality, errors in payment to the producer, unnecessary corrective action by the producer, and a more variable finished product. Agencies and producers using AASHTO T 308 are encouraged to evaluate the differences in correction factors between their furnaces and laboratories to quantify the impact of errors on their quality assurance programs for asphalt mixtures.

A Quality Improvement Approach to Modification of a Point-of-Care Ultrasound Curriculum.

There is increasing emphasis on resident involvement in quality improvement (QI) efforts, yet resident engagement in QI has remained low for many reasons. Although QI methods are classically applied to clinical processes, there are many opportunities to incorporate QI principles into curricular design and implementation. Demonstrate the utility of QI methods when applied to curricular design and the implementation of a novel point-of-care ultrasound portfolio development and quality assurance program at a large internal medicine residency program. We applied foundational QI methods, including process mapping, plan-do-study-act (PDSA) cycles, time-trap identification, run-chart analysis, and qualitative interviews throughout the curricular design and implementation phases to rapidly identify areas for improvement and perform timely tests of change. Fifty-one interns participated in the curriculum, submitting 731 images in the first trimester. Process mapping and submission review revealed that 29% of images were saved to the incorrect digital archive. Resident-reviewer interpretation concordance was present in 80.7% of submissions. In 95.2% of completed quality assurance cards, the same information was provided in the commentary feedback and the evaluator's checklists, representing a time trap. Interventions included restricting access to image archives and removing redundant fields from quality assurance cards. The time to feedback fell from 69.5 to 6.5 days, demonstrating nonrandom variation via run-chart analysis. This pilot study demonstrates the successful application of QI methods to a novel point-of-care ultrasound curriculum. The systematic use of these methodologies in curricular design and implementation allows expeditious curricular improvement. Emphasizing the relevance of QI methods to subject matter beyond clinical processes may increase resident engagement in QI efforts.