Chapter 1: Introduction to Quality Management

Diagnostic imaging is a multistep process by which information concerning patient

anatomy and physiology is gathered and displayed with the use of modern technology.
 Unfortunately, numerous sources of variability, in both human factors and
equipment factors, can produce subquality images if not properly controlled.
 This can result in repeat exposure that increase both patient dose and
department cost and possibly decrease the accuracy of image interpretation.
 This in return can result decreased customer satisfaction (customer being
physicians, vendors, insurance companies, employees and patients)
Note: Once you repeat your x-ray, automatic the patient dose will be increase. For
example, if you have cut off in your right lobe in chest x-ray, what will you say to the
patient if you have to repeat the x-ray? “White lies because we cannot tell the patient
that you an incorrect film because it can add problems the situation. 1. you must not be
cut off, 2. Rate of the patient. You just have to inform the patient that the doctors
requests another view so we need to repeat the procedure. Another is “Ma’am, we have
another problem in your breathing so we need to repeat the exposure”
Note: If they’re not satisfied with the result or your patient care, then they will not be
satisfied.
The Purpose of Quality Management
 Purpose of Quality Management program is to control or minimize these
variables as much as possible. These variables include equipment; image
receptors system; quality of image processing; viewing or display conditions; and
competency of the technologist, support staff.
 It doesn’t matter if you have a good equipment as long as the technologist is
good, experienced and competent.
The National Academy of Medicine (NAM) defines quality care is providing patients
with appropriate service in a technically competent manner, with good communication,
shared decision making, and cultural sensitivity.
Note: Cultural sensitivity is important because it allows us to effectively function in
other cultures, allows us to respect and value other cultures, and can reduce cultural
barriers between professionals and their patients. Like for example, the only
technologist that time is you (male) and he wants a female technologist, how will you tell
the patient that you’re the only technologist available or how will you handle the patient?
I will tell the patient if she really insisting to request a female rad tech then we will
schedule her examination.
When discussing the quality of particular goods or services, one must keep in mind the
3 levels on which quality is determined:
1. Expected Quality – Level of quality of the product or service that is expected by
the customer and may be influenced by outside factors such as prior word of
mouth from friends and relatives.
 Example: You have expected quality that radiologic technologist is good in
DDH; they always produced good quality image and they’re good in
patient care but they’re expensive.
2. Perceived Quality – Customer’s perception of the product or service.
 Example: “If you’re going to Davao doc, their service is expensive, it costs
a lot of money.
3. Actual Quality – Uses statistical data to measure outcomes and considers all
factors that can influence the final outcome.

Note: So, if the hospital can cope up with the expected quality, then you have the
perceived quality and actual quality.
Note: If the patient has high expectation, usually ang kawawa dyan is ang
employee.
Since the early 1980s, Health Care delivery in the US has undergone dramatic changes
that have affected diagnostic imaging departments. These changes include the
following:
 Advances in technology, equipment and procedures
 Legislation and government regulations
 Accreditation procedures
 Corporate buyouts and mergers
Note: In DDC, we already have Dental X-ray (Digital). In radio, we do have different
areas like Ultrasound, CT, MRI. In other department, we have Nuclear Medicine (which
is the machine is gamma camera). For the RT, we have LINAC (Linear Accelerator) and
their new machine which is the Tomotherapy.
Advances in technology, equipment, and procedures.
 The digitization of radiography
 Magnetic resonance imaging (MRI)
 Spiral computed tomography (CT)
 Electron beam tomography
 Positron emission tomography (PET)
 Digital radiography and fluoroscopy
 Single-photon emission computed tomography (SPECT), has increased the cost
of equipment acquisition, installation, and maintenance
Legislation and government regulations
In Philippines, we are legislated with the DOH, they are responsible in creating policy
and guidelines. Once you will set up hospitals or clinics, they will set guidelines that
would you follow to check if you’re following government regulations.
 Safe Medical Devices Act (SMDA) of 1990
 Mammography Quality Standards Act (MQSA) of 1992
 Mammography Quality Standards Reauthorization Act (MQSRA) of 1998
 Medicare Improvements for Patients and Providers Act of 2008 has increased
the responsibility of diagnostic imaging department managers and staff to
document proper equipment operation and procedures.
Accreditation Procedures
Davao Doc is accredited in accreditation Canada; Saint Luke’s is accredited with JCI
(Joint Commission International); SPMC is accredited with ISO (International Standard
Organization)
 The accreditation procedures of The Joint Commission (TJC)
 Quality assurance (QA)
 Total quality management (TQM)
Corporate buyouts and mergers
Many others have been purchased by “for profit” healthcare organizations or have
merged to condense costs or reduce competition, or both.
 Methods of reimbursement for services rendered. The previous method of “fee
for service” reimbursement of healthcare expenses is rapidly being replaced by
managed care plans such as health maintenance organizations (HMOs) and
point of service plans such as preferred provider organizations (PPOs).
Note: MPIC – Metro Pacific Investment Corporation, they are the one who bought
Davao Doctors Hospital same with Davao Doctors College. After buying that, they own
the share of Davao Doc. Once they are procured by this business man, automatic, the
leadership style would change. They will be based on profit based or profit driven.
Note: Oncology – they are treating cancer patients
STANDARDS, REGULATIONS, AND QUALITY MANAGEMENT
Standard is a statement that is defined and promoted by a professional body or
organization, by which the quality of practice or service can be evaluated.
Accreditation is a method that is used to assess organizations and determine whether
they meet minimum established standards.
Standards that have been written into local, state, or federal law that are employed in
controlling, directing, or managing an activity, organization, or system are known as
regulations.

HISTORY OF QUALITY MANAGEMENT IN DIAGNOSTIC IMAGING

In the 1860s, Florence Nightingale – first to use a systematics approach to collecting
and analyzing mortality rates and other data in hospitals, and recommending changes
based on these data.
In 1910, Ernest Codman, MD (who helped found the American College of Surgeons),
proposed the “end result system of hospital standardization.” With this system, a
hospital would track patients to determine whether the treatment given was effective.
In the work of an industrial engineer named Frederick Winslow Taylor. Taylor is
considered the “Father of Scientific Management” because of his philosophy that the
planning function and the execution stage of production be separate and that numerous
individuals be assigned specific tasks within the production process to minimize the
complexity of the task.
The Joint Commission
 TJC, formerly known as the Joint Commission for the Accreditation of Healthcare
Organizations, or JCAHO), was founded in 1951 and is an independent, not-for-
profit organization that accredits and certifies more than 20,000 healthcare
organizations and programs in the United States.
 Accreditation is voluntary, but hospitals and medical centers that do not have it
may not possess Medicaid certification, hold certain licenses, have a residency
program for training physicians, obtain reimbursements from insurance
companies, or receive malpractice insurance.
Det Norske Veritas Healthcare
DNV Healthcare, Inc., is part of Det Norske Veritas, a global foundation that was
established in Oslo, Norway, in 1864 and has been operating in the United States since
1898. Their stated purpose is to safeguard life, property, and the environment.
These standards are based on very similar quality management principles as TJC
standards, namely; part of core standard in making or guide in accrediting hospital.
1. Customer focus – how you deal with your customer
2. Leadership
3. Involvement of people
4. Process approach
 5. System approach to management – If your system is efficient in handling your
people
6. Continual improvement – it pertains to your learning, if you continue to handle
seminars to all of your staff
7. Factual approach to decision making – based on the facts in handling cases
8. Mutually beneficial supplier relationships – if you have a good relationship with
your supplier; supplier that we need in medical – for example, from the pharmacy
down to the medicine; in equipment, we have biomedical concern
Quality Assurance
 Quality assurance (QA) is an all-encompassing management program used to
ensure excellence in healthcare through the systematic collection and evaluation
of data.
 Quality assurance should not be confused with quality assessment, which is the
measurement of the level of quality at some point in time with no effort to change
or improve the level of care.
Quality Control
Quality control (QC) is the part of the QA program that deals with techniques
used in monitoring and maintaining the technical elements of the systems that affect the
quality of the image.
Level I: Noninvasive and Simple. Noninvasive and simple evaluations can be
performed by any technologist and include tests such as the wire mesh test for screen
contact and the spinning top test for timer accuracy.
 Problems of the wire mesh test is your film is not properly in contact with the
intensifying screen. If it’s not in contact, the images might be blurry on its
edges; this can be done by the rad.tech.
Level II: Noninvasive and Complex. Evaluations should be performed by a technologist
who has been specifically trained in quality control procedures.
 This can also be done by the rad.tech. but trained to undergo this type of
procedure because he trained as RSO (Radiation Safety Officer)
Level III: Invasive and Complex. Evaluations involve some disassembly of the
equipment and are normally performed by engineers or physicists.
Continuous Quality Improvement
Continuous Quality Improvement (CQI) which is defined as the organizational
process for involving personnel in planning and executing a continuous flow of
improvements to provide quality healthcare that meets or exceeds expectations.
 In 1991, TJC began incorporating the concepts of continuous quality
improvement (CQI), which is defined as a structured organizational process for involving
personnel in planning and executing a continuous flow of improvements to provide
quality healthcare that meets or exceeds expectations, to replace the older QA/QC
philosophy into their program of accreditation of healthcare organizations.
CQI evolved from total quality management (TQM) concept in the manufacturing
industry, also referred to as total quality control (TQC), total quality leadership (TQL),
total quality improvement (TQI), and statistical quality control (SQC). This concept is
based on the “14 Points for Management” developed by W. Edwards Deming.
Administrative Procedures
 Establish thresholds of acceptability
 Establish an effective communication network
 Provide for patient comfort
 Ensure accepted performance of diagnostic imaging personnel
 Develop a record-keeping system
 Establish corrective action procedures
PROCESS IMPROVEMENT THROUGH CONTINUOUS QUALITY IMPROVEMENT
The concept of process improvement through CQI is based on the following premises:
 85/15 Rule - the process or system in place is the cause of problems 85% of the
time, and the people or personnel within the process are the cause of problems
15% of the time.
o 85% - It could be your computer work, system you are following. For
example, if no receptionist, the radtech will receive the request; with this
example, even though personnel involved, it was not approved by the
management to have that receptionist that’s why we have 85% problem of
the system and 15% of the people or personnel. If you have sufficient staff
for the reception then you have 3 radtechs then you won’t have this type
of 85/15 rule.
 80/20 Rule - 80% of the problems are the result of 20% of the causes.
 Workers who are closest to the problem probably know what is wrong with the
process and are better able to fix it.
o If the worker or the radiation technologist already knows the problem,
double time. If that rad tech loves his/her or he/she is a hardworking
worker, he would work double time. But if he/she will finish the x-ray as
soon as possible, it will hamper the quality assurance or the patient care
to our patient because you are in too much of a hurry; for example, you
have senior patient and regular patient and that senior patient wants to be
prioritized, you can alternate them but the more patient would wait
 because it’s not easy to cater the senior. It would take time to position the
senior and will also depend on his case.
 Structured problem solving processes that use statistical means to verify
performance produce better long-term solutions than processes that are not
structured.
o We need to structure or evaluate every problem to create a policy or
guidelines so that we can have structured program
 Improving quality is the responsibility of everyone within an organization because
all are a part of the process.
o Even us, we are radiologic technologist, we are part of this process. For
example, 3 rad techs and one of them likes to play video games, the flow
will be hampered because there are some workers or colleagues who
didn’t work diligently.
A process is an ordered series of steps that help achieve a desired outcome or all the
tasks directed at accomplishing one particular outcome grouped in a sequence.
A system is a group of related processes.
A supplier is an individual or entity that furnishes input to a process (person,
department, organization) or one who provides the institution with goods or services.
 In hospital, if we’re going to talk to those people, we have person, department,
organization. In terms of person, if we’re referring to another person, it could be
your supplier. If other department, like medicine or laboratory. In terms of
organization, we have nursing services, or ancillary services, it could be the
medical records. In a hospital, it’s a complex operation we are dealing the
different types of suppliers, people and organization. We are not the only workers
in the hospital because if you know, are performing x-ray, if you will send out
outside, automatic, it will have a feedback from the patient. For example, you are
performing an x-ray and you didn’t care the patient, and that patient go back to
his room or outside hospital or within hospital, if that patient is inpatient, if you’re
not good in your patient care, you will be reported. You are channeling your
problem to another department then you will be reported, given an incident
report, and you will be investigated. The best thing to do is you are at your best
in giving the patient quality patient care.
Input is information or knowledge necessary to achieve the desired outcome or
everything that is used to produce one or more outputs from a process.
Action is the means or activity used to achieve the desired outcome or the steps or
activities carried out to convert inputs to one or more outputs. The action steps are
sometimes referred to as the workflow.
 For example, for the x-ray, check first if “mauna ka sa counter or in the
receptionist. We need to have a workflow because we need to verify the request.
 For example, if your workflow is it would start from the receptionist then the
receptionist will check the requests and after that, he will be reporter to go to
billing. After reported in the billing then he will be reported back to the
receptionist and after that, we have to care the patient to the x-ray.
Output refers to the desired outcome, result, product, or characteristics that satisfy the
customer or one or more outcomes.
 We have x-ray request, then after that, you performed the x-ray. You are
expecting a good quality patient care and the output is that the result would be
released at this time with the reading of the doctor.
Customer refers to a person, department, or organization that needs, uses, or wants
the desired outcome or a process.
 That is given because in the hospital, the services is linked between other
department because the doctor could request from one laboratory test, medical
test or diagnostic test to another then it would be performed.
Internal customers - In general, these are individuals or groups from within the
organization such as referring physicians, hospital employees, departments, and
department employees.
External customers - These are individuals or groups from outside the organization,
such as patients and their families, third-party payers, and the community.
Key Quality Characteristics
At an organizational level, healthcare metrics can be classified into the following basic
types:
 Financial - track the financial performance of the healthcare system from a
business perspective.
o It’s important that we have to know the financial aspect or status of the
hospital because for instance that hospital do have a complete equipment
but don’t have a patient meaning the hospital cannot received any amount
of money coming from a patient. In public, it is funded by the government.
In private, they really need to check it if they are gaining some income or
losing some income because that’s part of their survival if they have
enough money to give salary to continue the system, bills, doctors, many
factors. “What if the hospital has no income? You can sell it through
mergers or buyout to have a different perspective in operating hospital
business, you can also give it to other, let other govern or mange your
hospital so that it can be productive or you can also close the hospital
since you were not able to sustain the expenses or bills.” Note: There are
5 private hospitals in Davao City. New hospital: Lanang Premiere
Hospital.
  Utilization - characterize the number and type of basic services rendered, the
resources that are used, and the availability of care (e.g., MRI; Davao Doc and
San Pedro Hospital, SPMC, PET; if your area is populous, then you can cater
other region or other countries; an expensive modality in diagnosing cases in our
patient; range of PET in procedure is around 50-100,000 diagnostic)
o You have to utilize that is needed for the hospital.
 Cost/Productivity - used to reduce supply/labor costs and increase productivity
 Clinical Performance - also known as patient outcome data, these measure the
quality of patient care, such as mortality rates and accuracy of diagnosis.
 Patient Safety - metrics that characterize preventable medical mistakes that are
made
 Patient Satisfaction - measure satisfaction from a patient’s perspective
o Patient is the one who will grade your patient care because they are the
one who receive the care or the action coming from technologist; some
complainants are relative or watcher.
Key Process Variables
 Manpower refers to the personnel involved in the process.
o For example, x-ray procedure. We have multiple personnel to help you.
You have that receptionist, encoder, cashier, and radiologic technologist.
 Machines refers to the equipment used in the process.
o The machine can either malfunction or breakdown because you don’t
have PMS or the machine is overused.
 Materials refers to the type and quality of materials used in the process.
o In that case, if you’re using the DR or the manual system,

Components of a Quality Management Program in Diagnostic Imaging

 Equipment quality control. This aspect of a quality management program
involves evaluation of equipment performance to ensure proper image quality, as
well as patient and operator safety.
o That’s why we should have preventive maintenance service, there are
some services that requires monthly, quarterly, annual and annually so
that we can have a sufficient quality output that will be produced by x-ray
machine.
 Administrative responsibilities. Involves the establishment of various
processes to accomplish the specific departmental tasks that are required, such
as departmental procedure manuals for performing diagnostic examinations or
procedures for scheduling and routing of patients.
o We need to have this departmental procedure manual for example if
someone coming in or entered the department, then that someone is
somewhat crazy and suddenly he went wild so what procedural manual
would you do if that thing happens if you’re the receptionist? What will be
 the system or the flow? Notify the supervisor, if that supervisor is not on
duty, notify the chief, radiologic technologist or unit manager. If not, you
can go to security guard.
 Risk management. The ability to identify potential risks to patients, and visitors
at the healthcare institution and establish processes that would minimize these
risks is extremely important to healthcare organizations.
 Radiation safety program. This is to ensure that patient exposure is kept as low
as reasonably achievable (ALARA).
Threshold of Acceptability
 The threshold of acceptability includes level of accuracy, sensitivity, and
specificity of diagnosis. It also should include such items as the number of
radiographs per examination.
o In assessing this, you need to have this level of accuracy, sensitivity, and
specificity of diagnosis. What you will do is you have to repeatedly x-ray
the film using a phantom to have this accurate reading/images from that
image phantom. If you’re trained to do this (Level I), you can do this but if
not, radiation physicist would do this.
Communication Network
 Proper communication among all members of a diagnostic imaging department is
essential for a successful quality management program.
Patient Comfort
 Patient comfort, convenience, and privacy should be provided within reasonable
limits in diagnostic imaging departments.
Personnel Performance
 Policies should be developed to ensure that diagnostic personnel are performing
their duties within accepted professional standards for areas such as proper
equipment operation.
Record-Keeping System
 A record-keeping system is necessary to document that quality management and
quality control procedures are being implemented and that they are in
compliance with accepted norms.
o You need to have this big storage capacity so that we can store or keep
the data because it is a requirement that you should compare your one x-
ray to another given the fact that not more than 5 years. Now we have
that PACS (picture archiving and computer system) to store the data or
keep the data.
Corrective Action
  If equipment or personnel are not performing to accepted standards, corrective
action must be taken and documented.

RISK MANAGEMENT
 An important aspect of a quality management program for diagnostic imaging
departments is risk management.
 Risk can be defined as the chance of an event or incident happening that may
threaten or damage an organization.
 Safety is defined as the freedom from accidental injury or death, and is a key
dimension of healthcare quality.
o For instance, that if the patient slides, that would include to the safety
problem or concern. What is needed is the gripping factor, anti-slippery or
rubber to prevent this type of incident.
 Error is defined as the failure of a planned action to be completed as intended or
the use of a wrong plan to achieve an outcome.
Risk Analysis
 Risks to patients. Patients may slip and fall, be hit by equipment, have a
reaction to contrast media, have entered the department with a traumatic injury
and be improperly manipulated, or receive the wrong diagnostic procedure.
 Risks to employees and medical staff. Injuries from falls, back injury from
lifting patients or heavy equipment, repetitive stress injuries, needle pricks
(number one risk in hospital), exposure to infectious diseases, exposure to
ionizing radiation, and exposure to toxic chemicals such as processing solutions.
 Risk to others. Includes such persons as students, visitors, and volunteers and
is the most difficult category to assess.
 Once a risk analysis is performed and policies and procedures have been
created to reduce any potential risks, the next step in a risk management
program is to create an investigation procedure for any incidents that may occur.
An incident is any occurrence that is not consistent with the routine care of a patient or
the normal course of events at a particular facility.
Policies and Procedures
 Risk analysis - to identify all potential hazards and risks that can occur
 Written policies and procedures - to reduce all risks and deal with incidents as
they occur
 Employee education - to inform employees of all policies and procedures
 Periodic inspection - to ensure that all policies and procedures are being
implemented
  Record keeping - to document that all policies and procedures have been
implemented.

RADIATION SAFETY PROGRAM

Patient Radiation Protection
The federal government recommends that the “as low as reasonably achievable”
(ALARA) concept be used during all diagnostic x-ray procedures. ALARA is covered in
detail in the National Council on Radiation Protection (NCRP). Some of the main
recommendations of the ALARA program for radiographic examinations include the
following:
 Use of high kilovolt (kVp) and low milliampere-second (mAs) exposure factors
 Use of high speed image receptor systems
 Use of proper filtration
 Use of the smallest field size possible, along with proper collimation
 Use of optimum processing conditions
 Avoidance of repeat examinations
 Use of PA instead of AP
 Use of gonadal shielding
Fluoroscopic Examinations
It have the potential to deliver a considerable dose of radiation to the patient.
Therefore ALARA protocols, including the following, should be in place for these
examinations:
 Ensure that the fluoroscopic system does not exceed maximum entrance
exposure
 Keep (mA) and time as low as possible when performing fluoroscopy.
 Use high (kVp) if possible
 Limited field size as much as possible
 Use intermittent fluoroscopy
o Some of the fluoroscopic machine have 5-minute timer, the autotimer.
When it reaches 5 minutes, it will automatically stop and is needed to
press it again. But some doctors would demand, especially if the
procedure is ortho, neuro, spinal procedures
 Use the last image hold feature
 Avoid the magnification mode
 Keep the patient to image intensifier distance as short possible during mobile
fluoroscopic studies with a C-arm
  Reduce the number of spot images, and reduce the spot image size.
Visitor Protection
 “Visitors” to diagnostic imaging departments are persons other than patients or
radiology department staff. They may include relatives or friends of patients,
hospital volunteers, security personnel, or other hospital employees who do not
normally work in radiation areas (e.g., nurses, patient care technicians,
respiratory therapists).
Personnel Protection
Personnel who perform diagnostic procedures using ionizing radiation can potentially
receive significant amounts of radiation and must therefore follow proper radiation
practices. According to NCRP report number 116, maximum total effective dose
equivalent for occupational personnel are as follows:
Whole-body exposure 5rem (50mSv) per year
Eye lens 15rem (150mSv) per year
All other body parts (such as hands) 50rem (500mSv) per year
 Chapter 3: Imaging Quality
Image or Pixel Brightness
 Because digital images are viewed on a display monitor, each pixel in the matrix
will be assigned a brightness level (black, white, or gray shade) by the computer
to demonstrate patient anatomy. This would be comparable to the optical density
of film-based images. Factors that affect pixel brightness are discussed in the
following subsections.
Quantity and Quality of Energy Reaching the Image Receptor
 Depending on the modality, the amount and/or energy that reaches the image
receptor can determine the shade of each pixel that is displayed in the final
image.
o Before, in radiology, we have 1 darkroom. Not necessary to have
darkroom in CT, MRI, x-ray, ultrasound, Nuclear Medicine, even ortho and
oncology.
o X-ray = Dose passbox
 In imaging systems that use x-rays (radiography, fluoroscopy, and computed
tomography [CT]), the amount and energy of the x-rays striking the detector array
or imaging plate will help determine the brightness of each pixel and therefore
the overall brightness of the image displayed.
o Your CT should be calibrated or a good detector in order for you to have
these images.
 In magnetic resonance imaging, the strength and frequency of the radio waves
that return from the patient’s body is interpreted by the computer and helps
determine pixel brightness.
 In ultrasonography, the strength of the return echo received by the transducer
elements determines the pixel brightness.
 In nuclear medicine scans, the amount of radiation emitted from a particular
organ or tissue of the body helps determine the brightness value of each pixel.
Software
 No matter which imaging modality is being utilized, computer software helps
create pixel brightness values that best demonstrate the anatomy of interest. In
 digital radiographic studies, the computer software utilizes histogram analysis
and rescaling to create optimum pixel values.
 Each image is only a “window” on the total range of data. The range between the
largest-possible signal intensity, or frequency, divided by the smallest-possible
signal value that a system can process or display is called the dynamic range
(similar to film latitude). The dynamic range of the digital signal carrying data to
the computer will be far wider (digital radiography [DR] has a dynamic range of
10,000:1 compared with film, which has 40:1) than the range of grayscales in the
image on the monitor (500:1).
In simple terms, dynamic range is described as the number of gray shades that can be
represented in an image. It can also be defined as the range of exposures over which a
detector can acquire image data.

 The gray shades that make the image on the monitor are called the window. The
computer can easily change the level and width of the display window by
mathematical recalculations. The window level controls image brightness in
digital modalities. The window level is the level within the signal that produces
the center brightness level in the window.
Photometry
The radiant energy that strikes or crosses a surface per unit of
time or radiant energy emitted by a source per unit time is
called radiant flux and is measured in watts (W). The watt is
defined as the number of joules (J) of energy per second, or 1
W = 1 J/s. Radiant flux, evaluated with respect to its capacity
to evoke the sensation of brightness, is called luminous flux.
 If certain procedures like this and then you are trained,
you can perform this if the radiation physicist or the
 Radiation safety officer (RSO) trained you to do this, then the radiologic
technologist will perform this. If such education and expertise is highly needed,
radiation physicist is the one who is going to perform this.

Illuminance
 Illuminance is the amount of luminous flux incident per unit area, or the amount
of light that is projected onto a given surface. It is not the amount of brightness of
a light source, but rather the result of that light source in illuminating a particular
area. For example, we are often more interested in the intensity of light falling on
a surface than we are in the brightness of a light source. If you are reading, you
are more concerned with the brightness of the page than with the brightness of a
particular light bulb. The brightness of the page that you are reading is the
illumination; the brightness of a particular light bulb is the luminance.
Luminance
 Luminance is the luminous intensity per unit of projected area of source, or the
amount of light that is emitted or scattered from a particular source. In other
words, luminance measures the brightness or intensity from a particular light
source.
Image Contrast
 Image contrast is defined as the difference in pixel brightness values between
the various areas of the image. Images with a relatively small number of gray
shades in addition to black and white shades are classified as having high
contrast (because of the high or large difference between shade values) or short-
scale contrast (because of the small range or scale of shade values).
 Images that have a relatively large number of gray shades in addition to black
and white are classified as having low contrast (because there is a low or small
difference between one shade value and the next) or long-scale contrast
(because of the many gray values in addition to black and white).

It’s critical that Radiation physicist

do their monitoring because they
have this level and window.
How are we going to do this? Exposing multiple films, exposing phantoms and you
compare it to one image to another.
If the radiation physicist did this, the x-ray room would not be use for hours to finish this
evaluation of this machine.

Subject Contrast
 This refers to the distribution of tissue densities and/or physiologic changes that
are present in the anatomic part undergoing the diagnostic study.
 Two sets of factors that influence subject contrast:
o Internal factors such as tissue densities within the part and pathology
o External factors such as radiation quality, presence of scatter radiation,
using a different radiopharmaceutical (NM), use of contrast agent such as
iodine (CT and x-ray) or gadolinium (MR), changing pulse sequence in
MR, or changing the angle of the ultrasound probe with respect to the
vessel in Doppler ultrasound.
Inherent Contrast
 Type of contrast that the imaging system is capable of delivering. For example,
digital radiographic systems can deliver different contrast options than
film/screen radiographic systems.
Displayed Contrast
 This refers to the contrast created by the computer hardware and software and
then displayed on the viewing monitor. This is affected by variables such as
computer software, computer hardware, and the viewing monitor.
 Computer Software
o During processing, digital imaging systems utilize Look-up-tables (LUT) to
create the most desirable image contrast for the examination that is
selected in the imaging
protocols. Once the image has
been created and displayed on
the viewing monitor, the image
contrast can be manipulated in
digital imaging by using a factor
called the window width.

This figure show contrast resolution evaluation

using a Leeds test stool
Spatial Resolution
 Spatial resolution (also known as high-contrast resolution) is the ability of an
imaging system to create separate images of closely spaced high-contrast
(black-and-white) objects.
Computer Matrix
 The matrix size of the computer refers to the total number of pixels that will be
used to create the image. The larger the matrix size (number of pixels), the
greater the spatial resolution (or sharper image). This is because the size of each
pixel would also have to be smaller in order to fit into a matrix of the same
dimensions. A smaller pixel size is comparable to having a smaller paint brush to
paint a scene containing fine detail, whereas a larger pixel size would be like
trying to paint with a larger brush. The disadvantage to having more pixels in a
matrix is that it will increase the storage requirement of the image data in the
Picture Archiving and Communication System (PACS) system.
Table 3.3 – Matrix Size for Various Imaging Modalities
Digital mammography 4096 x 6144
Computed radiography & digital radiography 3520 x 4280
Digital fluoroscopy 1024 x 1024
Computed tomography 512 x 512
Multislice computed tomography 512 x 512
Ultrasonography 512 x 512
Magnetic resonance imaging 256 x 256
Nuclear medicine 128 x 128

Display Monitor
 Like computers, digital display monitors have a built-in matrix made up of a
specific number of pixels, and the more the pixels in a specific matrix size, the
smaller each pixel and the greater the spatial resolution in the displayed image.
Aperture Size, Detector Size, or Sampling Frequency
 The aperture size refers to the number of detectors per millimeter in the image
receptor (i.e., number of detector elements or DELs in a DR active matrix array
or number of detectors in the CT gantry). This can also be referred to as the
sampling frequency. The smaller the detectors used, the more can be placed per
millimeter in an array, which will yield a greater sampling frequency and therefore
greater spatial resolution.

Table 3.4 – Pixels in Television and Computer Monitors

Format 4:3 Aspect Ratio 16:9 Aspect Ratio Megapixels
(MP)
Standard definition (SDTV) 640 x 480 720 x 480 0.3
High Definition (HDTV1) NA* 1280 x 720 0.9
High Definition (HDTV2) NA* 1920 x 1080 2.0
Ultra high definition (UHD) NA* 2840 x 2160 4.0
Computed radiography and NA* 3520 x 4280 15.0
digital radiography monitor
Digital mammography monitor NA* 4096 x 6144 25.0
*NA – Not Applicable
  The bigger the value that you can detect, the clearer the image that can be
produced.
 The radiation physicist will be the one to perform this.

Measurement of Spatial Resolution

 Spatial frequency is the line pairs per millimeter (lp/mm) and is obtained with a
resolution chart. A line pair includes an opaque line and a radiolucent space.
 The greater the lp/mm value, the smaller the object that can be imaged and the
better the spatial resolution. The limiting spatial resolution (also known as the
Nyquist frequency) is the maximum number of lp/mm that can be recorded by the
imaging system.
Point Spread Function
 Point spread function (PSF) is a graph that is obtained with a pinhole camera and
a microdensitometer.
 The pinhole camera creates a black dot in the center of a film, and a
microdensitometer is used to take readings of this point. These values are plotted
on a graph versus the distance from the center of the point.
 The narrower the peak on the graph, the better the spatial resolution and quality
of the image. The width is usually measured at half the maximum value and is
termed full width at half maximum (FWHM).

Line Spread Function

  Line spread function is a graph that is more accurate and easier to obtain than
the PSF graph. It requires an aperture with a slit that is 10 μm wide instead of the
pinhole camera. Density readings of the centerline are taken and plotted. FWHM
values also can be obtained from this graph and interpreted much the same way
as discussed with PSF.
Edge Spread Function
 Edge spread function requires a sheet of lead to be placed on a cassette and
exposed. Density readings are taken at the border between the black-and-white
areas and plotted on a graph.

Modulation Transfer Function

 Modulation transfer function (MTF) is a numeric value that is used to measure
the spatial resolution from the line spread function graph with a mathematic
process known as Fourier transformation. Just as a mathematic number (slope)
can be obtained from a linear graph, Fourier transformation can obtain a number
from a curve. This number ranges from 0 to 1 (0% to 100%), with 1 being the
maximum spatial frequency. An easier way to think of MTF is demonstrated by
the following equation:
MTF= Information recorded in an age image
Information recorded in the part
Contrast-Detail Curve
 A method for evaluating both contrast resolution and spatial resolution
simultaneously is to construct what is known as a contrast-detail curve.
 The curve plots the object contrast percentage on the Y axis and the just
perceptible size that is visualized on the X axis. A test tool made up of rows and
columns of holes of various sizes and depths is required. The curve shows that
when the object contrast is high (i.e., large differences in size or thickness), small
objects can be imaged. If object contrast is low (small differences in size or
thickness), objects must be large to be visualized.

Detective Quantum Efficiency

 Detective quantum efficiency (DQE) refers to how well the imaging system
converts SNR2 incident on the detector into SNR2 in the image.
DQE = SNR2out/SNR2in.
 This value is best used in x-ray detection systems to indicate how efficient the
system is in converting the amount of radiation received by the detector into a
useful image; in other words, it is a measure of x-ray absorption efficiency.
Diagnostic Performance Measurement
 The main outcome of a diagnostic imaging examination is an accurate diagnosis
of a patient’s condition so that proper treatment can be administered. This is
affected by factors such as image quality (for which the technical staff is
responsible) and the competency of the radiologist to interpret the image
(determining whether the anatomy demonstrated in the image is healthy).
 In images of certain anatomic structures, the distribution of healthy patients
follows a bell-shaped normal distribution. The distribution of patients with
diseases also follows a normal distribution but with a different mean value (which
can be larger or smaller depending on the patient population studied).
  If a test result (such as a biopsy) reveals that the diagnosis is correct, a
designation of true positive (TP) is given. Patients are designated as false
positive (FP) if further study indicates that they do not have the disease despite
the positive finding from the image.
 Healthy patients with no disease present are considered negative. If a diagnosis
of negative is determined from an image and supported by follow-up studies, it is
designated as true negative (TN). If a negative diagnosis is given to a patient
who later has the disease, then a designation of false negative (FN) is assigned.
 A decision matrix or truth table can be used to demonstrate these values. The
FDA mandates that this information be derived for mammographic procedures.
From this information, the values of accuracy, sensitivity, and specificity;
prevalence; positive predictive value; and negative predictive value can be
obtained.

Accuracy
 Accuracy is the percentage or fraction of cases that are diagnosed correctly.
Sensitivity
 Sensitivity also is referred to as the TP fraction and indicates likelihood of
obtaining a positive diagnosis in a patient.
Receiver Operator Characteristic Curve
 A receiver operator characteristic curve (ROC curve; also known as a relative
operator characteristic curve) is a plot of the true-positive probability or sensitivity
versus the false-positive probability, which also can be described positive
diagnosis can range from strict to lax and represent different compromises
between the need to increase sensitivity while minimizing the number of false
positives. An ideal image would yield a true-positive probability of 1 (100%) and a
false-positive probability of 0.
Data points that would fall toward the upper left-hand corner of an ROC curve would
indicate an accurate diagnosis. If data points fall on a line that is at a 45° angle within
the graph, it would indicate random guessing by the observer.
This area measures discrimination, that is, the ability of the test to correctly classify
those with and without the disease.
Radiologists or other readers of diagnostic images with low sensitivities and low false
positives would be categorized as “underreaders,” whereas image readers with very
high sensitivities and correspondingly high false positives would be categorized as
“overreaders.” ROC evaluations of image readers can be used to establish the relative
merits of a diagnostic imaging test.