Krista Veine, BSRT(R)

When an organization decides to invest in new technology for computed radiography (CR) and digital radiography (DR), questions arise concerning quality assurance, training, continuing education, image quality, and picture archiving and communications systems (PACS). The radiology group may also wonder how to determine whether optimal image quality is being obtained at the lowest possible radiation dose.

Searching for CR and DR quality-control (QC) information on the Internet and in radiology journals may prove fruitless because little has been published in this area and standards have not yet been established. As a result, the diagnostic radiology department at Spectrum Health, Grand Rapids, Mich, found it necessary to design its own QC programs for CR and DR.

Spectrum Health is a not-for-profit health system in western Michigan that offers a full continuum of care through seven hospitals, more than 140 service sites, and a 450,000-member health plan (Priority Health). The system’s 13,000 employees, 1,400 medical staff, and 2,000 volunteers are committed to delivering care of the highest quality to those in medical need; the system provided $88 million in community benefit during 2005.

In 2003, the organization decided to invest in a comprehensive, one-vendor CR-DR system to help achieve its organizational vision (to be the nation’s highest quality and most successful health care enterprise by 2010). Spectrum Health diagnostic radiology group wanted to help the organization achieve that vision by implementing a CR-DR program of high quality. This called for the creation of a QC plan and a program team.


Several key members should be involved in any QC program. These include representatives of the system vendor, the physicists, the clinical engineering department, the PACS team, the education department, and the radiologists. The vendor plays an important role not only in deploying the equipment, but also in providing basic education and QC tools. CR and DR are new technologies to many organizations, so the vendor should provide basic education for technologists, creating an understanding of the technology in use. However, this level of education may not be provided by the vendor unless the purchaser makes this an expectation at the outset. Developing a strong partnership with the vendor is vital to maintaining an effective, lasting CR-DR program. A vendor should be highly interested in listening to feedback from users concerning how to improve the product; a good vendor may base development strategy upon such feedback.

At Spectrum Health, the physicist group has played a supportive role in the QC program; an internal radiology physicist was also hired recently. When the CR-DR system was implemented, the contracted physicist group was asked to help outline a QC program, but found no examples available. As the department began to create the program, the physicist group reviewed the program and ensured its completeness.

All vendors will issue warranties for their products for a period of time (typically a year). Once the warranty period has ended, the buyer must decide whether to extend the vendor’s service contract or rely on an in-house biomedical department. Spectrum Health combined these options by extending its service contract while sending biomedical staff for training in CR-DR equipment service and maintenance. When equipment is down, lost operating time equals lost revenue. If in-house service can handle basic problems, costly service calls and downtime can be prevented.

Any organization acquiring CR-DR equipment is likely to have a PACS in place or to be considering PACS implementation in the near future. Spectrum Health created a division of radiology and information technology that focuses solely on PACS development and quality. The PACS group is headed by a manager and staffed by analysts who monitor PACS patient data and image quality.

In health care, education and communication are vital to the success of any new venture. It is important to engage the staff early, teaching them what CR and DR technologies are, what makes them different from analog imaging methods, and what new factors will be most important to image quality. At Spectrum Health, the diagnostic radiology manager developed a basic pamphlet for the staff that covered these three areas and a timeline for the changes being made as the department converted to CR-DR use. The vendor also provided the department with various educational tools and with access to an applications specialist.

In 2004, the department hired a diagnostic radiology applications coordinator to implement and monitor the QC program, to help educate and train staff, to maintain complete understanding of the equipment and technology, to work with radiologists on their concerns or projects, and to work with the diagnostic radiology manager to develop QC strategies and other quality enhancements. The applications coordinator had 8 years of experience as a diagnostic radiographer and holds a bachelor’s degree in health care administration. This individual has had a positive influence in the transition to filmless operation and is available to help technologists with their questions about positioning, image quality, and technology. The applications coordinator travels to the vendor’s customer-feedback programs and applications training school, as well as to other education programs. Upon returning, the applications coordinator then informs the staff of current and future CR-DR innovations.

Radiologists, as the end users of the department’s CR-DR services, must be involved in the QC program. The department should ensure that its staff is sending the radiologists images of the highest possible quality, obtained at the lowest possible radiation dose. Spectrum Health has a high-volume imaging department, and its radiologist group, Advanced Radiology Services, Grand Rapids, Mich, has been an integral part of the QC program’s success. The radiologists have been patient and have provided great insight and constructive criticism on image quality. This in turn allows the department to meet its needs and those of the patients as well. In the reading areas of the radiology area, the department has placed QC trays for radiologists to leave comments/questions for the applications coordinator each day. Immediate concerns are addressed at once; the applications coordinator or diagnostic radiology manager contacts the commenting radiologist for clarification or to report that the situation has been resolved.


Responsibility assignments suggested for a typical quality-control program in computed radiography (CR) and digital radiography (DR); PACS=picture archiving and communications system. (Click the image for a larger version.)

The applications coordinator and diagnostic radiology manager developed a QC program that assigns responsibilities (see figure at right) and goals. When the department meets quarterly goals, the staff as a whole is rewarded (with a pizza party, cafeteria lunch, or other token of appreciation). This encourages the staff members to work together toward a common goal; it also makes the QC program positive, not punitive. Since the QC program has been in place for more than a year, some of its goals have now been incorporated into staff performance reviews.

Four basic components are monitored, with results reported to the staff monthly. These four components are the overall CR-DR repeat rate, the exposure indicator, the number of PACS edit notifications, and the applications coordinator’s image-review statistics.

CR-DR Repeat Rate. The repeat rate is a statistic that radiology departments have always monitored. However, the CR-DR product allows repeat rates to be tracked by technology and by individual technologists. The monthly and quarterly figures reported by the department are the overall repeat rate, the CR repeat rate, the DR repeat rate, and the individual technologists’ repeat rates; goals to be met or exceeded are also set. The overall repeat rate has ranged from 6.6% to 10.3% since CR-DR installation.

Exposure Indicator. The exposure indicator shows whether the image was overexposed, underexposed, or ideal. Exposure indicator is the generic term used in the CR-DR industry, but each vendor changes the name and value system to be specific to its own equipment. This has made learning the value system for equipment from different vendors difficult. Currently, the industry is developing a name for the exposure indicator and a consistent numeric value system. This unit of measure is very important to monitor because unwanted exposure creep is a common problem with CR and DR. An image can be adjusted to look ideal if too high a radiation dose is used (overexposing the patient to radiation). If underexposed, however, it cannot be adjusted as easily and will look noisy or grainy. Each vendor has a different numeric value used to reach ideal exposure. It is important to ensure that the department’s staff is neither underexposing nor overexposing the image, but trying to come close to the ideal exposure indicator. The goal is to use the lowest exposure indictor that creates an ideal image, as this indicates that a high-quality diagnostic image was produced at the lowest practical level of radiation exposure.

PACS Edit Notifications. PACS edit notifications are forms that the PACS team and applications coordinator use to notify staff and document issues when data have not properly crossed over into the PACS database. These notices are tracked for the department as a whole and for individual staff members. Technologists must check the PACS after every patient, just as if they were taking their films to be filed in the film library, because the PACS now serves as the film library. If a staff member does not check the PACS and there is a discrepancy in patient data, a PACS edit notification form will be generated.

Image Reviews. The applications coordinator performs daily and weekly image reviews. If an image could have been improved for any reason, the applications coordinator will document the problem and share it with the appropriate staff member. This process allows the applications coordinator and diagnostic radiology manager to see individual and departmental trends. The image review is also a great opportunity to share positive feedback with the staff and recognize high-quality work. It is vital to keep reviewing images daily in order to detect any quality problems before they become established. It is easy to conduct image review at any PACS workstation, since it is no longer necessary to locate and hang films for review.


While standards for QC in DR and CR do not exist yet, radiology departments must take steps to create their own metrics. It is necessary to work with all involved parties and create a program that works for each department’s staff, radiologists, and the organization overall. CR and DR technologies will continue to grow and change; QC programs must evolve with them.

Krista Veine, BSRT(R), is diagnostic radiology manager, Spectrum Health, Grand Rapids, Mich.