Exposure reduction through quality assurance for diagnostic x-ray procedures

Traditional state x-ray inspection programs concentrate on measurement of x-ray machine parameters such as kVp and mAs, timer accuracy, collimation, etc. In 1996, the New Jersey radiation control program began a paradigm shift from the traditional inspection to an outcome-based inspection that concentrated on two indicators of performance: image quality and entrance skin exposure (ESE). Through extensive outreach and involvement of stakeholders, a new approach was designed that placed an emphasis on quality assurance. Key to the positive outcome has been the credentialing of medical physicists. On 16 January 2001, the final regulation titled "Quality Assurance Programs for Medical Diagnostic X-ray Installations" was adopted. The new regulations require that each facility using diagnostic medical x-ray equipment (including radiographic, fluoroscopic, x-ray bone densitometric, and computed tomographic) establish and carry out a quality assurance program. The new regulation specifies the quality control tests, frequencies, and standards that are part of the quality assurance program. Five years of data have been gathered. Both ESE and image quality are checked and the inspectors conduct an audit of the facility's quality assurance program. ESE has been decreased by 34% for lumbar spine, 46% for chest, and 66% for foot x-ray procedures. Image quality has improved by 22%. Quality improvement initiatives were extended to the larger dental x-ray community. Through outreach and information sharing, stakeholders were instructed in the factors that affect patient radiation exposure and image quality and were encouraged to take actions to improve in these areas.