- Email: [email protected]
Improved X-Ray Safety, Quality Control, and Resource Management in Medical Imaging Using QATrack+
Journal of Medical Imaging and Radiation Sciences
Journal of Medical Imaging and Radiation Sciences xx (2020) 1-7
Journal de l’imagerie médicale et des sciences de la radiation
www.elsevier.com/locate/jmir
Research Article
Improved X-Ray Safety, Quality Control, and Resource Management in Medical Imaging Using QATrackþ Lesley Buckley, PhDa*, Gary Heddon, MRT(R) ACb, Ian Byrne, MRT(R)b and Crystal Angers, MSca a b
Department of Medical Physics, The Ottawa Hospital, Ottawa, Ontario, Canada Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
ABSTRACT Introduction/Background: Management of a quality assurance program in diagnostic imaging involves a variety of machine types, multiple vendors, and a large number of frontline staff who have different specializations. Standardizing tests across multiple platforms in the face of vendor recommendations, regulatory requirements, and professional practice protocols can present challenges to maintain a robust and coherent quality assurance program. The current work presents a unique application of an existing tool that can be used to manage a comprehensive quality assurance program in a diagnostic imaging department. Materials and Methods: QATrackþ is an open source, quality assurance platform originally developed for and currently widely used in radiation therapy departments. The use of QATrackþ for quality assurance program management within a large diagnostic imaging department is a novel use of this tool. Results and Discussion: QATrackþ was successfully implemented in a large, multisite diagnostic imaging department. The progression toward a single platform for the quality assurance program has addressed issues of end of life with previous software packages and has improved the standardization of testing across the institution. The configuration of the software has enabled frontline staff to be directly engaged in the quality control (QC) program, improving the efficiency of resource allocation for QC and promoting a strong safety culture and commitment to quality. Trending tools within QATrackþ allow for simplified review of tests and enable the early identification of potential failures. Conclusion: Originally developed for radiation therapy programs, QATrackþ is well suited to applications within diagnostic imaging. It is versatile and is easily adapted to the individual needs of a department for activities ranging from quality control testing, scheduling, test review, and data trending. It simplifies the standardization of quality control practices across platforms, thereby
facilitating training and promoting involvement in the quality assurance program by all staff. RESUM E Introduction/contexte : La gestion d’un programme d’assurance de la qualite en imagerie diagnostique implique un eventail de types de machines, plusieurs fournisseurs et un grand nombre d’employes de premiere ligne ayant des specialisations differentes. La standardisation des tests sur des plateformes multiples en tenant compte des recommandations des fournisseurs, des exigences reglementaires et des protocoles de pratique professionnelle peut poser des defis au maintien d’un programme d’assurance de la qualite robuste et coherent. Cet article presente une application unique d’un outil existant pouvant ^etre utilise pour gerer un programme complet d’assurance de la qualite dans un service d’imagerie diagnostique. Materiel et methodologie : QATrackþ est une plateforme d’assurance de la qualite en code ouvert conc¸ue au depart pour les services de radiotherapie et aujourd’hui largement utilisee par ces derniers. L’utilisation de QATrackþ pour la gestion du programme d’assurance de la qualite de grands services d’imagerie diagnostique est une nouvelle utilisation de cet outil. Resultats et discussion : QATrackþ a ete mis en œuvre avec succes dans un grand service d’imagerie diagnostique comprenant plusieurs sites. Le passage a une plateforme unique pour l’assurance de la qualite a permis de resoudre des problemes de fin de cycle de vie des logiciels anterieurs et d’ameliorer la standardisation des tests dans l’ensemble de l’organisation. La configuration du logiciel a permis au personnel de premiere ligne de s’engager directement dans le processus de contr^ole de la qualite (QC), d’ameliorer l’efficacite de l’allocation des ressources en CQ et de promouvoir une culture de la qualite solide et un engagement envers la qualite. Les outils de tendance de QATrackþ permettent un examen simplifie des tests et l’identification precoce des defaillances potentielles.
* Corresponding author: Lesley Buckley, PhD, Department of Medical Physics, The Ottawa Hospital, 501 Smyth Road, Box 927, Ottawa, Ontario K1H 8L3, Canada. E-mail address: [email protected] (L. Buckley). 1939-8654/$ - see front matter Ó 2020 Published by Elsevier Inc. on behalf of Canadian Association of Medical Radiation Technologists. https://doi.org/10.1016/j.jmir.2019.12.004
Conclusion : Developpe au depart pour les services de radiotherapie, QATrackþ est bien adapte a l’application dans les services d’imagerie diagnostique. L’outil est polyvalent et s’adapte facilement aux besoins individuels d’un service pour des activites allant des tests de contr^ole de la qualite, a l’ordonnancement, a l’examen
des tests et a l’etude des tendances de donnees. Il simplifie la standardisation des pratiques de contr^ole de la qualite entre les plateformes, facilitant ainsi la formation et favorisant l’engagement de tout le personnel dans le programme d’assurance de la qualite.
Keywords: Quality control; quality improvement; medical imaging; software tools; workflow
Introduction Management of a quality assurance (QA) program within a medical imaging department requires considerable resources, depending on the complexity and breadth of the program. Aspects of a comprehensive QA program include, among other things, safety, equipment verification and maintenance, patient dose monitoring, and image quality. Numerous publications make specific recommendations for tests that form part of the QA program [1–3]. In addition to recommended tests, imaging departments may be subject to regulatory requirements or accreditation criteria [4,5]. Beyond the management of routine quality control (QC) tests, a comprehensive QA program also needs to promote quality within the department through staff engagement and awareness and must continually review and analyse results to further improve the system [6,7]. A QA program must be sufficiently robust to meet all requirements and flexible enough to permit the program to adapt to advances in technology and changes in clinical practice. A major component of any QA program is the administration and tracking of machine performance via QC tests. There are a number of commercial software platforms designed for overall (QC) data management in the medical imaging setting. Examples of such software platforms include Total QA (Image Owl, Greenwich, NY, www.imageowl.com) and QC Track (Atirix Medical Systems, Minneapolis, MN, www.atirix.com). Many software platforms used in diagnostic imaging are instrument and test specific, for example, Piranha Premium (RTI, Molndal, Sweden, www.rtigroup.com) and RaySafe X2 (Unfors RaySafe, Billdal, Sweden, www.raysafe. com), which include their own QC reporting software. Many vendors also incorporate routine QC tests directly into their operator stations. Regardless of department size, maintaining multiple software platforms and multiple databases increases the overall support burden, and difficulties can arise if operating system and hardware requirements conflict. The use of multiple platforms also complicates program review for a QA program administrator. The present work describes the clinical implementation of QATrackþ [8] within the medical imaging department of the Ottawa Hospital. The medical imaging department at the Ottawa Hospital spans three hospital campuses, each at different geographic locations in the city. The QC program is overseen by two QC technologists who are responsible for scheduling and performing most of the tests, for tracking all test results and for all required regulatory reports. The introduction of QATrackþ for QC program management replaces 2
a series of in-house developed spreadsheets and databases as well as commercially available software platforms that had reached the end of life. QATrackþ is recognized and well used within the radiation therapy community, and the extension of the QATrackþ software into the medical imaging environment offers a novel use for the software platform and facilitates the management of a comprehensive QC program for any size of diagnostic imaging facility. Within the Ottawa Hospital, QATrackþ is now used for the management of the QC and radiation safety programs in the radiation therapy, nuclear medicine, and medical imaging departments [9], showing its versatility and applicability to large, multidepartmental facilities. Materials and Methods QATrackþ is an open-source QA software platform developed at the Ottawa Hospital and clinically implemented within the radiation therapy department in 2012 [8]. The radiation therapy installation is currently being used by more than 200 therapists, physicists, and technologists to record and monitor all routine machine- and patient-specific QC for 20 treatment and imaging units. More than 1,700 test lists are executed and recorded each month within this database. QATrackþ was implemented in the nuclear medicine department in 2015. In the medical imaging department, QATrackþ is used by the QC technologists and frontline medical radiation technologists to record and track routine QC on more than 25 imaging units, including CTs, x-ray units, and emergency department machines. Worldwide, QATrackþ is now in use at over 45 centres (http:// qatrackplus.com/index.html#whos-using). QATrackþ operates as a Web application in which QC test data are entered through an online interface accessible using a Web browser, making it ideal for a multicampus facility and simplifying access for a large number of staff. All data are stored in a centralized database and are accessible via the same Web interface. Initially developed for use in radiation therapy departments, there is nothing in the framework that limits its applicability to the diagnostic environment. The software is written in the Python programming language using the Django Web framework and is made freely available to the public (https://bitbucket.org/tohccmedphys/qatrackplus/) under a permissive open-source license. The newest release of the software, not yet implemented in the medical imaging department, includes a service event log, allowing service events to be integrated with QC testing [10]. The software is
L. Buckley et al./Journal of Medical Imaging and Radiation Sciences
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configurable to the needs of the department from the front facing view to the administrative settings. The use of an open-source software platform comes with significant cost savings for the clinic. There is no cost associated with the software acquisition or installation, and there is an active online community supporting the product that is used for housing the source code, associated documentation, bug reports, and feature requests (https://bitbucket.org/ tohccmedphys/qatrackplus/). Version control is managed using git (https://git-scm.org), which is well supported on Linux, Windows, and OSX and is widely used for version control in open-source software projects. Maintenance of the source code includes a test suite of unit and integration tests to ensure consistency between version releases. This test suite is run locally on developers’ computers as well as using online continuous integration services: Travis CI (https:// travis-ci.org) and AppVeyor (https://appveyor.com/). The implementation project in medical imaging comprised four main stages as shown in Figure 1. Collaboration between the medical physics department and the department of medical imaging was essential to ensure that careful consideration was given to clinical impacts and that adequate training and staff awareness was achieved. The planning phase involved primarily the medical physics department and the QC technologists in medical imaging. A clinical rollout plan and the justification for the project was submitted to administration in medical imaging to get support for the project. The only hardware required was the server on which to house the software and the database. The size and specifications of this server would depend on the size of the installation, and guidelines are given in the QATrackþ documentation on the website. The configuration was completed by the QC technologists and medical
physicists. Individual sites, units, and test lists were configured to best suit the needs of the QC program. The units were divided into geographic campus and imaging modality for ease of selection when performing the QC. Where possible, the test lists mimicked existing tests performed in other software platforms; however, this was also used as an opportunity to review tests and tolerances. Clinical rollout was streamlined using the Windows login option within QATrackþ. This option means that each user logs into the software using their standard hospital user account and password. It avoids the need to create users and simplifies the access for staff. The clinical rollout was done in stages, beginning with the CT staff. This was a relatively small group, and a QC technologist was on site to provide training and assistance. Feedback from staff could be used to improve the process when moving to other units with the department. Rollout to the general x-ray units was done about 1 month after the initial implementation in CT. Results Oversight of a QA program within a medical imaging department will vary with local policies and depends on several factors, including machine workload and clinical hours and availability of staff to perform the QC tests and the expertise of the staff involved with the QA program. A comprehensive software platform for a QA program must permit efficient recording of QC results but must also facilitate a simple review of QC data and scheduling of tests. Figure 2 shows the main page for the medical imaging installation of QATrackþ at the Ottawa Hospital. From this page, the user can select the unit for which they would like to perform QC. In the present version of the software,
Figure 1. Breakdown of the main phases of the implementation project in the department of medical imaging.
L. Buckley et al./Journal of Medical Imaging and Radiation Sciences
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3
Figure 2. Home page for selecting a machine on which to perform QC testing. The machines are grouped according to machine type and location.
the machines can be grouped by machine type and by site. The grouping is entirely configurable. In this example, the machines are grouped by unit type, which in this case has been used to also group by geographic location. Selecting an individual machine will take the user to the list of all available tests for that unit. A similar view is available under the ‘‘Review Data’’ tab, which allows a user to see previous test results. The user interface that individuals see is configurable to allow users to only see the tests or machines that are relevant to their work. This is particularly useful in a large facility or in the case of multiple sites. Access and permissions can be
controlled on a user-by-user basis or by group, which permits front line staff to have simplified views within the software, where only tests assigned to them are shown. Other users may be permitted to see the entire suite of tests if their role requires this access. Within a group, specific permissions (perform a test, approve tests, and create and delete tests) are also configurable. Table 1 shows an example of the group structure within the medical imaging department at the Ottawa Hospital. The oversight of the QC program within a medical imaging facility relies on the ability to schedule and review tests. Test frequencies are configured within the software, and the
Table 1 Example of a User Group Configuration Within QATrackþ User Group
Access
Permissions
CT techs
Only CT machines are visible, and within each unit, only daily and weekly tests assigned to this group are seen. Only general x-ray units are visible, and within each unit, only daily and weekly tests assigned to this group are seen. All machines and tests are visible.
Permission to perform tests only.
X-ray techs QC group
Permission to perform tests only. Full permissions: perform, modify approve, edit, create, and delete tests and test instances
Groups can be used to make the interface more user friendly by limiting how much is visible to an individual and are used to assign different permissions within the software. CT, computed tomography; QC, quality check.
4
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Figure 3. Overview for a single machine, showing due or overdue status as well as the pass/fail status of the most recent test instances. The overview page shows this dashboard for all units and provides a rapid snapshot of the current status of the QC program.
due or overdue status is shown on the QC overview page, which uses a red light/green light dashboard to show the due date and pass/fail status of each test for all machines. This permits a very rapid assessment of the current state of the program. Figure 3 shows this overview dashboard for one machine at the Ottawa Hospital. In this case, no tests are overdue, as indicated by the green dates. Tests that are due would show as yellow, and any overdue tests would show as red. The frequencies and the windows of time in
which to complete the tests are set at the time of configuration. Understanding trends in QC data is an important aspect of a QA program. Trends in data can be used to predict machine failures and can inform proactive machine service events. A careful review of QC data trends can also lead to program improvements by influencing the frequency of tests and the tolerance and action limits set within the software. Figure 4 shows the data trending feature within the QATrackþ
L. Buckley et al./Journal of Medical Imaging and Radiation Sciences
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5
Figure 4. Trending feature of QATrackþ showing 1 y of data from two tests for a single CT unit. Shown are the data for the CT number of water and the image uniformity as measured weekly. Trending options also permit the comparison of data from different units.
software for two weekly tests for a single CT unit. The green bands show the current tolerance levels set in the software. The trending feature allows a user to compare tests from different units or to plot data from a single unit as desired. The implementation plan was well received by hospital management and frontline staff. Initial feedback from front line staff was very positive, and staff felt that the system was easy to use and did not negatively impact their efficiency in any way. Based on the initial feedback, there were no changes required to the clinical implementation plan, and the rest of the rollout proceeded as intended. Conclusion The use of QATrackþ for comprehensive management of a QC program within diagnostic imaging offers an effective method to meet the needs of any imaging department. Although initially developed for the radiation therapy environment, QATrackþ is easily configured to accommodate the varied technologies and regulations present in diagnostic imaging. It is independent of machine or QC equipment vendor and is a cost-effective solution for any QC program. At the Ottawa Hospital, QATrackþ has been successfully launched in the department of medical imaging. By increasing the engagement of frontline staff in the x-ray safety program, it has also had a positive impact on the radiation safety culture of the organization. Feedback from staff has been positive, and the clinical implementation went smoothly with minimal training required. Furthermore, the use of QATrackþ has increased the efficiency of the delivery and tracking of QC test results, enabling better oversight of the program and facilitating quality improvement initiatives within the department resulting from improved use of resources. 6
Extending the use of QATrackþ to medical imaging greatly improves the standardization of the QC and radiation safety programs across departments within the hospital. It builds on local expertise with the platform and enhances collaboration across modalities.
Acknowledgments The authors wish to thank their colleague Ryan Bottema, from the medical physics department, for his help in configuring the QATrackþ server for the medical imaging department. They would also like to thank their colleague Alan Thibeau, from medical imaging, for his initiative and vision in getting this project off the ground. Contributors: The work described in this manuscript is original work and each of the authors listed on this manuscript have made substantial contributions to the conception, design and implementation of this work, and as such, meet the requirements for authorship. Competing Interests and Ethical Approval: None of the authors have any conflict of interest to declare in relation to this work and the work does include human studies or clinical trials.
References [1] American College of Radiology (2016). ACR-AAPM technical standard for diagnostic medical physics performance monitoring of radiographic equipment. Reston, VA: ACR. [2] Safety Code 35: Safety Procedures for the Installation, Use and Control of X-ray equipement in Large Medical Radiological Facilities. 2008. Health Canada, cat. no. H128-1/08-545E. Available at: https://www.canada. ca/en/health-canada/services/environmental-workplace-health/reportspublications/. Accessed February 4, 2020.
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[3] Jones, A. K., Heintz, P., & Geiser, W., et al. (2015). Ongoing quality control in digital radiography: report of AAPM Imaging Physics Committee Task Group 151. Med Phys 42(11), 6658–6670. [4] Regulation 543: x-ray safety code. Healing Arts and Radiation Protection Act. (1990) Government of Ontario, Ministry of Health. Available at: https://www.ontario.ca/laws/regulation/900543. Accessed February 4, 2020. [5] Radiation Control Program Offices. American Society of Radiologic Technologists. Available at: https://www.asrt.org/main/standardsand-regulations/legislation-regulations-and-advocacy/radiation-controlprogram-offices. Accessed July 25, 2019. [6] Delis, H., Christaki, K., & Healy, B., et al. (2017). Moving beyond quality control in diagnostic radiology and the role of the clinically qualified medical physicist. Phys Med 41, 104–108.
[7] Periard, M., & Chaloner, P. (2007). Diagnostic x-ray imaging quality assurance: an overview. Health Canada: Health Protection Branch. Available at: https://www.canada.ca/en/health-canada/services/environm ental-workplace-health/reports-publications/radiation/diagnostic-imaging -quality-assurance-overview.html. Accessed February 4, 2020. [8] Taylor, R., Angers, C., La Russa, D., Studinski, R., Mason, D., & Clark, B. G. (2013). A flexible, free, open-source and multi-platform software solution for QC data management. Radiother Oncol 108(S1), S101. [9] Juma, I., Buckley, L., & Thibeau, A., et al. (2017). An interprofessional approach to the standardization of a quality assurance program in medical imaging using QATrackþ. Med Phys 44(8), 4373–4374. [10] Angers, C., Bottema, R., & Buckley, L., et al. (2019). Streamlining regulatory activities within radiation therapy departments using QATrackþ. Health Phys 117(3), 306–312.
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Journal of Medical Imaging and Radiation Sciences xx (2020) 1-7
Journal de l’imagerie médicale et des sciences de la radiation
www.elsevier.com/locate/jmir
Research Article
Improved X-Ray Safety, Quality Control, and Resource Management in Medical Imaging Using QATrackþ Lesley Buckley, PhDa*, Gary Heddon, MRT(R) ACb, Ian Byrne, MRT(R)b and Crystal Angers, MSca a b
Department of Medical Physics, The Ottawa Hospital, Ottawa, Ontario, Canada Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
ABSTRACT Introduction/Background: Management of a quality assurance program in diagnostic imaging involves a variety of machine types, multiple vendors, and a large number of frontline staff who have different specializations. Standardizing tests across multiple platforms in the face of vendor recommendations, regulatory requirements, and professional practice protocols can present challenges to maintain a robust and coherent quality assurance program. The current work presents a unique application of an existing tool that can be used to manage a comprehensive quality assurance program in a diagnostic imaging department. Materials and Methods: QATrackþ is an open source, quality assurance platform originally developed for and currently widely used in radiation therapy departments. The use of QATrackþ for quality assurance program management within a large diagnostic imaging department is a novel use of this tool. Results and Discussion: QATrackþ was successfully implemented in a large, multisite diagnostic imaging department. The progression toward a single platform for the quality assurance program has addressed issues of end of life with previous software packages and has improved the standardization of testing across the institution. The configuration of the software has enabled frontline staff to be directly engaged in the quality control (QC) program, improving the efficiency of resource allocation for QC and promoting a strong safety culture and commitment to quality. Trending tools within QATrackþ allow for simplified review of tests and enable the early identification of potential failures. Conclusion: Originally developed for radiation therapy programs, QATrackþ is well suited to applications within diagnostic imaging. It is versatile and is easily adapted to the individual needs of a department for activities ranging from quality control testing, scheduling, test review, and data trending. It simplifies the standardization of quality control practices across platforms, thereby
facilitating training and promoting involvement in the quality assurance program by all staff. RESUM E Introduction/contexte : La gestion d’un programme d’assurance de la qualite en imagerie diagnostique implique un eventail de types de machines, plusieurs fournisseurs et un grand nombre d’employes de premiere ligne ayant des specialisations differentes. La standardisation des tests sur des plateformes multiples en tenant compte des recommandations des fournisseurs, des exigences reglementaires et des protocoles de pratique professionnelle peut poser des defis au maintien d’un programme d’assurance de la qualite robuste et coherent. Cet article presente une application unique d’un outil existant pouvant ^etre utilise pour gerer un programme complet d’assurance de la qualite dans un service d’imagerie diagnostique. Materiel et methodologie : QATrackþ est une plateforme d’assurance de la qualite en code ouvert conc¸ue au depart pour les services de radiotherapie et aujourd’hui largement utilisee par ces derniers. L’utilisation de QATrackþ pour la gestion du programme d’assurance de la qualite de grands services d’imagerie diagnostique est une nouvelle utilisation de cet outil. Resultats et discussion : QATrackþ a ete mis en œuvre avec succes dans un grand service d’imagerie diagnostique comprenant plusieurs sites. Le passage a une plateforme unique pour l’assurance de la qualite a permis de resoudre des problemes de fin de cycle de vie des logiciels anterieurs et d’ameliorer la standardisation des tests dans l’ensemble de l’organisation. La configuration du logiciel a permis au personnel de premiere ligne de s’engager directement dans le processus de contr^ole de la qualite (QC), d’ameliorer l’efficacite de l’allocation des ressources en CQ et de promouvoir une culture de la qualite solide et un engagement envers la qualite. Les outils de tendance de QATrackþ permettent un examen simplifie des tests et l’identification precoce des defaillances potentielles.
* Corresponding author: Lesley Buckley, PhD, Department of Medical Physics, The Ottawa Hospital, 501 Smyth Road, Box 927, Ottawa, Ontario K1H 8L3, Canada. E-mail address: [email protected] (L. Buckley). 1939-8654/$ - see front matter Ó 2020 Published by Elsevier Inc. on behalf of Canadian Association of Medical Radiation Technologists. https://doi.org/10.1016/j.jmir.2019.12.004
Conclusion : Developpe au depart pour les services de radiotherapie, QATrackþ est bien adapte a l’application dans les services d’imagerie diagnostique. L’outil est polyvalent et s’adapte facilement aux besoins individuels d’un service pour des activites allant des tests de contr^ole de la qualite, a l’ordonnancement, a l’examen
des tests et a l’etude des tendances de donnees. Il simplifie la standardisation des pratiques de contr^ole de la qualite entre les plateformes, facilitant ainsi la formation et favorisant l’engagement de tout le personnel dans le programme d’assurance de la qualite.
Keywords: Quality control; quality improvement; medical imaging; software tools; workflow
Introduction Management of a quality assurance (QA) program within a medical imaging department requires considerable resources, depending on the complexity and breadth of the program. Aspects of a comprehensive QA program include, among other things, safety, equipment verification and maintenance, patient dose monitoring, and image quality. Numerous publications make specific recommendations for tests that form part of the QA program [1–3]. In addition to recommended tests, imaging departments may be subject to regulatory requirements or accreditation criteria [4,5]. Beyond the management of routine quality control (QC) tests, a comprehensive QA program also needs to promote quality within the department through staff engagement and awareness and must continually review and analyse results to further improve the system [6,7]. A QA program must be sufficiently robust to meet all requirements and flexible enough to permit the program to adapt to advances in technology and changes in clinical practice. A major component of any QA program is the administration and tracking of machine performance via QC tests. There are a number of commercial software platforms designed for overall (QC) data management in the medical imaging setting. Examples of such software platforms include Total QA (Image Owl, Greenwich, NY, www.imageowl.com) and QC Track (Atirix Medical Systems, Minneapolis, MN, www.atirix.com). Many software platforms used in diagnostic imaging are instrument and test specific, for example, Piranha Premium (RTI, Molndal, Sweden, www.rtigroup.com) and RaySafe X2 (Unfors RaySafe, Billdal, Sweden, www.raysafe. com), which include their own QC reporting software. Many vendors also incorporate routine QC tests directly into their operator stations. Regardless of department size, maintaining multiple software platforms and multiple databases increases the overall support burden, and difficulties can arise if operating system and hardware requirements conflict. The use of multiple platforms also complicates program review for a QA program administrator. The present work describes the clinical implementation of QATrackþ [8] within the medical imaging department of the Ottawa Hospital. The medical imaging department at the Ottawa Hospital spans three hospital campuses, each at different geographic locations in the city. The QC program is overseen by two QC technologists who are responsible for scheduling and performing most of the tests, for tracking all test results and for all required regulatory reports. The introduction of QATrackþ for QC program management replaces 2
a series of in-house developed spreadsheets and databases as well as commercially available software platforms that had reached the end of life. QATrackþ is recognized and well used within the radiation therapy community, and the extension of the QATrackþ software into the medical imaging environment offers a novel use for the software platform and facilitates the management of a comprehensive QC program for any size of diagnostic imaging facility. Within the Ottawa Hospital, QATrackþ is now used for the management of the QC and radiation safety programs in the radiation therapy, nuclear medicine, and medical imaging departments [9], showing its versatility and applicability to large, multidepartmental facilities. Materials and Methods QATrackþ is an open-source QA software platform developed at the Ottawa Hospital and clinically implemented within the radiation therapy department in 2012 [8]. The radiation therapy installation is currently being used by more than 200 therapists, physicists, and technologists to record and monitor all routine machine- and patient-specific QC for 20 treatment and imaging units. More than 1,700 test lists are executed and recorded each month within this database. QATrackþ was implemented in the nuclear medicine department in 2015. In the medical imaging department, QATrackþ is used by the QC technologists and frontline medical radiation technologists to record and track routine QC on more than 25 imaging units, including CTs, x-ray units, and emergency department machines. Worldwide, QATrackþ is now in use at over 45 centres (http:// qatrackplus.com/index.html#whos-using). QATrackþ operates as a Web application in which QC test data are entered through an online interface accessible using a Web browser, making it ideal for a multicampus facility and simplifying access for a large number of staff. All data are stored in a centralized database and are accessible via the same Web interface. Initially developed for use in radiation therapy departments, there is nothing in the framework that limits its applicability to the diagnostic environment. The software is written in the Python programming language using the Django Web framework and is made freely available to the public (https://bitbucket.org/tohccmedphys/qatrackplus/) under a permissive open-source license. The newest release of the software, not yet implemented in the medical imaging department, includes a service event log, allowing service events to be integrated with QC testing [10]. The software is
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configurable to the needs of the department from the front facing view to the administrative settings. The use of an open-source software platform comes with significant cost savings for the clinic. There is no cost associated with the software acquisition or installation, and there is an active online community supporting the product that is used for housing the source code, associated documentation, bug reports, and feature requests (https://bitbucket.org/ tohccmedphys/qatrackplus/). Version control is managed using git (https://git-scm.org), which is well supported on Linux, Windows, and OSX and is widely used for version control in open-source software projects. Maintenance of the source code includes a test suite of unit and integration tests to ensure consistency between version releases. This test suite is run locally on developers’ computers as well as using online continuous integration services: Travis CI (https:// travis-ci.org) and AppVeyor (https://appveyor.com/). The implementation project in medical imaging comprised four main stages as shown in Figure 1. Collaboration between the medical physics department and the department of medical imaging was essential to ensure that careful consideration was given to clinical impacts and that adequate training and staff awareness was achieved. The planning phase involved primarily the medical physics department and the QC technologists in medical imaging. A clinical rollout plan and the justification for the project was submitted to administration in medical imaging to get support for the project. The only hardware required was the server on which to house the software and the database. The size and specifications of this server would depend on the size of the installation, and guidelines are given in the QATrackþ documentation on the website. The configuration was completed by the QC technologists and medical
physicists. Individual sites, units, and test lists were configured to best suit the needs of the QC program. The units were divided into geographic campus and imaging modality for ease of selection when performing the QC. Where possible, the test lists mimicked existing tests performed in other software platforms; however, this was also used as an opportunity to review tests and tolerances. Clinical rollout was streamlined using the Windows login option within QATrackþ. This option means that each user logs into the software using their standard hospital user account and password. It avoids the need to create users and simplifies the access for staff. The clinical rollout was done in stages, beginning with the CT staff. This was a relatively small group, and a QC technologist was on site to provide training and assistance. Feedback from staff could be used to improve the process when moving to other units with the department. Rollout to the general x-ray units was done about 1 month after the initial implementation in CT. Results Oversight of a QA program within a medical imaging department will vary with local policies and depends on several factors, including machine workload and clinical hours and availability of staff to perform the QC tests and the expertise of the staff involved with the QA program. A comprehensive software platform for a QA program must permit efficient recording of QC results but must also facilitate a simple review of QC data and scheduling of tests. Figure 2 shows the main page for the medical imaging installation of QATrackþ at the Ottawa Hospital. From this page, the user can select the unit for which they would like to perform QC. In the present version of the software,
Figure 1. Breakdown of the main phases of the implementation project in the department of medical imaging.
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Figure 2. Home page for selecting a machine on which to perform QC testing. The machines are grouped according to machine type and location.
the machines can be grouped by machine type and by site. The grouping is entirely configurable. In this example, the machines are grouped by unit type, which in this case has been used to also group by geographic location. Selecting an individual machine will take the user to the list of all available tests for that unit. A similar view is available under the ‘‘Review Data’’ tab, which allows a user to see previous test results. The user interface that individuals see is configurable to allow users to only see the tests or machines that are relevant to their work. This is particularly useful in a large facility or in the case of multiple sites. Access and permissions can be
controlled on a user-by-user basis or by group, which permits front line staff to have simplified views within the software, where only tests assigned to them are shown. Other users may be permitted to see the entire suite of tests if their role requires this access. Within a group, specific permissions (perform a test, approve tests, and create and delete tests) are also configurable. Table 1 shows an example of the group structure within the medical imaging department at the Ottawa Hospital. The oversight of the QC program within a medical imaging facility relies on the ability to schedule and review tests. Test frequencies are configured within the software, and the
Table 1 Example of a User Group Configuration Within QATrackþ User Group
Access
Permissions
CT techs
Only CT machines are visible, and within each unit, only daily and weekly tests assigned to this group are seen. Only general x-ray units are visible, and within each unit, only daily and weekly tests assigned to this group are seen. All machines and tests are visible.
Permission to perform tests only.
X-ray techs QC group
Permission to perform tests only. Full permissions: perform, modify approve, edit, create, and delete tests and test instances
Groups can be used to make the interface more user friendly by limiting how much is visible to an individual and are used to assign different permissions within the software. CT, computed tomography; QC, quality check.
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Figure 3. Overview for a single machine, showing due or overdue status as well as the pass/fail status of the most recent test instances. The overview page shows this dashboard for all units and provides a rapid snapshot of the current status of the QC program.
due or overdue status is shown on the QC overview page, which uses a red light/green light dashboard to show the due date and pass/fail status of each test for all machines. This permits a very rapid assessment of the current state of the program. Figure 3 shows this overview dashboard for one machine at the Ottawa Hospital. In this case, no tests are overdue, as indicated by the green dates. Tests that are due would show as yellow, and any overdue tests would show as red. The frequencies and the windows of time in
which to complete the tests are set at the time of configuration. Understanding trends in QC data is an important aspect of a QA program. Trends in data can be used to predict machine failures and can inform proactive machine service events. A careful review of QC data trends can also lead to program improvements by influencing the frequency of tests and the tolerance and action limits set within the software. Figure 4 shows the data trending feature within the QATrackþ
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Figure 4. Trending feature of QATrackþ showing 1 y of data from two tests for a single CT unit. Shown are the data for the CT number of water and the image uniformity as measured weekly. Trending options also permit the comparison of data from different units.
software for two weekly tests for a single CT unit. The green bands show the current tolerance levels set in the software. The trending feature allows a user to compare tests from different units or to plot data from a single unit as desired. The implementation plan was well received by hospital management and frontline staff. Initial feedback from front line staff was very positive, and staff felt that the system was easy to use and did not negatively impact their efficiency in any way. Based on the initial feedback, there were no changes required to the clinical implementation plan, and the rest of the rollout proceeded as intended. Conclusion The use of QATrackþ for comprehensive management of a QC program within diagnostic imaging offers an effective method to meet the needs of any imaging department. Although initially developed for the radiation therapy environment, QATrackþ is easily configured to accommodate the varied technologies and regulations present in diagnostic imaging. It is independent of machine or QC equipment vendor and is a cost-effective solution for any QC program. At the Ottawa Hospital, QATrackþ has been successfully launched in the department of medical imaging. By increasing the engagement of frontline staff in the x-ray safety program, it has also had a positive impact on the radiation safety culture of the organization. Feedback from staff has been positive, and the clinical implementation went smoothly with minimal training required. Furthermore, the use of QATrackþ has increased the efficiency of the delivery and tracking of QC test results, enabling better oversight of the program and facilitating quality improvement initiatives within the department resulting from improved use of resources. 6
Extending the use of QATrackþ to medical imaging greatly improves the standardization of the QC and radiation safety programs across departments within the hospital. It builds on local expertise with the platform and enhances collaboration across modalities.
Acknowledgments The authors wish to thank their colleague Ryan Bottema, from the medical physics department, for his help in configuring the QATrackþ server for the medical imaging department. They would also like to thank their colleague Alan Thibeau, from medical imaging, for his initiative and vision in getting this project off the ground. Contributors: The work described in this manuscript is original work and each of the authors listed on this manuscript have made substantial contributions to the conception, design and implementation of this work, and as such, meet the requirements for authorship. Competing Interests and Ethical Approval: None of the authors have any conflict of interest to declare in relation to this work and the work does include human studies or clinical trials.
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[3] Jones, A. K., Heintz, P., & Geiser, W., et al. (2015). Ongoing quality control in digital radiography: report of AAPM Imaging Physics Committee Task Group 151. Med Phys 42(11), 6658–6670. [4] Regulation 543: x-ray safety code. Healing Arts and Radiation Protection Act. (1990) Government of Ontario, Ministry of Health. Available at: https://www.ontario.ca/laws/regulation/900543. Accessed February 4, 2020. [5] Radiation Control Program Offices. American Society of Radiologic Technologists. Available at: https://www.asrt.org/main/standardsand-regulations/legislation-regulations-and-advocacy/radiation-controlprogram-offices. Accessed July 25, 2019. [6] Delis, H., Christaki, K., & Healy, B., et al. (2017). Moving beyond quality control in diagnostic radiology and the role of the clinically qualified medical physicist. Phys Med 41, 104–108.
[7] Periard, M., & Chaloner, P. (2007). Diagnostic x-ray imaging quality assurance: an overview. Health Canada: Health Protection Branch. Available at: https://www.canada.ca/en/health-canada/services/environm ental-workplace-health/reports-publications/radiation/diagnostic-imaging -quality-assurance-overview.html. Accessed February 4, 2020. [8] Taylor, R., Angers, C., La Russa, D., Studinski, R., Mason, D., & Clark, B. G. (2013). A flexible, free, open-source and multi-platform software solution for QC data management. Radiother Oncol 108(S1), S101. [9] Juma, I., Buckley, L., & Thibeau, A., et al. (2017). An interprofessional approach to the standardization of a quality assurance program in medical imaging using QATrackþ. Med Phys 44(8), 4373–4374. [10] Angers, C., Bottema, R., & Buckley, L., et al. (2019). Streamlining regulatory activities within radiation therapy departments using QATrackþ. Health Phys 117(3), 306–312.
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