Diagnostic quality control: The missing link in dental radiology quality assurance

Diagnostic quality control: The missing link in dental radiology quality assurance Clifton E. Crandell, B.S., D.D.S., M.S., M.Ed.,* Houston, Texas DENTAL

BRANCH.

UNIVERSITY

OF TEXAS

A diagnostic quality-control program that includes assessment an ongoing process is described. (ORAL SURC. ORAL MED. ORAL PATHOL. 621212-217,

Q

212

Associate Dean and Professor of Oral Diagnosis.

and remediation

as

1986)

uality assurance is a concept whose time has come. Much emphasis is being placed today on the concerns of consumer advocates with respect to the production, marketing, and consumption of inferior merchandise or services. Major efforts have been expended by federal, state, and private agencies to formalize standards of acceptance that will protect the public. The health professions have not been immune to those societal pressures seeking to protect the consumer. The health professions have responded favorably and in many cases have produced useful peer review guidelines and other documents. For example, a set of principles for voluntary medical peer review was adopted by the American Medical Association House of Delegates in 1981. The principles included definition of medical peer review as an organized effort to evaluate and analyze medical care services delivered to patients and to assure the quality and appropriateness of these services. Peer review was viewed as a local process, with the physician ultimately responsible. Two of the principles cited are of particular interest in this article: (1) any system of medical peer review must have established procedures and (2) peer review is an ongoing process of assessmentand evaluation. The development of quality-assurance procedures in dental radiology has received considerable attention. This is only natural because dental radiology procedures result in the production of a product that is readily available for subsequentreview by as many persons as necessary from all levels of training and experience. Furthermore, dental radiographs are not readily changeable after they have been exposed and *Executive

of film quality, critique,

processed. Also, the size of the group of qualified reviewers is extremely large, since it includes not only dentists with special training and experience in dental radiology, but all other dentists and dental auxiliaries, who receive sufficient training in radiographic quality analysis and film interpretation, and even lay persons (such as dental insurance claim reviewers) whose job specifications, training, and experience may require them to evaluate dental conditions and diseasesseen on dental radiographs. Despite the extensive effort to formalize qualityassurance procedures in dental radiography, there is a missing link that has received scant attention but is at least as important as any other procedure and is easily implemented. The missing link is an ongoing established procedure of diagnostic quality control that includes assessmentand evaluation with feedback to the radiographer, including specific recommendations for improvement of technique in making radiographs. REVIEW OF THE LITERATURE

An early effort to identify errors in radiographic technique and to use this information in remediation was reported by Crandell,’ who catalogued the errors in (1) vertical angulation, (2) horizontal angulation, (3) film placement, (4) film bending, and (5) miscellaneous (cone cutting and film, tube, or patient movement). Efforts to standardize the training of dental auxiliaries in dental radiology were made by the American Academy of Dental Radiology in the late 1960s. These requirements were centered around intraoral technique, and it is obvious that the recent proliferation of panoramic and other dental radiographic techniques clearly requires a revision of these minimal standards.2*3

Volume Number

Diagnostic quality

62 2

control

2 13

RADIOGRAPHIC CRITIQUE Intraoral Films Critiquer

Radiographer 1

Radiographer

- use left

half

Critiquer

of window

- use riglit

half

of window

Left

Right

WRITE CODE IN WINDOW WHERE PROBLEM IS EVIDENT:

CODE- FULL SERIES TBCHNIQUE EC Excessive Contraat HA Horimntal Angle IC Insufficient contrast VE Vertical Elongation OE Overexposed VF Vertical Foreshortening UE Underexposed cc cone cut M Movement MA Missing Apices BF Backward Film MC Missing CrowUS 0 Other MF Missing Film PP Packet Placement

CODE- PROCESSING TECHNIQUE SR Streaks SA Stained SC Scratched F Fog R Reticulatlorf SM Smudges P Partial Image SP spots 0 Other ST Static

CODE- MOUNTING WPwrong Position LL Light Leak ID Improper ID UN Unmounted

COMMENTS:

Fig.

1. lntraoral radiographic critique form.

Wuehrmann,4 in developing evaluation criteria for intraoral radiographic film quality, developed a form that included film density, demonstration of tooth apices, demonstration of tooth contact areas, depiction of the most distal segments in each jaw, and demonstration of normal structure beyond all apical pathosis. Beideman, Johnson, and AlcoxS developed an efficient system for evaluating radiographs in 1000 preauthorization case submissions. A frequency distribution of errors indicated that a majority of films submitted to a third-party carrier were substandard. Deficiencies identified included an insufficient number of films, improper density, films not mounted or identified, improper processing, root apices not visible, improper horizontal angle, improper vertical angle, improper film positioning, pathosis not visualized, cone cut, and bent film. Burnett, Mazzaferro, and Church6 reported on the incidence and causes of retake examinations in two large hospitals. In one hospital one quality-control

x-ray technologist was responsible for reviewing radiographs and ordering retakes when necessary. In the other hospital the decision to retake radiographs was left solely to the individual technologist. There was no significant difference in the retake rate. The Bureau of Radiological Health, United States Department of Health, Education and Welfare, in collaboration with the World Health Organization, published a diagnostic radiology quality-assurance catalogue in 1977.’ The catalogue included procedures and devices for controlling processor quality, x-ray unit quality, sources of instruction, and publications. A supplement8was published in 1978. In 1981 several publications appeared. The American Dental Association Council on Dental Materials, Instruments, and Equipment9 published its “Recommendations in Radiographic Practices, 1981” and included a paragraph on quality assurance which said: “. . . establish a quality assurance program to ensure consistently high quality radio-

2I 4

Crandell

Oral August.

Surg. 1986

RADIOGRAPHIC CRITIQUE Panoramic Film

DIlX,bS%lC.W,

PITIEM

N-R

-I-

U?IT,USR

WRITE CODE OVER AREA WHERE PROBLEM IS EVIDENT: CODE - PANoRAnIC TECNNIQ"E CB CP CD C"

Chin Chin Chin Chin

Back Forward Down "p

cs H Ke so PO

Fig.

CODE - PROCESSING TECHNIQ"E

Cassette wrong tivemenr Machine Pre-op Segittal Off Frankfurt Off

SA SC SM SP ST

2. Panoramic radiographic

graphic images. This includes routine monitoring of x-ray generators, processing equipment, and processing conditions. Maintenance should be performed at regular intervals.” These are excellent, but they relate only to the production of images. No suggestions were made on how to assure consistently high-quality radiographic image evaluation. In a conference on technology assessment, the National Center for Health Care Technology Radiology Planning Committee developed several desirable attributes for quality assurance.‘OThe Committee said: “Quality assurance programs that will fit into the normal pattern of daily activities of patient care in dentists’ offices must be developed.” The University of Iowa College of Dentistry and the American Academy of Pedodontics sponsored a conference on radiation exposure in pediatric dentistry in 1981.“-I* Quality assurance was addressedwith the suggestion that such a “. . . program should be established in the dental office to ensure high quality radiographic images. Areas that require assessment include generator performance; tube head stability; film processing; dark room integrity; view box or viewing environment; and film quality.” Again, no specific suggestions as to how this evaluation could be accomplished were given. Valachovic, Reiskin, and Kirchhof13 published a detailed program, which requires little equipment

Stained Scratched Smudges spots stetic

SR r P P 0

Streaks Fag Reticulation Partial Image Other

critique form.

and is easily implemented in dental offices. The program includes image processing, test of the x-ray generator, x-ray receptors, and darkroom integrity. The paper also includes an excellent review of the literature. Crabtree14refers to the Federal RegisterIS:“Quality administration procedures are those management actions taken to guarantee that monitoring techniques are properly performed and evaluated, and that necessary corrective measures are taken.” He indicates further that a positive and unwavering attitude toward quality assurance is desired. The most comprehensive recommendations have come from the Quality Assurance Committee of the American Academy of Dental Radiology.16A retake log, which would include date, operator, reason for retake, and corrective action, is suggested. Gratt and Gould’7-‘9 describe a system, developed at the University of California for the dental office, which involves a pre-exposure measure of radiation factors. Manson-Hing and BloxomZoreport a fast, inexpensive test for monitoring film processing and x-ray machine output in dental practice. Jerge and Orlowski*’ emphasize a feedback loop as being an essential feature of a quality-assurance system that uses dental records, but they do not reference the system to dental radiology.

Volume 62 Number 2

Diagnostic quality control

Fig.

215

3. Quality review form.

PROCEDURE

Having had the opportunity and responsibility for supervising the radiology section of a large group practice of sixty dentists representing general dentistry and all the dental specialties, I made a thorough search of the dental literature. This produced many procedures for improving quality control and quality assurance in the production of dental radiographs. These procedures were implemented as rapidly as resourcespermitted. Immediate improvement was noted where complaints (many of which were well founded) of poor or inadequate service had been reported in the past. Notably lacking in the literature were suggestions or procedures that focused on the diagnostic quality of films, interpersonal relations, and management. Therefore, it was decided that techniques that had been successful in other applications should be used.

In interpersonal relations, emphasis was placed on (1) pride of ownership, (2) complete exchange of information in radiographic requisitions, and (3) the handling of complaints. In order to appeal to the radiographer’s pride of ownership, the appropriate forms were revised to assurethat the radiographer’s name was recorded on the log of films made, on the film mount, and on the film itself where indicated. The design and implementation of the forms and procedures were done with participative management techniques and included all radiographers, a selection of dentists with complaints, and other administrators. Improvements in interpersonal relations also focused on instilling friendly attitudes toward practitioners, patients, and staff. On occasion, more than one radiographer was available to perform some procedures. Consideration was given to allowing the

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Crandell

dentist to select a particular radiographer for his particular procedure. This idea was rejected in order to build a more amicable relationship between the radiographers and to emphasize that the radiology section was committed to a team effort. In order to avoid musunderstandings, the information required on the film requisition form was extended to include areas where conflicts had traditionally arisen during verbal exchanges. Recording the patient’s name, number, date, and films needed was not deemed sufficient. It was emphasized that the radiographer, in order to perform to an optimal level, neededto know the condition, disease,or entity that the practitioner wished demonstrated, how it was expected that this would be accomplished, and why this projection was needed. The radiographer also needed to know where the patient was located, when he or she would be available for radiography, and where the patient and the films were to be delivered after radiography. Another step taken to improve interpersonal relations was to ask the practitioners to channel complaints to the director rather than to the radiographers. This afforded an opportunity to review the films in question and to discuss problems at a time and place specifically designated for that purpose. The development of an ongoing established procedure for diagnostic film review and critique was the area in the literature that was most deficient. A diagnostic-quality-review procedure was developed over a period of several months. Frequent revisions were made. Resistance to implementation of these procedures was nil because the timing of major changes was geared to episodes of participative management. It was assumedthat all films would be reviewed by at least one practitioner in the course of delivering treatment. Some might believe that no further review is indicated. This concept was rejected for three reasons: (1) the reviewers are less than maximally qualified, not having had any special training in dental radiology, (2) the feedback was almost always negative, and (3) there was no documentation of the types of errors and the remediation needed. Special forms, which would allow the recording of errors on each film according to objective criteria, were therefore developed. Each month the radiographic exposure log is checked and a random selection of at least five full-mouth series and five panoramic films made by each radiographer are evaluated for quality. These evaluations are combined into a composite score, which indicates the level of acceptability of the films.

Oral Surg. August, 1986

The films are evaluated according to the criteria shown on the radiographic critique form (Figs. 1 and 2). Errors are clearly indicated by the choice of one or more of the abbreviations on the form. The radiographers record their evaluation of the films in the left side of the appropriate film window, and the critquer uses the right side. This information is then summarized on the quality review form (Fig. 3) After evaluation, there is a review of the films and the evaluation forms by the radiographer and the critiquer. This session is pointed toward building on strengths and remediation of weaknesses. Retakes are identified and made by the radiographer, at the same visit if possible. While it would be ideal if the director could assume the responsibility of identifying and remediating retakes, this would not be cost-effective in this situation. Since the implementation of other quality-control measures reduced the retake rate from 5.5% to 0.46% in a few months, self-evaluation for retakes is a justifiable compromise. In addition, on a daily basis, the films that have been made but not yet filed are reviewed and critiqued. The implementation of these procedures has resulted in a substantial improvement in the diagnostic quality of films, a reduction in complaints by practitioners, and better interpersonal relations with patients and staff. SUMMARY

Film-quality review, critique, and remediation as an ongoing established process of assessmentand evaluation as part of quality assurance programs in dental radiology have been neglected. This article reports successful efforts to establish such a procedure in a large group practice. The procedure, suitably scaled, would be suitable for other institutions, smaller group practices, or solo practitioners. REFERENCES I. Crandell CE: Cause and frequency of intraoral x-ray errors by dental and hygiene students. J Dent Educ 22: 189-I 96, 1958. 2. Crandell CE, et al: The American Academy of Dental Radiology training requirements in radiology for the dental assistant. Dent Assist 39: 21-22. 1970. 3. Crandell CE, et al: Training requirements in dental radiology for hygienists. J Am Dent Hyg Assoc 45: 49-50. 1970 4. Wuchrmann AH: Evaluation criteria for intraoral radiographic film quality. J Am Dent Assoc 89: 345-352, 1974. s. Bcideman RW. Johnson ON, Alcox RW: A study to develop a rating system and evaluate dental radiographs submitted to a third party carrier. J Am Dent Assoc 93: 1010-1013, 1976. 6. Burnette BM, Mazraferro RJ. Church WW: A study 01 retakes in radiology departments of two large hospitals. DHEW Publication (FDA) 76-8016. Washington , D.C.. 1976. Superintendent of Documents, Government Printing Olke.

Volume 62 Number 2 7. Bureau of Radiological Health: Diagnostic radiology quality assurance catalog. DHEW Publication (FDA) 778028. Washington, D.C, 1977, Superintendent of Documents, Government Printing Office. 8. Bureau of Radiological Health: Diagnostic Radiology Quality Assurance Catalog Supplement. DHEW Publication (FDA) 78-8028. Washington, D.C., 1978, Superintendent of Documents. Government Printing Office. 9. American Dental Association: Recommendations in radiographic practices. 1981. J Am Dent Assoc 103: 103-104, 1981. 10. National Center for Health Care Technology: Dental radiology: a summary of recommendations from the Technology Assessment Forum. J Am Dent Assoc 103: 423-425, 198 I. 1 I. Nowak AJ, et al: Summary of the Conference on Radiation Exposure in Pediatric Dentistry. J Am Dent Assoc 103:426428, 1981. 12. Academy of Pedodontics: Conference proceedings, Radiation Exposure in Pediatric Dentistry. Pediatr Dent (Special Issue 2) 3: 379-461, 1981. 13. Valachovic RW, Reiskin AB, Kirchhof ST: A quality assurance program in dental radiology. Pediatr Dent 3:26-32, 1981. 14. Crabtree CL: A radiographic quality assurance program for dental teaching institutions, Presentation at the scientific sesson of the American Academy of Dental Radiology, Oct. 23, 1981. 15. U.S. Department of Health, Education, and Welfare: Quality

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assurance programs for diagnostic radiology facilities, final recommendations. Fed Reg 44: 7172871740. Dec. 11, 1979. 16. Gratt BM, et al: Recommendations for quality assurance in dental radiography. ORAL SURG ORAL MED ORAL PATHOL 55: 42 l-426, 1983. 17. Gould RG, Gratt BM: A radiographic quality control system for the dental office. Dentomaxillofac Radio1 II: 123-127, 1982. 18. Gould RG, Gratt BM: Technical aspects of a dedicated quality control system for dental radiology. ORAL SURG ORAL MED ORAL PATHOL 56: 437-444,

1983.

19. Gratt BM, Gould RG: Clinical trials of a dental radiographic quality control system. Dentomaxillofac Radio1 12: 35-38, 1983. 20. Manson-Hing LR, Bloxom RM: A stepwedge quality assurance test for machine and processor in dental radiography. J Am Dent Assoc 110: 910-913, 1985. 21. Jerge CR, Orlowski RM: Quality assurance and the dental record. Dent Clin North Am 29: 495-498, 1985. Reprint requests to: Dr. Clifton E. Crandell Office of the Dean Dental Branch University of Texas Health Science Center P.O. Box 20068 Houston, TX 77225