QUALITY IN DENTAL RADIOLOGY

1
QUALITY IN DENTAL RADIOLOGY
2
Ionising Radiations Regulations 1999

• Regulation 32(1) Equipment condition should
  limit patient dose.
• Regulation 32(2) Requires a Quality Assurance
  (QA) Programme.

3
Health Safety Executive

• PM77 (IRR85) Fitness of Equipment used for
  Medical Exposure to Ionising Radiation.
• Draft HSG226 (IRR99) Revision of PM77

4
Draft HSG226 -

• A suitable QA programme is one that establishes
  those planned and systematic actions necessary to
  provide adequate confidence that the equipment
  will satisfy the requirements of IRR99 Reg. 32(1).

5

• For QA to be successful it has to be managed.

6
Definition 1 - Quality

• The degree to which all the constituent parts of
  the radiographic system represented in the form
  of a radiograph satisfies the need which led to
  the original request.

7
Definition 2 Quality Assurance

• A systematic process of checking to see whether
  the radiographic process and the resulting
  radiograph, meets specific requirements, or,

8

• to put it another way The planned and organised
  actions necessary to provide adequate confidence
  that diagnostic x-ray equipment will produce
  quality radiographs, reliably, with minimal doses
  to staff and patients.

9
Management of Quality

• 1930s Inspection
• 1950s QA
• 1990s TQM
• Total Quality Management

10
Total Quality Management

• Centered on QUALITY
• Manages the ENTIRE SYSTEM
• Essential part of GLOBAL MANAGEMENT

11
TQM in Dentistry

• Managing the quality of all aspects of a patients
  journey, from first to last contact with the
  dental service, to ensure the highest quality
  care and treatment, with the least mental and
  physical stress.

12

• Poor QualityManagement Shortfall

13
QA Programme Goal 1

• To provide necessary, accurate and useful
  diagnosis which benefits the patient.

14
QA Programme Goal 2

• To consistently achieve Goal 1 via a quality
  image whilst minimizing exposure (ALARP
  principle).

15
QA Written Procedures 1

• Identify who is responsible for implementing the
  programme.
• Include test equipment, test procedures and
  frequencies.
• Contain descriptions of content of any essential
  supporting records and the frequency for formal
  checking of the records.

16
QA Written Procedures 2

• Example Fault log Should include
• A clear description of the nature of the fault
• Whether the equipment was removed from service
• What action was taken
• What tests were made before returning the
  equipment to service.

17
Essential QA Procedures 1

• Should cover
• Image Quality
• Patient Dose X-ray Equipment
• Films, Sensors, Processing Darkrooms.
• Training
• Audit

18
Essential QA Procedures 2

• Special consideration should be given to
  equipment used for medical exposure of children.

19
Essential QA Procedures 3

• Formal records need to be maintained.

20
QA Regulations

• The QA programme will take into account relevant
  statutory and advisory requirements.

21
Statutory/Advisory Requirements 1

• 1995 - RCR/NRPB Joint Working Party Guidelines
  on Radiology Standards for Primary Dental Care.
• Fully Comprehensive QA Programme in all dental
  radiology areas by 1998.
• All systems subject to audit by 2001
• 23 Recommendations.

22
Statutory/Advisory Requirements 2

• 2001 - IRR99 Guidance Notes for dental
  Practitioners on the Safe Use of X-ray Equipment.
• Paras. 108-131 of the RCR/NRPB Report for Chapter
  5 in the guidance.
• GNs were distributed to every private dental
  practice in UK.

23
Statutory/Advisory Requirements 3

• 2002 Medical Dental Guidance Notes for
  hospital sector dental service.
• Only Chapters 5 6 are relevant and are the same
  as Chapters 3 4 of private dental GNs.
• Because more useful info on managing QA from
  private dental GNs, will refer to that from now
  on.

24
Private Dental GNs - Chapter 5

• Procedures for Dental Radiology
• Image Quality/Rating System/Quality Targets.
• Patient Dose and X-ray Equipment
• Darkrooms, Desktop Processors, Films and
  Processing.

25
Private Dental GNs - Chapter 5

• Working Procedures as part of the Radiation
  Protection File, including the Legal Persons
  Procedures and Local Rules.
• Operational Procedures and Procedures Log
• Procedures for Training.
• Requirements for QA Audit, Clinical Audit and
  Peer Review.

26
Chapter 2 - Establishing an Administrative
infrastructure 1

• Legal responsibilities, including Radiation
  Protection Supervisors, Referrers, Practitioners,
  Operators, Radiation Protection Advisors and
  Medical Physics Experts.

27
Chapter 2 - Establishing an Administrative
infrastructure 2

• Risk Assessment
• Dose Limitation
• Training
• Radiation Protection File
• Patient Protection
• Quality Assurance

28
Chapter 3 Practical Procedural Aspects of
Dental radiology

• Controlled Areas
• Classification of Staff
• Personal Dosimetry
• Maintenance Testing
• Detectors, Processing and Viewing
• Operational Procedures for intra-oral, Panoral
  and Cephalometry.

29
Chapter 4 Equipment Aspects for Dental Radiology

• Beam Filtration
• X-ray Operating Parameters
• Beam Size Limitation
• Film Holders and Distance Control
• Warning signals
• Exposure Controls

30
Appendices include

• Appendix 2 Risk Assessment.
• Appendix 3 X-ray Operating Parameters.
• Appendix 4 Essential content of the Radiation
  Protection File.
• Appendix 5 Guidance on Equipment Testing.
• Appendix 6 Essential legal Requirements.

31
Last but not Least Equipment Performance

• IPEM Report 77 Recommended Standards for the
  Performance Testing of Diagnostic X-ray
  Equipment.
• Contains guidance on the essential QC Tests to be
  carried out on X-ray equipment, along with
  performance levels.
• Includes Remedial Suspension Levels, along with
  tolerances.
• Also contains nationally agreed Reference Doses.

32
Benefits of a QA Programme 1

• Achieving compliance with relevant legislation
• Improving radiation protection standards and
  reducing the collective dose to patients.
• Improving the diagnostic quality and value of
  radiographs

33
Estimate of Collective Dose Saving 1

• Prior to implementation of the Working Party
  recommendation the Collective Annual Dose in the
  GDS was estimated to be
• 172 man Sieverts per year.

34
Estimate of Collective Dose Saving 2

• Following implementation of all recommendations
  other than Rectangular Collimation, the
  Collective Annual Dose in the GDS was estimated
  to be
• 76 man Sieverts per year
• Saving 96 man Sieverts per year
• Or 5.3m per year in economic terms

35
Estimate of Collective Dose Saving 3

• To include Rectangular Collimation would result
  in the collective Annual Dose in the GDS reducing
  to
• 43 man Sieverts per year
• Saving 129 man Sieverts per year
• Or 7.1m per year in economic terms

36
Estimate of Collective Dose Saving 4

• A further calculation projected the cost of
  implementation of the recommendations over a 10yr
  period to be
• 29m
• but Total Benefit to be
• 53m

37
Diagnostic Image Value

• It was also estimated that up to
• 25 of Panoral
• and,
• 50 of Intra-oral radiographs in the UK are of
  inadequate diagnostic quality.

38
CONCLUSION 1

• Individual doses low but Collective doses
  significant.
• Implementation of a QA programme as detailed in
  the 1995 Working Party report and the 2001
  Guidance Notes would effect a significant
  reduction in the Collective dose and therefore
  benefit the population as a whole.

39
CONCLUSION 2

• Implementation of all the recommendations would
  result in a significant improvement in the
  standards and diagnostic value of individual
  radiographs.

40
CONCLUSION 3

• Given that the GDS spends some 40m per year
  (1995), improvement in quality, and compliance
  with the regulations and guidance has the
  potential for enabling a significant financial
  saving to be made in the dental service.

41
CONCLUSION 4

• It is for each and every one of you involved in
  the dental radiology chain to be aware of where
  you can affect and improve the quality of the
  service you provide to the patient.

42
CONCLUSION 5

• The first step to fulfilling the high standard of
  quality sought, is to be aware of what is
  required, and where the weaknesses exist.
• You are therefore urged to read and inwardly
  digest the relevant published information
  available to you.
• You will then be empowered to improve the quality
  of service provided.