Mammography Tests

Ontario Breast Screening Program
Digital Mammography Quality

Control for the Mammographic
Technologist
Authors: G.E. Mawdsley, A.K. Bloomquist, M.J. Yaffe
October 2011
Revision 3.1
Mammographic Physics Consulting Group

Ontario Breast Screening Program
Main:
Room S6-32
Sunnybrook Health Sciences Centre
2075 Bayview Avenue
Toronto, ON M4N 3M5
QC Support:
Sunnybrook Imaging Research
obspp@sri.utoronto.ca
Telephone: 416.480.5705
Fax: 416.480.6719
The latest version of this manual can be downloaded from:

http://www.sunnybrook.utoronto.ca/~yaffegrp/OBSP/
Or from: http://obsp.webexone.com (‘Documents’ section)
Blank page
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Digital Mammography Quality Control – Technologist - Rev. 3.1
TABLE OF CONTENTS
I. INTRODUCTION 3
QC Test Images – Suggested Names and Client ID:............................................................................................................ 9
Changes to the Mammographic Imaging System .............................................................................................................. 10
Mammography QC Test Image and Record Retention ...................................................................................................... 14
End-of-Month QC Reports for Digital Mammography Systems ....................................................................................... 16
Equipment Downtime and Technical Problem Report ......................................................................................................... 18
Yearly QC Submission: X-Ray Safety Policy & Procedures ............................................................................................. 19
X-Ray Safety Policy and Procedures ................................................................................................................................... 20
X-Ray Safety Policy & Procedures Signature Sheet ............................................................................................................ 23
Phantoms, Test Tools and Test Images for Digital QC ...................................................................................................... 24
ACR/CAR Mammographic Accreditation Phantom .......................................................................................................... 25
II. IMPORTANT POINTS 26

1. Time for Quality Assurance Procedures ........................................................................... 26
2. Information Storage and Mammography Unit Identification .............................. 28
3. Establishing Operating Levels and Control Limits ..................................................... 31
4. Test Frequencies ............................................................................................................................ 31
5. Control Charts.................................................................................................................................. 32
6. Mammography QC Checklists ................................................................................................. 33
7. Technique Charts ........................................................................................................................... 39
8. Image Viewing Conditions ....................................................................................................... 40
9. Third Party Printing...................................................................................................................... 40
III. DIGITAL MAMMOGRAPHY QUALITY CONTROL TESTS 42

1. Daily Quality Control Test Procedures .............................................................................. 42
Test #1: Monitor Inspection, Cleaning and Viewing Conditions......................................................................................... 43
Test #2: Daily Checklist ...................................................................................................................................................... 45
Test #3: Laser Printer Sensitometry .................................................................................................................................... 47
Test #4: Daily Flatfield Image............................................................................................................................................. 54
Test #5: Visual Inspection for artefacts (CR systems only)................................................................................................. 57
Test #6: Image Plate Erasure (CR systems only) ................................................................................................................ 59
2. Weekly Quality Control Test Procedures ......................................................................... 60
Test #7: Phantom Image Quality ......................................................................................................................................... 61
Test #8: Display Monitor QC .............................................................................................................................................. 69
Test #9: Viewbox Cleanliness ............................................................................................................................................. 79
3. Monthly Quality Control Test Procedures........................................................................ 81
Test #10: Full Field Artefacts Test ...................................................................................................................................... 82
Test #11: Monthly Checklist of Exam Room ...................................................................................................................... 87
Test #12: Laser Printer Artefact Test .................................................................................................................................. 91
Test #13: Retake Analysis ................................................................................................................................................... 94
4. Quarterly Quality Control Test Procedures .................................................................. 100
Test #14: Resolution / MTF .............................................................................................................................................. 101
Test #15: Printed Image Quality Test ................................................................................................................................ 105
Test #16: Analysis of Fixer Retention ............................................................................................................................... 109
5. Semi-annual Quality Control Test Procedures ........................................................... 111
Test #17: Compression Force ............................................................................................................................................ 111
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OBSP Mammographic Physics Consulting Group
IV. REVISION CHANGES FROM 2.6 114
V. REFERENCES 115
VI. APPENDIX – SAMPLE CHARTS 116
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I. INTRODUCTION
This document lists the quality control (QC) procedures, their frequencies, and
action limits that should be used for clinical Digital Mammography (DM)
systems used in the Ontario Breast Screening Program. DM includes systems
previously identified as: Full-Field Digital Mammography (FFDM), computed
radiography (CR), and digital radiography (DR). All QC procedures listed here
must be performed at the required intervals or more frequently if the individual
situation dictates. The tests in this manual are those required by the OBSP, and
form a set of comprehensive tests performed in a standardized manner that
can be compared across machines and facilities.
These tests must be done by all OBSP sites to maintain accreditation. Some
manufacturers have QC tests in their manuals which are similar to tests in this
manual; since those tests provide essentially the same information, those
manufacturer’s QC tests do not need to be performed by the site to maintain
CAR accreditation. There are also some manufacturer specific tests which a site
could perform in addition to the OBSP required tests, and additional tests that
must be done in order to use the equipment, but those are not required by
OBSP. The site should continue to perform any additional manufacturer tests
that are required for their unit to ensure it stays correctly calibrated and does
not void the manufacturer’s warranty. If you are confused about which tests
are necessary, please consult with your physicist and applications training or
service person.
This QC Manual for the mammographic technologist has procedures with

frequencies ranging from daily to semi-annually. There is also a Medical
Physicist’s Manual which has tests that are to be performed upon installation,
semi-annually or when significant changes or repairs have been made to the
unit. The site is responsible for notifying OBSP when changes or repairs are
made to the unit.
The data charts used to record test results are provided in this manual in paper
form. In addition, each chart is downloadable in Excel format from the OBSP
Physics website:
http://www.sunnybrook.utoronto.ca/~yaffegrp/OBSP/,
And from the OBSP Collaborative Webspace: http://www.obsp.webexone.com

(‘Documents’ section).
The use of the Excel spreadsheets will simplify procedures significantly, since
many plots and calculations are done automatically.
An automatic software package called “Gladys” is being evaluated for use by
the OBSP. This package was developed for use in the Flemish part of Belgium,
and has a number of important features, greatly reducing the effort (recording
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and plotting) required for the QC program. The mammographic acquisition
system automatically sends images of a client named ‘QC Mammo’ to a
program that performs a complete analysis of the image quality, reporting the
results to OBSP Physics through the internet. This greatly reduces the effort
involved in regular QC, and enables detection of subtle problems. It will allow
the physics group to detect problems quickly, and intervene before a problem
becomes critical as well as reduce clerical and technologist time requirements.
The tests described in this manual are designed to verify the correct operation
of the entire imaging chain by evaluating the three components of digital
mammography systems: image acquisition (x-ray generation and detection,
flat-field correction), image processing (dynamic range adjustment,
sharpening, peripheral equalization), and image display (gray-scale calibration
and display resolution for both monitors/softcopy and printed/hardcopy
images). When problems are detected, further tests may be required to
diagnose and isolate the cause of the problems so that they can be corrected.
Depending on the resources available at the facility and the nature of the
problems, such diagnostic testing may be performed by the quality control
technologist, the facility’s medical physicist, equipment service personnel, or
other suitably trained and qualified personnel.
The mammographic technologist must understand that the CAR accreditation

requirements require the medical physicist to either perform a mammography
equipment evaluation “whenever a new unit or processor is installed, a unit or
processor is disassembled and reassembled at the same or a new location, or
major components of a mammography unit or processor equipment are
changed or repaired”, or to review the results of the testing performed by
another qualified individual. This includes the replacement of detectors, as well
as moving the machine from one room to another. For new mammography
units, this equipment evaluation is essentially an “acceptance test” and
involves more complete testing and evaluation than that required for the
annual survey. All tests must pass before the equipment may be used for
the mammography of clients and in order to comply with HARP Regulations,
the report must be sent by the facility within 60 days of the test to:
The X-ray Inspection Service

Performance Improvement and Compliance Branch
55 St. Clair Ave. W., 8th Floor,
Toronto ON M4V 2Y7
In addition, the facility can minimize costly mistakes by involving the medical
physicist in the purchase decision, the siting, the viewing room design and
specifying the computer requirements, well in advance of installation.
The importance of involving the medical physicist in the purchase decision and
the value of his or her equipment evaluation prior to equipment use is even
4
more critical for digital mammography than it was for screen film, as facilities
rapidly depart from a single-vendor environment where appropriate
communication among system components was assured by design. It is not
uncommon for a facility to install several different acquisition systems,
interface them with review workstations from different vendors, and share the
images over an existing picture archiving and communications system (PACS).
When this occurs the medical physicist must perform an equipment evaluation
on the review workstations and it must pass the softcopy tests described in the
medical physicist’s manual, using test images that imitate those produced by
each acquisition system. If the workstation properly displays test images that
imitate those from a given acquisition device, that workstation passes the
equipment evaluation. However, this does not confirm that hanging protocols
will be properly followed, or that a given manufacturer’s image processing will
be properly applied.
As in screen-film mammography, DM QC is only effective if the procedures are

performed correctly, results are charted and compared to previous results and
to test limits as data are collected, and appropriate corrective actions are
taken when needed. QC is ineffective if procedures are not performed
regularly, if tests are performed but results are not charted, or if the charted
results are not reviewed carefully to determine if corrective actions are needed.
To aid in recognizing when corrective actions should be taken, specific test or
action limits are given for all QC test results.
Because these action limits have been developed based on the performance of
only a few units of each design and from the earlier DM systems, some of the
action limits may need to be revised as systems improve over time. These will
be periodically reviewed by OBSP Physics and updates will be provided by your
OBSP Regional Centre. Updates will also be available on the OBSP Collaborative
Webspace.
Some tests specify that corrective action must be taken immediately; this
means that the device must not be used for clients until the problem is
corrected. For example, if corrective action must be taken immediately on a
review workstation, the interpreting physicians (radiologists) may not use it for
interpretation until the problem is satisfactorily repaired. However, the facility
is not required to immediately cease mammography; they may continue to
acquire client images for a reasonable length of time. In this example, a
“reasonable length of time” would be 3 working days since acceptable medical
practice involves notifying health care providers of positive examinations as
soon as possible (as guidance, within 3 business days).
Images are generally provided to PACS systems in a “For Presentation” or

“processed” form. Some of the tests in this quality control program require
images in the “For Processing” or “raw” format. In order to properly evaluate
signal levels and noise in the system using phantoms, edge enhancement and
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dynamic range compression (thickness equalization) must not be applied to the
images. It may also be important to ensure that the “auto-push” DICOM server
is set to the appropriate state at the completion of the testing.
The mammographic technologist’s Procedures for DM for all units are shown in
Table 1 and Table 2 below. Most evaluations can be recorded directly on the
checklists (Daily and Weekly Tests and Monthly, Quarterly and Semi-Annual
Tests). Note: the tests and frequencies may vary with the type of
processing used (wet vs. dry) with the laser printer.
6
Table 1: DM Radiologic Technologist’s QC Procedures and Minimum
Frequencies without Laser Printer
Test Minimum Corrective Action
Test DM Systems Charts
# Frequency Timeframe
Monitor inspection,
1. cleaning and All Daily Immediately Chart A
viewing conditions
Immediately, before
Chart A,
2. Daily checklist All Daily checked component
Chart 1
is used for clients
Chart A,
4. Daily flatfield image All Daily Immediately
Chart 4
Visual inspection
5. CR Daily Immediately Chart A
for artefacts
Image plate
6. CR Daily NA Chart A
erasure
Phantom Image
7. All Weekly Immediately Chart 5
quality
Immediately:
workstation-before
client images
Chart 6,
8. Display Monitor QC All Weekly interpreted;
Chart 7
acquisition station
monitor-before
clients imaged
Immediately, before
All where
client images
Viewbox prior films
9. Weekly interpreted or Chart A
Cleanliness are
comparison films
hardcopy
reviewed
10. Full field artefacts All systems Monthly Immediately Chart 8
Immediately or
11. Monthly Checklist All Monthly within 30 days, Chart 9
depending on check
Within 30 days of Chart 11,
13. Repeat Analysis All Quarterly
the test date Chart 12
All with
Resolution/
scanned
14. Modulation Transfer Quarterly Immediately Chart B
image
Function (MTF)
acquisition
17. Compression Force All Semi-Annually Immediately Chart B
7
Table 2: DM Radiologic Technologist’s QC Procedures and Minimum
Frequencies including Laser Printer
Test Minimum Corrective Action
Test DM Systems Charts
# Frequency Timeframe
Monitor inspection,
1. cleaning and All Daily Immediately Chart A
viewing conditions
Digital
Immediately, before
mammography Chart A,
2. All Daily checked component
equipment daily Chart 1
is used for clients
checklist
Laser printer Daily (wet) Immediately, before Chart 2,
3. All hardcopy
sensitometry Monthly (Dry) client images printed Chart 3
Chart A,
4. Daily flatfield image All Daily Immediately
Chart 4
Visual inspection
5. CR Daily Immediately Chart A
for artefacts
Image plate
6. CR Daily NA Chart A
erasure
Phantom image
7. All Weekly Immediately Chart 5
quality
Immediately:
workstation-before
client images
Chart 6,
8. Display monitor QC All Weekly interpreted;
Chart 7
acquisition station
monitor-before
clients imaged
Immediately, before
client images
9. Viewbox cleanliness All hardcopy Weekly interpreted or Chart A
comparison films
reviewed
10. Full field artefacts All Monthly Immediately Chart 8
Immediately or
11. Monthly Checklist All Monthly within 30 days, Chart 9
depending on check
Laser printer Immediately, before
12. All hardcopy Monthly Chart 10
artefacts client images printed
Quarterly Chart
Within 30 days of the
13. Repeat analysis All (pref. 11,
test date
Monthly) Chart 12
All with
scanned
14. Resolution/ MTF Quarterly Immediately Chart B
image
acquisition
Printed image Immediately, before
15. All hardcopy Quarterly Chart 13
quality client images printed
All hardcopy
Analysis of fixer Within 30 days of the
16. with wet Quarterly Chart B
retention test date
processors
17. Compression force All Semi-Annually Immediately Chart B
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QC TEST IMAGES – SUGGESTED NAMES AND CLIENT ID:
Client ID numbers assigned to the test images should be chosen so they fall
outside the range used for imaging real clients. This is done to avoid
difficulties with any PACS, radiology information system (RIS) or health
information system (HIS) in use. The numbers assigned should also be unique
to each test. Below we suggest possible ID numbers for the technologist’s QC
test images, which can be used provided they meet the above criteria. Table 3
lists the images generated by the technologist’s QC tests along with a
suggested client naming convention. Suggested Client IDs are given, in the
following format: 990XUYYMMDD where X is the test number, U is the
mammography unit or room number and YYMMDD is the date the images are
acquired.
Table 3: Mammographic Technologist’s QC Test Images and Suggested

Names and Client ID
Test Images Suggested Client # of Images
Test Client Name
# Required ID Expected
Monitor
1. NA No NA NA
cleaning
2. Daily checklist NA No NA NA
Laser printer 1 film/day (wet) or
3. NA Yes NA
sensitometry 1 film/month (dry)
Daily flatfield Flatfield,
4. Yes 9904UYYMMDD 1/day
image Test
Visual
5. inspection for NA No NA NA
artefacts
Image plate
6. NA No NA NA
erasure
Phantom image Phantom, 9907UYYYMMD
7. Yes 1/week
quality Test D
Display monitor
8. NA No NA NA
QC
Viewbox
9. NA No NA NA
cleanliness
Full field Artefact,
10. Yes 9910UYYMMDD 2 or more
artefacts Test
Monthly
11. NA No NA NA
checklist
Laser printer
12. NA Yes NA 1 film/month
artefacts
13. Repeat analysis NA No NA NA
Resolution/ Phantom,
14. Yes 9914UYYMMDD 1/quarter
MTF Test
15. Printed image NA Yes NA 1 film/quarter
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quality
Analysis of 1 film/quarter
16. NA Yes NA
fixer retention (wet)
Compression
17. NA No NA NA
force
CHANGES TO THE MAMMOGRAPHIC IMAGING SYSTEM

To comply with CAR Accreditation requirements, all changes to the imaging
system that might affect image quality must be done in consultation with the
OBSP Regional Administration and the medical physicist for your site, and must
be reported to the CAR office when completed.
Specifically, if new equipment is installed, the mammography machine is

moved, the X-ray tube is replaced, the detector is replaced or the image
processing (software) is changed, these items must be discussed, and may
require additional tests to be performed. If site personnel change (radiologists
and technologists) this must also be reported to the CAR office (this is a CAR
requirement, not the OBSP’s).
Following this section, Table 4 details some specific changes and the
associated requirements.
In general, for any proposed change(s):
Contact the OBSP Regional Administration and the OBSP Physics Consulting
Group to notify them of the proposed change(s) before they are implemented.
Additional testing and/or submission of phantom images, flat-field images and
processor sensitometry may be required. For major changes, or new
installations, a physics visit must be scheduled. Note that while rush visits are
possible to arrange, frequently visits to other facilities have been scheduled,
and rush visits may not be possible. There will be a delay before the facility
can image patients.
Contact the CAR and notify them of the change(s). The CAR will inform the
centre as to what is required in order to maintain CAR accreditation. In most
cases, an accredited facility will be required to submit their most recent QC
chart and a phantom image (both from the same month), to ensure that the
same high level of quality that was originally demonstrated at the time of
accreditation has been maintained following the change.
Note:
• Clinical as well as phantom images must be submitted when the

unit is changed.
10
• Clinical images are not necessarily required for changes in grid,
equipment location, or a tube replacement.
• Physicist’s reports submitted to the CAR must be signed by a

physicist accredited in Mammographic Physics by the Canadian
College of Physicists in Medicine.
Table 4: Required Action for Specific Changes to the Imaging System
Changes to the Imaging System

Proposed Step 1 Step 2 CAR Fee*
Change Notify OBSP Physics of the With a Without a
Notify the CAR of
proposed change(s) prior physicist’s physicist’s
the change
to implementation. report report
Replacement the service personnel
X-ray Tube installing the tube will
complete HARP testing;
However, the physicist Phantom image &
must be consulted prior to QC data (with a
installation and may physicist’s report)
either:
o Visit the centre to $210.00 $210.00
perform tests of their Phantom image,
own, OR Dose & QC data
(without a
o Request a copy of the physicist’s report)
service report along
with phantom images to
evaluate and dose
information.
Replacement Physics may request:
Grid or o Phantom and flat-field
Replacement images after the
Detector installation and dose Phantom image &
Or information. If so, a QC data (with a
Replacement follow-up report will be physicist’s report)
Imaging issued to the site after
Plates for CR the images have been $210.00 $210.00
evaluated, OR Phantom image,
o Regular 6 month testing Dose & QC data
(without a
may be arranged to
coincide with the physicist’s report)
replacement. The new
grid can be evaluated at
that time.
*
The fees charged by CAR were current at the time of printing. Always check with CAR for
current fees.
11
Notify the CAR of
the change
Image o Processed phantom
Processing image(s) after the
Software or installation. If so, a
Algorithm follow-up report will be
issued to the site after
the image(s) have been
evaluated N/A N/A N/A
OR
o Regular 6 month testing
may be arranged to
coincide with the
software can be
evaluated at that time.
Monitor(s) for
o Installation Report and
Radiologist’s
Review Monitor QC after the
Workstation or installation
demonstrating that the
Technologist’s
Acquisition monitors are calibrated
Workstation to meet OBSP
requirements (DICOM
GSDF) N/A N/A
N/A
OR
may be arranged to
coincide with the
monitor(s) can be
evaluated at that time.
New Printer Physics may request:
o AAPM-TG18 test image
and uniform test
image, as well as
printer sensitometry
after the installation. A
follow-up report will be
issued after these
materials are reviewed; Phantom image & $210 $210
OR Printer QC data
may be arranged to
coincide with the
installation. These
changes can be
evaluated during the
visit.
12
Notify the CAR of
the change
o Acceptance Testing by
physicist (refer to Page For relocating an
4) is required when a
new unit is acquired by a existing unit, the
centre, or an existing CAR requires an
unit is relocated. This is application be
Moving an $210 $210
required by HARP, CAR made to register
Existing Unit and OBSP, and is covered the unit
by OBSP Physics. Physics
(Full clinical image
will issue a report to the
submission is not
centre including the
required).
results of the acceptance
testing.
o The results of the
Acceptance Testing must
be submitted to the
HARP Commission For a new unit, the
within 60 days of the CAR requires an
installation (and/or set- application be
up after a move) of the made to register N/A $2100
New Unit new unit(s). the unit, including
o The report, including full phantom and
entrance exposure for clinical image
the average client, must submission.
be kept on site in the
quality control log.
A New or There is no specific requirement for testing;
Recalibrated However, this will affect the film laser printer QC
Densitometer program that was initially established. N/A
(for sites It will be necessary to re-establish the
printing baseline operating levels for the film laser
images) printer (refer to Section III.2.3.B.)
New Contact CAR if a site images the dosimeter
Dosimeter incorrectly or damages it in some way and it $157.50
cannot be imaged and used, but it must be
replaced.
Lost Contact CAR if a site loses the dosimeter and $78.75
Dosimeter need to replace it for imaging.
13
Notify the CAR of
the change
Changes to
*This is a CAR Changes to
Personnel:
requirement, not the personnel must be
OBSP’s; however, the reported to the CAR
Regional OBSP and require the
Administrator should be following:
notified.
New Change Form N/A N/A
Radiologist & Curriculum Vitae
-----> (40 hours) & C-MAP
One New ---------------------------- Copy of license & N/A N/A

Technologist -----> CME
All ---------------------------- Clinical Images, N/A N/A

Technologists -----> Copies of licenses &
CME
MAMMOGRAPHY QC TEST IMAGE AND RECORD RETENTION

As with screen-film mammography QC, the medical physicist will review the
facility’s DM QC data, including test results and images during their annual
inspection. Table 5 summarizes the length of time these records must be
maintained at the facility.
HARP regulations require that QC records be “maintained for at least six years
from the time of their making in the facility in which the x-ray machine to
which the records referred is operated”. These records must include type and
result of test, frequency of testing and actions taken to correct each deficiency
identified, but do not include the actual images.
Table 5: OBSP Requirements for Mammography QC Test Image

Retention
QC Images / Records Retention
Daily QC Images – previous 60 days
Weekly QC Previous 12 weeks
Until the next semi-annual inspection has been
Monthly QC
completed and it has been determined that the facility
is in compliance with the quality assurance
requirements.
Quarterly QC Until the next semi-annual inspection has been
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requirements.
Until the next semi-annual inspection has been
Semi-annual QC tests
requirements or until the test has been performed two
additional times at the required frequency, whichever is
longer.
Images documenting test failures be provided to the
Mammography Equipment
facility to assist them in making corrective actions.
Evaluations
These should be kept for 12 months.
15
END-OF-MONTH QC REPORTS FOR DIGITAL MAMMOGRAPHY SYSTEMS
At the end of each month a CQ report is to be submitted to OBSP. This report
can be sent by email to: obspp@sri.utoronto.ca, or through the Regional
Centre.
All charts are available in Excel format from the physics group, Or from the
OBSP Collaborative Webspace: http://www.obsp.webexone.com (‘Documents’
section). The Excel versions of the charts perform calculations and plot data
automatically.
Please include the Monthly QC Report Cover Sheet with the submission (see
example on following page).
Information to be submitted includes:
• Monthly QC Report Cover Sheet – requires an email address and

phone number for the QC contact at the site as essential information.
• Chart 2 – Laser printer sensitometry (only if hardcopy reading is
performed)
• Chart 4 – Daily flatfield image
• Chart 5 – Phantom measurements
o signal level in region of interest (ROI) - this gives a measure of
sensitivity
o noise level (standard deviation) in same ROI
o signal-difference (SD) - provides a measure of contrast
o signal-difference to noise ratio - an index of image quality
o mAs ties the results to dose
• Chart 6 and Chart 7 – Display monitor QC summary (replaces processor

QC)
• Chart 12 – Retake analysis for digital images
The monthly QC submission must also include clear notes documenting

problems (i.e.: when values on chart 5 were out of range) and any corrective
action(s) that were taken (including copies of service reports). The form,
“Equipment Downtime and Technical Problem Report,” is provided here
(following the cover page) and should be completed for each occurrence where
regular mammography activity has to be stopped for service/repairs to
equipment (this includes the mammography unit(s), viewing stations and CR
readers). This form must be kept in the QC files on site, and a copy should also
be included with the monthly QC submission.
If you are submitting QC electronically, emailing the Excel spreadsheet, do not

delete any charts; instead, email us the entire file. Deleting charts from the
spreadsheet can result in broken links.
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Monthly QC Report Cover Sheet
Facility Name:
Address:
Phone:
Email address:
Excel File Submission
Prepared by:
Date:
Attention: OBSP Physics Consulting Group
Email Address: obspp@sri.utoronto.ca
Number of Files:
Re: Monthly QC for
Equipment Downtime/Service Report
Other
If images are not read on site (no Review Work Station), please list locations where OBSP
images are read below:
Message:
Please contact the HEAD QC TECHNOLOGIST as soon as possible if you do not receive all pages.
Name:
Phone: ext.
Department:
Confidientiality Statement:
The documents accompanying this transmission contain confidential information intended for a specific individual and purpose. The
information is private and protected by law. If you are not the intended recipient, you are hereby notified that any disclosure of the contents
of this information is strictyl prohibited. Ifyou have received this information in error, plse notify us immediately by telephone and return the
Version 3.0
17
Equipment Downtime and Technical Problem Report
This includes mammography units, viewing stations and processing facilities. Send in
one copy to OBSP Physics (FAX 416-480-6719) and keep one in your QC binder.
Facility:
_______________________________________________________________
Date of Occurrence:_______________ Date of Report: ________________
Equipment/Product Affected:
________________________________________________________
Nature of Problem (and diagnosis by technologist):

Include description of symptoms and degree of inconvenience / urgency.
Service Company (name): _________________________________________

Time service company contacted:_ ___________Individual: _______________
Promised arrival time: __________ Actual arrival time: ___________________
Technician / Engineer name: ________________________________________
Diagnosis of Problem (as reported by service rep):
Service action taken:
Length of time to complete service: ______Charge for service: __________

Number of Clients re-booked: _______ Machine downtime: ____________
Was problem completely solved? ___________
Follow up action required:
Comments:
Other Centres Affected? (Y/N) _______

Other Centres Notified (or Head Office) _______
Physics Group Informed? _____ if so, date sent to Physics Group: _______________
Other Action:
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YEARLY QC SUBMISSION: X-RAY SAFETY POLICY & PROCEDURES
In January of each year, all of the Mammography Technologists (including part-
time) should read the current X-ray Safety Policy & Procedures pages of this
QC manual and sign the X-ray Policy and Procedures Signature Sheet. The
CMRTO registration number for each MRT must also be recorded on this sheet
in the column provided. The relevant pages and the signature sheet
immediately follow this section.
A copy of the completed signature page should be sent by FAX to the OBSP
Physics Consulting Group (416-480-6719) by the middle of January each year,
as well as being posted in the technologists’ work area with the X-ray Policy
and Procedures sheets.
In addition to the above mentioned yearly submission, the X-ray Policy and
Procedures Signature Sheet should also be completed and submitted by FAX to
the OBSP Physics Consulting Group in the following circumstances:
a) When a New Revision of the OBSP QC Manual has been Published
All of the Mammography Technologists (including part-time) and every

radiologist at the facility must review the new manual in its entirety, and
familiarize themselves with the changes and updates that have occurred
since the last revision.
The X-ray Policy & Procedures Signature Sheet should then be completed
and submitted to the OBSP Physics Consulting Group by FAX (416-480-
6719).
b) When a Mammography Technologist/Radiologist is Newly Hired

During the Year
The new Mammography Technologist and/or Radiologist must review the

current OBSP QC Manual in its entirety, including the X-ray Safety Policy
& Procedures pages, and sign the X-ray Policy and Procedure Signature
Sheet.
A copy of the completed signature sheet should then be sent by FAX to the
OBSP Physics Consulting Group (416-480-6719).
NOTE: Changes to personnel must be reported to the CAR (refer to “Changes

to the Mammographic Imaging System”, and Table 4).
19
X-Ray Safety Policy and Procedures
This policy will be periodically reviewed and updated. Latest revision: October,
2011.
The Mammography Technologist must be registered with the CMRTO.
All technologists must read and sign these X-ray Policy and Procedures pages
and record their CMRTO registration number annually.
The entire QC manual must be reviewed, and the X-ray Policy and Procedures
pages read and signed by each technologist and radiologist when:
• they are newly hired
• a new revision of the OBSP QC Manual is published and distributed
A Radiation Protection officer must be designated for the facility. This person
must be a radiologist and is normally the radiologist for the centre.
A technique chart must be posted. Most centres will use Automatic Exposure
control and Automatic kVp for nearly all patients. If manual kVp is used, 28 or
29 kVp is recommended for use with the average patient, increasing to 32 kVp
for very dense or thick breasts. The radiographic technique as well as
compression thickness must be recorded either in the image header, or on the
client’s mammography record sheet.
Views: For screening, bilateral Craniocaudal and bilateral mediolateral oblique

views will be taken unless otherwise indicated. The nipple is to be in profile in
at least one view for each breast if possible. Nipple markers may be used, but
are not required.
Consent: A signed consent for the procedure is not required by the program.
X-ray shielding devices are not required for patient protection; however they
can be used to allay fear of radiation exposure. The aprons and thyroid collar
are not to be kept on display in the mammography room, and should be kept
in a drawer or in another room.
The table acts as a complete beamstop and does not permit any primary
radiation to hit the client behind it. Scatter from the surface of the breast is
minimal (less than 1/1000) of the entrance exposure and radiation at 30 kVp
has much less penetration than that normally used for general radiography.
The exposure to the thyroid is extremely small (less than .03 mGy for a 4 view
study). The average glandular dose to the breast for a 4 view study is about 3
mGy for the average client.
20
An overexposure is defined as: An examination in which the entire breast
tissue is over-penetrated and the mAs have exceeded 600 at 28 kVp. Double
exposures due to equipment failure may cause this.
When overexposure occurs:
• Inform Radiation Protection Officer, who is to contact the Director of X-

Ray Safety, Ontario Ministry of Health at (416) 963-1030 as well as
the Physics Support Group at (416) 480-5724.
• Before imaging another client, determine cause of problem and if it

requires repair, rebook all clients until problem is corrected.
The door of the mammography room must be closed during exposure.
The door must have a warning sign stating "Unauthorized Entry Prohibited" and
have an automatic door closer as required in HARP regulations.
A copy of the OBSP Quality control manual(s) must be kept in the

technologists’ work area, and all tests must be carried out when required and
recorded in the manual. A record of the acceptance tests and 6-month checks
is to be kept in the same location.
A copy of the HARP Act and Regulations should be on site (available at

http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_900543_e.htm).
Dosimeters: Mammography Technologists are not required to wear dosimeters

if they only perform mammography. If they are performing other radiography,
their employers for that site will provide dosimetry if required. In that case,
the technologist should wear the same badge at both locations.
Pregnant technologists will be treated no differently than other technologists,

since a negligible exposure is received when the equipment is operated from
the control area.
CR cassettes will be stored in a shielded area within the mammography room,

preferably on a shelf beside the mammography unit, and behind the operator
shield.
Equipment problems are to be repaired as soon as possible and the appropriate

service organization must be contacted directly by the local centre. The
technologist should attempt to provide the service personnel with an idea of
the nature of the problem, if possible, by telephone. Below is a short list of the
most likely problems, and how to approach them.
• AEC malfunction: Determine the nature of the failure using the DSB
phantom. If the problem cannot be reproduced, continue imaging
21
clients, monitoring the mAs used. If the problem is consistent, call
service and rebook all clients for the next day. Manual timing using a
technique chart may be acceptable, but not recommended.
• Burnt-out collimator lamp: call for "non-urgent" service; position clients

carefully.
• QC action limits exceeded: determine cause of problem following

troubleshooting chart. Call equipment Service Company. Do not
radiograph clients until the system is within limits.
• Cracked or ripped compression paddle: order a new one, "rush". You may
use the other size compressor plate if required. It may be advisable to
keep a spare compression plate on site.
• Acquisition Display Monitor QC test failure: The monitors should be

cleaned and re-calibrated to meet the DICOM Grayscale Standard
Display Function (GSDF) when displaying mammography (MG)
images.
• MTF test failure: Service should be contacted to recalibrate/repair the CR

plate reader.
A Record of Repairs and Problems must be kept in the Quality Control Manual
for the equipment, including the time the service company was called, and the
total downtime for the problem.
22
X-Ray Safety Policy & Procedures Signature Sheet
Facility: __________________________________________________________
Submission for:
Annual review* of the latest X-Ray Safety Policy and Procedures pages for
Mammography Technologists in the Ontario Breast Screening Program.
Newly hired Mammography Technologist(s) and/or Radiologist(s)†.

Current OBSP QC Manual, including the latest X-ray Policy and
Procedures pages, has been reviewed.
New revision of the OBSP QC Manual received. All Mammography

Technologists and Radiologists at the facility have reviewed it and are
familiar with the major updates.
Name Signature CMRTO Date

Reg No. signed

The Radiation Safety officer is:______________________________________
Phone:_________________________________________________________
*
This sheet should be filled out by each of the mammography technologists including part-
time staff. A copy is to be Faxed to the Physics Group (Fax: 416-480-6719) by the middle of
January each year.
†
CAR must be notified of all personnel changes (refer to Table 4).
23
PHANTOMS, TEST TOOLS AND TEST IMAGES FOR DIGITAL QC
The only phantoms required to perform OBSP and CAR QC at the site are the
Digital Mammography Uniform Phantom (DMUP) and the Digital Standard
Breast (DSB) Phantom. Both are provided by the OBSP Physics Group.
The DMUP is a 4 cm thick slab of PMMA (poly methyl methacrylate, a clear

plastic) which covers the entire image receptor (see Figure 1). This phantom
is also used to evaluate the uniformity of the image, and the presence of
artefacts. If the DMUP phantom is damaged through misuse or lost, the cost of
replacement is $750 (less than a CAR phantom).
Figure 1: OBSP Digital Mammography Uniform Phantom (DMUP) with 1

mm thick contrast disc on top.
The DSB phantom is a new phantom. It consists of two semi-circular slabs of
PMMA which total 4.5 cm in thickness. It comes with a 1 mm thick contrast
disc which is placed on the top of the phantom and used to measure the
system “speed” and “contrast” (see Figure 2). Until the DSB phantom is
provided, use the DMUP Phantom in its place. If the DSB phantom is damaged
through misuse or lost, the cost of replacement is $550 (less than a CAR
phantom). The disc has a $10 replacement fee.
24
Figure 2: OBSP Digital Standard Breast (DSB) phantom with 1 mm disc
on top
Facilities which have CR systems will need to have the phantom specified by
the manufacturer to perform the quarterly MTF (resolution) test or a suitable
resolution test pattern such as Fluke Biomedical models 07-521, 07-515 or 07-
523-2000, available from www.maquet-dynamed.com .
Monitor test patterns (AAPM TG-18) should be loaded on your acquisition

workstation and onto your review workstations by your physicist or service
person, and should not be removed. The images will also be available on
DICOM compliant CD from OBSP Physics.
ACR/CAR MAMMOGRAPHIC ACCREDITATION PHANTOM

This phantom was a cornerstone of accreditation programs in the U.S. and
Canada for screen-film mammography, and while not designed for QC, has
been used for that purpose for screen-film mammography. It has been
demonstrated, however, that this phantom is of little value for QC in digital
mammography and is therefore not recommended for that purpose in the
OBSP. Nevertheless, since these phantoms are available in most sites as a
holdover from screen-film mammography, some facilities may choose to image
them periodically.
Imaging of the CAR phantom weekly is at the discretion of the facility, but is
not required to meet OBSP QC requirements.
As well, at the time of writing, the submission of an image of this phantom is

still part of the CAR Mammography Accreditation Program. Therefore facilities
should be prepared to submit such images at the time of renewal of
accreditation.
25
II. IMPORTANT POINTS
1. TIME FOR QUALITY ASSURANCE PROCEDURES

Each of the elements of a facility’s quality assurance program must be assigned
to individuals who are qualified for their assignments and the facility must
allow these individuals adequate time to perform these duties. The
approximate times to implement, analyze, and document the DM QC tests
described in this manual are listed in Table 6. Additional time must be
allocated for retesting, corrective action, and retesting again if the initial
results do not meet performance criteria.
Table 6: Responsibilities of the QC Technologist and Typical Amount of

Time Required
Nature of Procedure / Task and
Time Required*
Minimum Performance Frequency
Daily
Daily checklist 2 min
Monitor Cleaning 2 min
Daily flatfield image 5 min
Visual inspection for artefacts (CR) 0 min (ongoing)
Image plate erasure (CR) 20 min
Total Time Daily 9 min (29 CR)
Weekly
Phantom Image Quality Test (SDNR and Flat-Field) 6 min
Display Monitor 6 min
Viewbox Cleanliness 5 min
Total Time Weekly 17 min
Monthly
Laser printer sensitometry 3 min
Full Field Artefact Evaluation 15 min (45 min CR)
Monthly Checklist 2 min
Laser Printer Artefacts 4 min
Total Time Monthly 17 min (47 min CR)
Repeat Analysis 20 min
Quarterly
MTF 4 min
Printed Image Quality 8 min
Meetings with Radiologist 45 min
Total Time Quarterly 69 min
Semiannually
Compression Force Test 5 min
Total Time Semiannually 5 min
63.6 hours Hard Copy
Total Time for QC per Year (5-day week) 62.5 hours Soft Copy
153.0 hours CR
*Estimated times include setup, testing, and recording of results for a facility with two
mammography units, one “dry” laser printer and one processor.
26
All of the routine QC must be performed by the quality control technologist or
by other personnel qualified to perform the tasks. When other personnel
perform these tasks, the quality control technologist must ensure the tasks are
completed properly.
The laser printer sensitometry test must be conducted daily for systems with
wet processing of printed images, and monthly for systems with dry
processing. Daily darkroom cleaning need not be performed by the
mammographic QC technologist if it is being performed adequately by other
qualified facility personnel; however, darkroom and monitor cleanliness must
be checked on a daily basis.
27
2. INFORMATION STORAGE AND MAMMOGRAPHY UNIT
IDENTIFICATION
In addition to quality requirements already in place for digital mammography,
we point out that it is important to ensure certain key information is
automatically transferred from the digital mammography image acquisition
system to the stored DICOM image.
This information is required for several purposes: 1) QC, 2) to enable review of

images by other facilities, 3) the estimation of client dose, 4) tracking of
imaging parameters, and, 5) for use in retrospective studies.
Specifically, systems MUST provide all information fields listed in Table 7,

ideally without additional manual entry by the operator. In addition, it is
DESIRABLE that systems also provide the information listed in Table 8.
The Institution Address must include at least the city, province and postal code
of the institution. The Station Name would preferably be the CAR Unit number.
Table 7: Required DICOM Header Tags

Tag Number Tag Description
0008,0080 Institution Name

0008,0022 Acquisition Date
0008,0032 Acquisition Time
0008,0081 Institution Address
0008,1010 Station Name
0008,1070 Operator
0010,0010 Patient Name
0010,0020 Patient ID
0018,0060 kV
0018,1152 Exposure or the two tags below
0018,1150 Exposure Time and
0018,1151 X-ray Tube Current
0018,1191 Anode Target Material
0018,5101 View Position
0018,7050 Filter Material
0020,0020 Patient Orientation
0020,0062 Image Laterality
To fully document the imaging technique used, either tag 0018, 1152
(Exposure) or both tags 0018, 1150 and 0018, 1151 (Exposure time and x-ray
tube current) must be included.
28
Table 8: Desirable DICOM Header Tags
Tag Number Tag Description
0018,1114 Radiographic Magnification factor
or the two tags listed below
0018,1111 Distance Source to Patient
0018,1110 Distance Source to Detector
0018,1400 Image Processing
0018,1401 Acquisition Device Processing Code
To know the magnification factor used (i.e., when imaging on a magnification

stand), either tag 0018, 1114 (Estimated Radiographic Magnification Factor) or
both tag 0018, 1111 (Distance Source to Patient) and tag 0018, 1110
(Distance Source to Detector) should be included.
The Integrating the Healthcare Enterprise (IHE) (www.ihe.org) mammography

handbook is useful for those who prepare “Request For Proposal” (RFP)
documents for digital mammography. By specifying how systems interact, the
standard ensures that images from different brands of mammography
machines will be displayed in a consistent manner on all brands of review
workstations. One of the requirements for compliance with IHE is the inclusion
and correct population of the DICOM tags listed in Table 9.
Table 9: Additional Desirable DICOM Header Tags for compliance with

IHE
Tag Number Tag Description Comments
0008,0070 Manufacturer
0008,1090 Manufacturer’s model name
0010,0030 Patient’s birth date
0010,1010 Patient’s age
0018,1000 Device serial number
0018,1004 Plate ID Required for CR
0018,1008 Gantry ID Required for CR
0018,1020 Software versions
0018,11A0 Body part thickness
0018,11A2 Compression force
0018,1405 Relative X-ray exposure
0018,1510 Positioner primary angle
0018,2112 Source image sequence Needed for CAD
0018,700A Detector ID DR only
29
0018,700C Date of last detector Required if detector
calibration undergoes periodic calibration
(e.g., may not be applicable
for CR).
0028,0120 Pixel padding value Required if background air
suppression has been
performed by replacing the
pixels with a value not used
within the breast tissue, so
that pixels with this value can
be excluded from contrast
transformations.
0028,0121 Pixel padding range limit Required if Pixel Padding
Value (0028,0120) is present
and the padding values are a
range rather than a single
value.
0028,0301 Burned in annotation Shall have the value “NO”
unless the image was
obtained by film digitization.
0028,1055 Window center and width Required if more than one
explanation Window Centre/Width pair or
at least one window
center/width and VOI LUT
sequence
0028,1056 Values of Interest Look-up Required if window center
table (VOI LUT) function and width are not intended to
be interpreted as parameters
of a linear function
0028,1300 Implant present
0028,3010 VOI LUT sequence Required if window center
and width not present
>0028,3003 >LUT explanation Required if more than one
sequence item or at least one
sequence item and window
center/width
0040,0316 Organ dose
0040,8302 Entrance dose in mGy
To the best of our knowledge, all current DM systems are capable of providing
this information; however, it has come to our attention that for some CR
systems, additional hardware or software might be required to achieve this
functionality. It would be IDEAL to have this information transferred
automatically, but manual entry is acceptable by the OBSP until automatic
transfer is available.
30
CAR and OBSP both require that if there is more than one mammography unit
in a facility, the Unit Number must be clearly identified on the image. Properly
operating and configured software will provide all of the required information in
the DICOM header. For computed radiography (CR) systems, radio-opaque
markers may be needed to identify the unit and view.
In addition, systems should have the capability of exporting DICOM images to

a portable external medium such as: DVD or USB flash disk.
As we become more familiar with digital mammography and as more new

systems are introduced, additional requirements may become evident.
3. ESTABLISHING OPERATING LEVELS AND CONTROL LIMITS

Control limits are established by the medical physicist at equipment evaluation,
when the equipment is known to be operating correctly.
When a quality control program is started or when equipment is newly

installed, it is necessary to establish operating levels and control limits. The
operating level is the level that is normally expected. For example, the
background pixel value or optical density measured on a phantom image would
be expected to be at, or close to, a particular value that is the standard
operating level. The control limits are performance criteria established based
on operating levels which, if reached or exceeded by subsequent
measurements, require additional action. If wet processing of hardcopy film is
performed in the testing procedure, operating levels should be established
using seasoned chemistry in the processor.
If repairs or changes are made to the equipment such that new baselines need
to be established, the medical physicist will either visit the site to determine
the new operating levels as part of an acceptance test of the repaired/modified
equipment or work with the site by telephone/email to guide the establishment
of the new baselines. If a site changes from using screen-film to CR cassettes
and a CR plate reader for mammography, a physics visit for equipment
evaluation is needed, and operating levels will be established at that time.
The only baselines that may be established by the site without consulting OBSP
Physics are for the laser printer, where new baselines may need to be set when
the film emulsion changes.
4. TEST FREQUENCIES
The frequency of tests specified in this manual (Table 1 and Table 2) is the
minimum frequency. The actual frequency that the QC tests should be
conducted may vary with factors such as the age and stability of the imaging
equipment and the number of problems being encountered.
31
After the operating levels have been determined, the tests should be run more
frequently than specified in this document for a few test periods. For example,
if the recommended frequency is weekly, then the test should be performed
daily for a few weeks. This provides a large amount of data quickly to
determine whether rapid changes are occurring and allows for operating levels
to be established accurately, where appropriate. It also allows the individual
performing the tests to gain more experience in a shorter period of time.
The frequency of the tests may be modified in consultation with the consulting
medical physicist. It may be prudent to increase the frequency of the tests if
problems are frequently detected.
NOTE: If problems are seldom detected, DO NOT discontinue testing or

reduce the frequencies below the OBSP/CAR minimums for any of the
tests in the quality control program! The lack of problems indicates
that the process is “in control” at the present time but does not predict
the stability of the process in the future.
The control limits should not be widened to accommodate varying

performance. If the equipment produces results which are consistently outside
of the control limits specified in this manual, then it will be necessary to have
the appropriate repairs made or the equipment replaced.
5. CONTROL CHARTS
The QC technologist will be monitoring quantitative performance of DM
systems in a number of QC tests (e.g., laser printer sensitometry, phantom
image quality, etc.). Plotting the results on a quality control chart will enable
the technologist to quickly and visually determine if the system is performing
as it should (i.e., within “control”), if trends are occurring which may eventually
lead to an out-of-control system, and if performance variations are related to
other events (e.g., service, calibration, etc). The QC technologist must
immediately plot the data on the control chart (either by hand or by computer)
for reliable monitoring of the measurements in the QC program. For example,
the film density, region of interest (ROI) mean value, SDNR and exposure time
or mAs should be plotted on a control chart. The date should be indicated,
along with the initials of the individual performing the test. Notes regarding
changes in operating conditions (e.g., recent service, new flat-field maps or
replacement of detector) should also be recorded.
Normally, if the control limits are reached or exceeded, the test procedure
should be reviewed to determine if human error was a factor and the test
should be immediately repeated to confirm the problem. If a repeat of the test
gives a similar out-of-limits result, then corrective action is required. In this
case, the out-of-control data point should be circled or annotated, the cause of
the problem noted (when known), the corrective action documented and the
32
in-control data point plotted. Corrective action may include contacting the
medical physicist to investigate the problem and recommend corrective
actions, or contacting a service engineer to correct a confirmed problem.
If the performance criteria or control limits from this manual are consistently
exceeded, then it will be necessary to determine the cause of the problem. The
cause may be the measurement technique. For example, if a CR plate is
processed immediately after exposure one time, and after a delay the next,
such variations in technique may be responsible for results that vary beyond
control limits. All of these variables should be eliminated and data collected for
another period of time before making a decision. If the control limits are still
consistently exceeded, then the measurement equipment (e.g., the
densitometer) should be evaluated.
If the measurement equipment is found to be functioning properly and all other

variables have been eliminated, then equipment repair, or in extreme
situations, replacement should take place. All of the problem data should be
reviewed by the medical physicist, who may be able to make recommendations
regarding correction of the problem.
NOTE: If the action limits are consistently exceeded, then it is

necessary to improve the quality control procedures, or repair or
replace the appropriate equipment. DO NOT widen the action limits
since the data are indicating that the process is “out of control” and
corrective action is essential.
Control charts also allow the detection of trends regarding an unstable process
or drifting equipment calibration. A trend is an upward or downward change in
the measured data when three data points move in the same direction. The
cause of a trend should be investigated before the control limits are reached or
exceeded.
Finally, there may be situations when operating levels and action limits need to
be re-established. Typical examples are when the detector is recalibrated or
changed or when new x-ray equipment is installed. This should be done in
consultation with the medical physicist.
6. MAMMOGRAPHY QC CHECKLISTS
Two DM quality control checklists are provided to help ensure that all QC tests
are completed (Chart A and Chart B). These checklists provide a quick
reminder of when quality control tasks are due and also provide a record
indicating that the appropriate tasks have been completed in a timely manner.
All dates should be filled in prior to use of the checklist. Each time a task is
completed, the individual carrying out the task should initial the appropriate
area on the checklist. Although Chart A and Chart B do not need to be
33
submitted monthly in the QC report, they should be completed for review by
the site radiologist and physicist.
Record all daily and weekly DM QC procedure results on Chart A. Record the
performance of all monthly, quarterly and semi-annual DM QC tests on Chart
B. Monthly, quarterly and semi-annual DM QC tests should be conducted on
the same day each week. It is suggested that approximately one-half hour be
set aside to conduct these procedures. The system should be allowed to
stabilize before acquiring phantom images. It may be helpful to conduct these
weekly procedures for the first time with your medical physicist present to
answer any questions that arise.
Each CAR Accredited facility has a lead interpreting physician who has the
general responsibility of ensuring that the quality assurance program meets all
CAR requirements. The CAR recommends that the lead interpreting physician
reviews the QC technologist’s test results at least once every 3 months. In
addition, the medical physicist must review the results of the technologists’ QC
at least semi-annually. Spaces are provided in the monthly, quarterly and
semi-annual DM QC checklist (Chart B) for the lead interpreting physician and
medical physicist to initial their reviews.
34
Chart A: Digital Mammography Quality Control Checklist (Daily & Weekly Tests)
Room: Month/Year:
Checkmark (9) = Pass/Adequate; 8 = Fail; initial when complete
Date
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Test
9
Initials
1 Monitor
Cleaning
2 Daily
Checklist
(Chart 1,
daily)
3 Laser Printer
Sensitometry
-wet (daily)
4 Daily Flatfield
Image
5 Visual
Inspection for
artefacts (CR
daily)
6 Image Plate
Erasure (CR)
7 Phantom
Image
Quality
(weekly)
8 Display
Monitor QC
(weekly)
9 Viewbox
Cleanliness
(weekly)
35
36
Date: Test: Comments:
Chart B: Digital Mammography Quality Control Checklist (Monthly, Quarterly & Semi-
annual Tests)
Room: Year: Minimum Resolution:
Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Test
Initials
Laser Printer Sensitometry – dry
2
(monthly)
10 Full-Field Artefacts
Monthly Mechanical Inspection
11
(Chart 8 - monthly)
12 Laser Printer Artefacts (monthly)
13 Repeat Analysis (monthly)
Resolution / MTF Horizontal Bars
(scanning-quarterly)
14 Resolution / MTF Vertical Bars
(scanning-quarterly)
Overall Pass/Fail
Printed Image Quality
15
(quarterly)
Analysis of Fixer Retention
16
(quarterly)
Compression Force (semi-
17
annually)
Radiologist Review (quarterly)
Medical Physicist Review (semi-
annually)
37
38
7. TECHNIQUE CHARTS
Ideally, digital mammography units should expose all breasts optimally.
However there are cases where the breast shapes or compositions do not fit
within the expectations of the equipment designer. This problem may be
reduced by using a Digital Mammography Technique Chart (Chart C) that
should be developed by the mammographic technologist in consultation with
the medical physicist.
Some mammography units offer the selection of an anode target material and
x-ray beam filter. In cases where the choices of target and filter are prescribed
by the mammographic technologist, those choices should be included on the
technique chart.
It may be necessary to use manual techniques to obtain appropriate exposures

on images of breasts containing implants. The appropriate information can also
be recorded on the technique chart.
Once the technique chart has been filled out, it should be posted on the DM
unit adjacent to the control panel and followed by every technologist using the
equipment when indicated. The manufacturer’s recommendations should be
followed, but the medical physicist, applications specialist and radiologist
should be involved in optimizing this chart, and in setting appropriate aim
values.
Chart C: Digital Mammography Technique Chart
No Implants
Compressed Breast Mammography AEC Target Filter kVp mAs Aim Value
Thickness (cm) Density Setting (S#, EI or
ADU)
Implants
Compressed Breast Mammography AEC Target Filter kVp mAs Aim Value
Thickness (cm) Density Setting (S#, EI or
ADU)
39
8. IMAGE VIEWING CONDITIONS
Viewing conditions are extremely critical in mammography. The information for
the procedures entitled, “Display Monitor QC” (Test #6) and, “Viewbox
Cleanliness” (Test #8) should be read and followed with great care. The higher
optical density mammograms needed to maximize lesion detection require high
luminance viewboxes, proper masking of each film, and low ambient room
light. All mammograms and mammography test images must be completely
masked when being viewed, i.e., no light should come directly from the
viewbox surface or monitor to the eye of the observer. These viewing
conditions apply to the technologist QC area as well as the area where the
radiologist interprets images. If printed digital mammograms are viewed on
the viewbox, it should be understood that the printer is calibrated for use with
a viewbox with a given intensity, and that the diagnostic quality of the image
may not be as expected.
The correct calibration of monitors used to view digital mammograms takes

into account the effect of ambient room light on the final appearance of the
image. Thus, appropriate room lighting should be determined during initial
setup of the monitors in consultation with the radiologist(s) and site physicist.
These viewing conditions should be maintained for all future use and testing of
the monitors. If the ambient illumination changes, it will be necessary to have
the monitor calibration adjusted.
Current research publications suggest that the ambient light level in reading
rooms can be higher than previously thought (20-40 lux). This level of light
(enough to read black text printed on a white page) may reduce eye-strain.
Whenever mammograms or phantom images are viewed, they should be

viewed under identical conditions. For example, phantom images should be
viewed on the same viewbox or monitor, with the same lighting conditions, and
using the same magnifier as used for viewing clinical mammographic images
and at the same time of day, for example, first thing in the morning. In
addition, the same viewbox masking should be used for both clinical and
phantom images.
Whenever it is necessary to make subjective judgments about phantom

images, e.g., determining resolution in test images, the perception of low
contrast changes or the detection of artefacts, the evaluation should be carried
out by the same person using conditions identical to those used for previous
evaluations.
9. THIRD PARTY PRINTING

If your site uses a third party (a different mammography facility or separate
entity) to print digital mammograms onto films, it is the responsibility of your
40
Digital Mammography Quality Control – Technologist- Rev. 3.1
site to verify that appropriate quality control of the printer(s) used is being
carried out, and that the printed image quality is acceptable. Your facility’s QC
technologist is responsible for overseeing the laser printer QC. This may be
done by obtaining the monthly QC records from the printing service and
evidence that problems are corrected when detected. Please forward the third
party’s monthly QC records to the OBSP Mammographic Physics Consulting
Group along with your monthly QC package. In addition, printed films of a
uniform image should be provided monthly and films of an appropriate test
pattern should be provided quarterly so that test procedures 11 and 14(Laser
Printer Artefacts Test and Printed Image Quality Test) can be performed.
Periodically, clinical cases should also be reviewed.
41
III. DIGITAL MAMMOGRAPHY QUALITY CONTROL TESTS
The QC test procedures required by the mammographic technologist are listed

in this section. Each test is numbered in order to coordinate with Table 1,
Table 2, Table 3, Chart A and Chart B.
1. DAILY QUALITY CONTROL TEST PROCEDURES

Performance of daily monitor cleaning and the daily checklist (Chart 1) should
be recorded on Chart A. Daily laser printer sensitometry should be recorded
on Chart 2. Baselines can be established using Chart 3. Performance and
results of the daily flatfield image test should be recorded on Chart 4.
42
Test #1: Monitor Inspection, Cleaning and Viewing
Conditions
Objective
To keep monitor screens free of dust, fingerprints and other marks that might
interfere with image interpretation. To confirm that image viewing conditions
are acceptable.
Frequency
Daily
Required Test Equipment
Dry, soft, lint-free cloth or lens tissue

Water or approved monitor face cleaner
Test Procedure Steps
1. Clean all monitor screens gently with the cloth lightly dampened with
water if required.
2. Record the monitor cleaning on the daily and weekly checklist (Chart A).
3. Ensure that appropriate cleaning solutions are in the examination room.
4. Record viewing condition status in the daily and weekly checklist (Chart
A).
Precautions and Caveats
Abrasive materials or alcohols should not be used on monitor faces, since the
anti-glare surface on the display might be destroyed.
Performance Criteria and Corrective Action
Monitor screens must be free of dust, fingerprints and other marks that might
interfere with image interpretation. There should be no “shiny” patches or
obvious non-uniformities on the surface.
The lighting conditions and room configuration must match what is described
on the medical physicist’s worksheet. Sources of bright light must not be
present in the room and must not be reflected from the viewbox and/or
monitor surfaces. Any required corrective action must be undertaken before
images are interpreted.
43
Timeframe for Corrective Action
Before client images are interpreted.
44
Test #2: Daily Checklist
Objective
To confirm that the digital mammography unit is functioning adequately.
Frequency
Daily
Daily checklist (Chart 1)
1. Visually inspect the unit for loose parts, cracks in the compression
paddles, compressor and Bucky cleanliness and overall integrity.
2. Check that all hoses and cables are free from breaks, crimps, or knots.
Hoses and cables should not be under other heavy equipment.
3. Ensure that the current technique chart is posted.
4. Ensure that the cleaning solution for the breast support plate and
compressor is available.
5. Perform any additional daily tests or procedures required by the

manufacturer’s QC programme.
6. Record status on the “daily–weekly” checklist (Chart A).
If the criteria for the manufacturer’s recommended daily checks are not met,
service support should be called.
Immediately, before any patients are imaged.
45
Chart 1: Daily Checklist
Facility:
Room: Month/Year
Date
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1
9
Initials
No Loose Parts
Overall Integrity
Cleanliness
No Cracks in
Paddles
Housing and
Cabling
Unobstructed
CR Reader
Cleanliness
Imaging Plate
Erasure
Date: Comments:
46
\
Test #3: Laser Printer Sensitometry
The printer should be set up by the manufacturer and tested before use by the
medical physicist to establish baseline performance. These baseline values are
called “reference operating levels” (ROL). Alternatively, the radiographer can
establish the ROL values for sensitometry as described later in this section.
Objective
To confirm and verify that the laser film processing system used to print client
images is working in a manner consistent with baseline performance as
established by the physicist so that printed image quality is consistently high.
Printing should be conducted from each workstation that is normally used to

submit client films for printing. Testing of all images sources is performed
during the quarterly ‘Printed Image Quality’ test.
Frequency
Daily
Systems with wet processing: daily or on each day before clinical images are
to be printed; and when changes in sensitometry are suspected.
Monthly
Systems with dry processing: monthly, and when changes in sensitometry
are suspected.
Densitometer
TG18-QC pattern (use one specific to one of your DM units – Figure 3) or,
Printer-produced sensitometry strip (gray-scale step wedge)
Chart 2 and Chart 3
A. Laser Printer Sensitometry
1. Expose and process a single TG18-QC film or a gray-scale step wedge.

Always use the same window width and level settings.
2. If using the TG18-QC pattern, note the box numbers run from darkest
(#1) to brightest (#18) (see Figure 3). Read and record the densities on
the pattern as follows:
a) Maximum density area (Dmax) – Box #1
Digital Mammography Quality Control – Technologist- Rev. 3.1 47

b) Density difference (DD) – Box #16 (DD1) minus Box #5 (DD2)
c) Mid-density (MD) – Box #11
d) Base+fog (B+F) – Box #18
3. If using a gray-scale step wedge, choose step numbers as follows:
a) Dmax – darkest step
b) DD – step closest to 2.20 (DD1) minus step closest to but not less
than 0.45 (DD2)
c) MD – step closest to but not below an optical density (OD) of 1.20

or your working OD
d) B+F – lightest step
4. Record and plot these four values (Dmax, DD, MD and B+F) on Chart 2.
5. Record completion of the sensitometry procedure on the daily and weekly

checklist (Chart A).
Table 10: Tolerances for film sensitometry

Parameter Acceptable tolerance Achievable tolerance
Dmaxa ≥ROL – 0.15 or 3.50 ≥ROL – 0.10 or 3.50
whichever is least whichever is least
DD ROL ± 0.15 ROL ± 0.10
MD ROL ± 0.15 ROL ± 0.10
B+F ≤ROL + 0.03 -
a
Note, that there is no upper control limit.
If the Dmax falls below the control limit of -0.15 of its respective
operating level or is < 3.50, the source of the problem must be determined
and corrected before digital mammograms are printed. (Note: there is no
upper control limit; darker Dmax values are desirable).
If the Dmax falls below -0.10 of its respective operating level but is
still above -0.15, the test should be repeated immediately. If the same result
is obtained, it is acceptable to print films, but the printer or processor should
be monitored closely.
If the DD or MD exceeds the control limit of ±0.15 from its operating

level, the source of the problem must be determined and corrected before
digital mammograms are printed.
48
If the DD or MD falls outside of the ±0.10 control limit but are within a
range of ±0.15, the test should be repeated immediately. If the same result
is obtained, it is acceptable to print films, but the printer or processor should
be monitored closely.
If the B+F exceeds the control limit of +0.03 from its operating level, the
source of the problem must be determined and corrected before digital
mammograms are printed.
The printer is in control and no further action is required when:

• the DD and MD are within ±0.10 of their respective operating levels
and
• the B+F is within +0.03 of its operating level and
• the Dmax is above -0.15 of its respective operating level.
If a change in the Dmax, DD, MD or B+F exceeds the performance criteria, it

will be necessary to determine the source or sources of this change and the
problems should be corrected immediately. In addition, the out-of-control data
point should be circled and the cause of the problem noted in the “Remarks”
section of the control chart. After correction, the in-control data point should
be plotted on the same date.
On wet processors, the most likely sources of change are processing chemistry,
replenishment, and temperature changes. For example: if few films have been
printed for some time, the processing chemistry may have oxidized and may
not have been properly replenished.
On dry processors, a likely source of change might be the drum temperature.
On either processor, a change in film emulsion batches may lead to a change in

film optical densities, and should initiate an internal re-calibration of the
printer.
Immediately; before any client images are printed.

Figure 3: TG18-QC Pattern
50
Chart 2: Laser Printer Sensitometry

B. Establishing Laser Printer Sensitometry Operating Levels
1. Print and process a TG18-QC film or gray-scale step wedge. Record the
window width and level settings used if printing the TG18-QC pattern.
2. Repeat step 1 for 5 days, obtaining 5 films. Ensure the window width and
level settings are the same each time.
a) Dmax – Box #1 contrast square (may not be less than 3.5)
b) DD – Box #16 (DD1) minus Box #5 (DD2)
c) MD – Box #11
d) B+F – Box #18
3. If using a gray-scale step wedge, read and record the densities on

Chart 3 as follows:
a) Dmax – darkest step (may not be less than 3.5)
b) DD – step closest to 2.20 (DD1) minus step closest to but not less
than 0.45 (DD2)
c) MD – step closest to but not below an optical density (OD) of 1.20 or

your working OD.
d) B+F – lightest step
4. Determine the averages for these four values (Dmax, DD, MD and B+F)
over the first five days. Use these as the operating levels on Chart 2.
5. Record the date the operating levels were calculated on Chart 3.
NOTE: New operating levels are only required when major

changes are made to the equipment. The printer should be re-
calibrated to meet the expected operating levels when film or
chemistry is changed. Consult your medical physicist.
52
Chart 3: Setting Operating Levels: Laser Printers
Date Values Valid From: _______________________________
Date
Step /
Average
Box #
Dmax
DD 1
Mid-
Density
DD 2
Base+Fog
Target Value
Density Difference
(DD1 – DD2)
Mid-Density
Dmax
Base+Fog
Reason for setting new target value:

Test #4: Daily Flatfield Image
It is important that artefacts which could interfere with clinical interpretation
be detected before image quality deteriorates significantly. If an artefact that
looks like a dead pixel or group of dead pixels occurs, it is very important to
know whether it persists in time, and whether its position changes on
successive days. Performance of a daily flat field image allows detection and
monitoring of such problems.
Objective
To ensure that clinical images produced are free from artefacts that might
interfere with image interpretation.
Applicability
All systems
Frequency
Daily.
OBSP Digital Mammography Uniform Phantom (DMUP) or

a uniform slab of PMMA that has been supplied by the manufacturer for flat-field
correction would also be acceptable. The slab should be free of scratches or
other imperfections that would cause artefacts. The slab should preferably
cover the entire area of the image receptor. The same test object should be
used each time. It is acceptable, but not required to have a contrast disc or
other fixed structure in the image.
1. Place the test object on the breast support centered laterally extending
slightly beyond the chest wall edge of the digital image receptor.
2. Apply compression force typically used clinically (e.g. 8 daN).
3. Acquire an image of the test object using standard clinical settings. The
DICOM “for presentation” version of the image should be used for this
test.
4. View the “for presentation” image on the acquisition display workstation.

Use the window width (WW) and window level (WL) as recommended by
your medical physicist. These settings result in the background of the
phantom being displayed with a mid-grey. The same WW and WL
settings (± 10) should be used each time an image is evaluated. An
54
appropriate choice of window width is critical to catch artefacts yet not
“fail” clinically acceptable images. Window width choice should be based
on what is appropriate/typical for breast images or for a phantom with
breast-like features.
5. With the same WW and WL as used above, evaluate the entire image for
overall appearance and for artefacts. Examine the entire image for both
broad area artefacts, such as non-uniformities, blotches, and streaks,
and for detailed artefacts, such as black or white pixels, clusters of
pixels, lines, or specks. Broad-area artefacts are typically best seen
while observing the phantom image as a whole, not piecewise. Detailed
artefacts are typically best seen while observing the phantom image at
full spatial resolution, where one pixel on the display corresponds to one
pixel in the image, or even in magnified form (with a magnification
greater than 1.0).
6. Record the absence or presence of artefacts on Chart 4.
An artefact is considered significant if it may mimic or obscure

anatomic features.
Performance Criteria and Corrective Actions
There should be no blotches or regions of altered texture appearance
There should be no observable lines or structural artefacts.
There should be no “bright” or “dark” pixels evident.
If any artefacts are visible that might mimic or obscure anatomic information
or if any patterns are seen, a recalibration or flat-fielding of the digital detector
may be needed for DR systems. The compression plate and all accessible
surfaces that are in the imaging field should be cleaned to remove any debris
or extraneous material. For CR systems, clean the imaging plate following the
manufacturer’s directions. After this has been done repeat the test. If
artefacts persist, contact your authorized service representative.
Immediately.
If this test fails, do not image patients until corrective action has
been taken.

56
Chart 4: Daily Flatfield Phantom
Facility: Room/Unit:
Manufacturer: Model:
Phantom Serial #:
Uniform phantom baseline Viewing Parameters (Processed Image)

Exposure mode (AEC/AOP) Window Width
Target/Filter Window Level
kV
Compression thickness (mm)
Compression force (daN)
Year
Month
Day
Initial
mAs
Artefacts Softcopy
Acceptable Hardcopy
Date: Remarks:
56
Test #5: Visual Inspection for artefacts (CR systems only)
Dust on the CR plates can create artefacts that mimic microcalcifications (Figure 4a).
Scratches or other defects on the plates can interfere with image interpretation and dust
in the optics of the plate reader can cause disturbing linear artefacts on images (Figure
4b).
(a) (b)
Figure 4: Artefacts caused by (a) dust on part of an imaging plate, (b) scrapes
on the imaging plate (horizontal arrow) and dust in the CR reader
optics (vertical arrows).
Objective
To ensure that clinical images produced with CR systems are free from artefacts that
might interfere with image interpretation
Applicability
CR systems only
Frequency
Daily, constantly throughout the day.
Cleaning cloth and solution as recommended by the CR plate manufacturer. An ultraviolet

inspection lamp is desirable.
Cleaning cloth/wipe approved for use on the breast support plate and compressor plate.
57
1. Inspect clinical images constantly during the day for excessive artefacts
attributable to dust on the imaging plates or in the readout system, or defects on
the imaging plates. Note that images from all plates in regular use should be
inspected.
2. If artefacts are detected at a level that could interfere with the diagnostic quality
of the images, then inspect the plates for dust (using the UV lamp if available) or
defects.
3. Record plate inspection and or cleaning status on the “daily-weekly” checklist

(Chart A).
Performance Criteria and Corrective Actions
If the plates are dusty, then clean the CR plates according to the manufacturer’s
protocol. Plates containing significant defects should be replaced.
If it is found that plates must be cleaned frequently (more than weekly) this may
indicate problems with dust or cleanliness of the imaging environment. If this is the
case, attention should be given to ventilation (possible need for improved air filtration or
humidity control in the room and/or the CR plate reader) and room cleaning protocols.
If there are small dot-like artefacts (normally from dust on the screens) or lines
(possibly caused by dust in the CR light path), then appropriate cleaning by the user,
using the manufacturer’s recommended cleaning procedure should be performed. If the
artefacts are not corrected, then service support should be called.
Note: Excessive frequency and/or aggressiveness of plate cleaning

may lead to premature wear of the plates.
Immediately
58
Test #6: Image Plate Erasure (CR systems only)
CR plates may retain signal from previous exposures (lag). In addition, they are
susceptible to artefactual signals arising from both naturally-occurring and manmade
sources of ionizing radiation. Although the plate reading system automatically erases
plates after each readout, it is necessary to perform additional erasure of plates that
have been unused for some time. It is recommended that this erasure be repeated
before clinical exposures on plates that have been unused for more than eight hours.
Some manufacturers provide a mechanism to carry out a more intensive erasure, which
should be performed periodically, typically weekly. In both cases, the manufacturer’s
instructions should be followed.
Objective
To ensure that all plates remain free from clinically significant artefactual signal arising
from naturally occurring and manmade sources.
Applicability
CR systems only
Frequency
Daily for standard erasure procedure. Weekly for intensive erasure or as recommended
by manufacturer.
1. Perform a daily/weekly erasure of each plate as recommended by the plate

manufacturer
2. Record on the “daily-weekly” checklist (Chart A) that task has been completed.
It should be recognized that CR plates have a finite lifetime during which they provide
their specified performance. If erasure procedures fail to remove residual artefacts, the
plates should be replaced.
Immediately
59
2. WEEKLY QUALITY CONTROL TEST PROCEDURES
These procedures should be conducted on the same day each week. It is suggested that
approximately one-half hour be set aside to conduct these procedures. Allow the system
to stabilize before acquiring phantom images. It may be helpful to conduct these weekly
procedures for the first time with your medical physicist present to answer any questions
that arise.
Record the performance of all weekly DM QC tests on Chart A. Record the data from the
phantom image quality test on Chart 5, and the data from the display monitor QC on
Chart 6 and Chart 7.
60
Test #7: Phantom Image Quality
In digital mammography, it is essential to perform routine assessments on the image of
a test object to confirm that there have been no substantial changes in imaging
performance from the baseline. The recommended method provides both subjective and
quantitative measures of performance.
Objective
To monitor consistency of imaging performance (e.g. variations in detector performance)

in terms of factors that affect dose and image quality. Comparison is made with baseline
performance levels using “for presentation” images as viewed by the radiologist.
Quantitative performance indicators are the mean pixel value (MPV), mAs employed for
imaging and signal difference to noise ratio (SDNR).
Frequency
Weekly
The Digital Standard Breast (DSB) Phantom - a 45 mm thick PMMA phantom, semi-circular
in shape (Figure 2). The same test object should be used each time.
1 mm thick, 25 mm diameter contrast disc (if the DSB phantom does not have a 1 mm well
in its top surface)
Chart 5 (OBSP DM QC Phantom Control Chart)Test Procedure Steps
1. Open a test client exam named QC Mammo at the acquisition workstation and give
it an ID number specific to the date (Use an ID number such as 9903UYYMMDD),
with U being the unit identifier. Using an image numbering system that tracks your
QC images over time in a consistent manner will allow you to find your QC records
in an easy way.
2. Ensure that the most commonly used compression paddle (or the paddle specified
by your medical physicist for QC procedures) is installed. The paddle to use
should be recorded at the top of Chart 5.
3. Place the DSB phantom on the breast support centred laterally and aligned with
the chest wall edge of the digital image receptor.
4. Place the 1 mm thick disc so that the center of the disc is about 50 mm from the
chest wall (or the edge of the disc closest to the chest wall is about 40 mm in), on
the centerline of the image detector. This should be located at the same place each
time, so if there is an AEC detector mark on the paddle, it would be a good
position to select.
61
5. Apply compression force typically used clinically (e.g. 80 N)*. Record the
compression force used at the top of Chart 5. Use that same amount of
compression force each time the DSB is imaged. Record the compression
thickness readout on Chart 5.
6. If there is a separate AEC sensor, confirm that it is not directly under the contrast
object (disc or well). The sensor should be in the same position every time the test
is performed.
7. Acquire an image of the test object using the settings provided in “Digital
Mammography QC Phantom Baseline Calculation Worksheet”. This should have
been provided by the physicist. If this chart is not available, then use the same
technique settings that you would use for a clinical exposure of a standard breast.
Normally this is achieved by using the automatic exposure mode. Otherwise, select
target, filter, kV, grid, density control position, operation mode (semiautomatic or
automatic) as appropriate. The DICOM “for presentation” version of the image
should be used for this test. .
The same exposure mode and paddle should be used for all subsequent
phantom exposures.
8. Record the technique used to acquire the image (target, filter and kV) on Chart 5.
For systems using automatic exposure control (AEC or AOP), the target material,
filtration and kVp should not change from one exposure to the next. Plot the mAs
on Chart 5. If the target, filtration or kV change, or the mAs value is outside the
action limits, repeat the image. If there is still a problem, either your medical
physicist or service organization should be contacted.
9. If client images are interpreted in softcopy, view the processed image on the
radiologist’s softcopy display station. Use the window width (WW) and window
level (WL) as recommended by your physicist. These settings result in the
background of the phantom being displayed with a mid-gray. The same WW and
WL settings (+/- 10 ADUs) should be used each time an image is
evaluated. An appropriate choice of window width is critical to catch artefacts yet
not “fail” clinically acceptable images. Window width choice should be based on
what is appropriate/typical for breast images or for a phantom with breast-like
features.
10. With the same WW and WL as used above, evaluate the entire phantom
image for artefacts. Examine the entire phantom for both broad area artefacts
(e.g., non-uniformities, blotches, and streaks), and for detailed artefacts (e.g.,
black or white pixels, clusters of pixels, lines, or dust particles). Broad area
*
The actual force should be similar to the typical value used clinically, but the same value should be used
for all testing. Note that in some systems and in some modes of operation the compressed breast
thickness is used in an automated algorithm to determine the technique factors and this thickness is, in
turn, dependent on the degree of compression applied.
62
artefacts are typically best seen while observing the phantom image as a whole,
not in pieces. Detailed artefacts are typically best seen while observing the
phantom image at full spatial resolution, where one pixel on the display matches
one pixel in the image, or even in magnified form (with a magnification greater
than 1.0).
11. Record the absence or presence of artefacts at the bottom of Chart 5.
It is not necessary to view the image on all available softcopy monitors.

This is a test of image acquisition, not display. Monitor performance is
assessed separately in test 8.
12. An automated algorithm which is provided by the manufacturer or QC

company [46] may be used to reduce the effort required by the technologist for
tests 5, 7 and 10 however, it is important to also visually inspect a flat-field image
at regular intervals. It is also important for the automated program to give the
results to the technologist immediately, before imaging on patients is performed.
An artefact is considered significant if it may mimic or obscure anatomic

features.
13. If client images are interpreted on hard-copy, print the image using the WW
and WL that would be used for a client image. View the image on a
mammographic quality viewbox, preferably the one used by the radiologist.
Evaluate the entire phantom image for artefacts, recording the absence or
presence of artefacts on Chart 5. Record whether the phantom image was
evaluated on hardcopy (H), softcopy (S), or both (B)
14. If it is possible, display the processed (“processed” or “for presentation”)

image on a workstation that provides region of interest analysis.
15. With the image displayed so that the signal difference to noise ratio (SDNR)
contrast disc or well is clearly visible (see Figure 5), place a circular ROI of
approximately 1 cm in diameter (approximately 0.8 cm2) over, and entirely
contained within the contrast object (disc or well). Use the same size (or as close
as possible) ROI each time.
16. Measure the mean pixel value (MPV) and label this value “A”. Record this
number on Chart 5.
17. In a region outside but immediately adjacent to the disc, measure the MPV
and standard deviation within a similarly sized ROI as used above as
measurements B and C and record on Chart 5.
63
Contrast disc or
well
5 cm
ROI for
value A
ROI for
values B
and C
Figure 5: ROIs in the image of the weekly QC phantom used to calculate the
signal difference to noise ratio.
18. Calculate the Signal Difference-Noise-Ratio (SDNR) as:
SDNR = (A-B)/C
19. An alternative method would be to use software built into the mammography
system or workstation to automatically calculate SDNR, if the manufacturer has
incorporated this test into their software. If Gladys software is running, this test
will automatically be performed, and recorded.
20. Record the SDNR on Chart 5.
21. For CR systems record the appropriate exposure index listed in Error!
Reference source not found..
64
Table 11: Exposure Indices for Testing CR Systems
Manufacturer/ Exposure
system index
Fuji S#
Philips S#
Agfa lgM/EI*
Carestream ROI tool
average value
Konica S#
The ROI placed over the 25 mm diameter contrast area should not touch or extend
beyond the edges of the disc or well. The ROI placed outside the disc should be to the
left or right of the disc (looking at the image receptor).
When recording signal mean and standard deviation values, it is not necessary to write
down all of the digits seen on the screen. Four significant digits (1234) are sufficient for
the signal value. Three significant digits are sufficient for the noise (standard deviation)
value. For example, if 123.4567 is displayed for the signal, record 123.4; if 9.87654 is
displayed for the standard deviation, record 9.88.
Note: Operating levels should only be recalculated when changes are made to
equipment such as replacement of tube or detector or re-calibration of detector, AEC or
generator. If the unit is serviced, new operating levels may need to be calculated.
Almost all of these conditions require an equipment evaluation by the medical
physicist.
Table 12: Tolerances when imaging weekly DSB Phantom

Parameter Acceptable tolerance with
respect to baseline values
mAs ±10%
Mean pixel value “B” (MPV) ±10%
Signal difference to noise ratio (SDNR) ±10%
*
Agfa have introduced a new dose index called the Exposure Index (EI) which is linear with dose. Some
new CR readers have implemented this change whilst others retain the SAL.
65
CR systems (Exposure Index)
Fuji, Philips & Konica (S#) ±10%
Agfa (lgM/EI/S) ±0.04 /±10%/±5%
Carestream (ROI average) ±21 units
In addition to the tolerances specified in Table 12:
• There should be no blotches of altered texture appearance
• There should be no observable lines or structural artefacts
• There should be no “bright” or “dark” pixels evident
If any of the quantities mAs, MPV, SDNR or, in the case of CR systems, the exposure
index is outside the action limits stated above, the test should be repeated if
applicable. If the results remain unacceptable it may be appropriate to contact the
responsible medical physicist for further advice in regard to implementing the
recommendations listed below.
1. Ensure the correct image type (“processed” or “for presentation”) is used for
signal measurements. Also check to see if service adjustment, ambient or detector
temperature, recalibration of the detector system, or software changes might be
responsible for the readings appearing outside of tolerances. If no service
adjustment has occurred, and if any of the values are still outside of tolerances on
a repeat test, contact your authorized service representative.
2. If it is found that during repeated exposures with the same phantom in place the
mAs varies excessively because the kV, target or filter has switched, the system
may be operating at a “switching point”. Under these circumstances, to facilitate
consistency testing the medical physicist may advise adding a thin slab (5 – 10
mm of PMMA) so that the AEC operates at a different point.
3. If any artefacts are visible which might mimic or obscure anatomic information or
if any patterns are seen, a recalibration or flat-fielding of the digital detector may
be needed for DR systems. Alternately, there may be a foreign material on the
compressor paddle, breast support or detector face. The compression plate and all
accessible surfaces that are in the imaging field should be cleaned to remove any
debris or extraneous material. For CR systems, also refer to Test # 4. After this
has been done repeat the test. If artefacts persist, contact your authorized service
representative. Do not image clients until the artefacts are removed.
Time Frame for corrective action
Immediately. If this test fails, do not image clients until corrective action
has been taken.
66
Chart 5: OBSP DM QC Phantom Control Chart
Facility: Room / Unit:
AEC mode Year:
Compression Force: Paddle:
Window Width Window Level
Month
Day
Init.
Thickness
Target
Filter
kV
A
B
C
Weekly mAs Value
+10 %
Baseline
-10 %
Weekly Signal Value (B)
+10%
Baseline
-10%
Weekly SDNR Value ((B-A)/C)
+10%
Baseline
-10%
Artefacts (Y/N)
Pass/Fail
67
Chart 5: OBSP DM QC Phantom Control Chart, Continued
Facility: Room / Unit:
AEC mode: Year:
Compression Force: Paddle:
Window Width Window Level
Month
Day
EI/S
L
Weekly Exposure Index (CR Only)
Baseline
-
Pass/Fail
Remarks
Date Action
68
Test #8: Display Monitor QC
The accuracy of the diagnosis and the efficiency of the radiologist are influenced by the
conditions under which the mammograms are viewed. Viewing conditions can affect the
diagnostic potential of even the best quality mammograms. These conditions are
determined by the luminance and calibration of the monitors used for softcopy
interpretation, the luminance of the view-boxes used for hardcopy interpretation, the
ambient room illumination (the amount of light falling on the monitor and/or view-box
surface), and good masking of films on the view-box.
Contrast is extremely important in the mammography image and is degraded by

extraneous light. Consequently, monitors and view-boxes should be positioned to avoid
incident light from windows, other monitors or view-boxes, and other sources of bright
light, either direct or reflected. General lighting in the room should be diffuse and at a
low level.
Objective
To ensure that images on the acquisition workstation monitor and on the monitor used
for interpretation are displayed at adequate contrast and resolution.
Applicability
This test should be performed on all primary medical display devices used to interpret
digital mammograms (radiologist’s workstations), and on all secondary display devices
as indicated. Secondary display devices include the monitor(s) attached to the
acquisition workstation that is used to verify client image quality and/or the monitor
used to manipulate and print the images (technologist’s workstations). If the
interpreting physicians provide final interpretations from hardcopy only, the tests will
only apply to the secondary display devices.
Frequency
Weekly
Modified AAPM TG18-QC test patterns with DICOM header to match processed images
produced by each acquisition system used at the site. (This test pattern may be obtained
from the DM unit’s or the workstation’s manufacturer.) For your convenience “right” and
“left” versions of the test pattern are provided so that the display software on the
radiologist’s workstation can display the image on both monitors simultaneously. The
“right” and “left” versions of the image are identical except for the mammographic
projection (view) information contained in the header. The images can be loaded as client
images in the same manner that previous images would be reviewed on the system. The
images should be loaded onto your PACS system or workstation by the medical physicist
when they perform the equipment evaluation. The images are also available on a DICOM
69
compliant CD from OBSP Physics. These images should be stored on the system and
should not be deleted.
Client images
Chart 6 and Chart 7.
A. Test Pattern Check
1. Before conducting this test, review the “Acceptable Viewing Conditions” worksheet
posted by your medical physicist in the room where the radiologist’s workstation is
located.
2. Ensure that the lighting conditions and room configuration match those described
on the worksheet. Ensure that sources of bright light are not present in the room,
and are not being reflected from viewbox and/or monitor surfaces.
3. If differences exist between the acceptable configuration and the current

configuration, adjust the room appropriately to ensure acceptable viewing
conditions (i.e., turn off lights that should be off, close curtains, etc.).
4. For each primary and secondary display device view the modified TG18-QC pattern
on each monitor used to display digital mammograms. For primary display devices
there are typically two monitors used to display digital mammograms.
5. Display the AAPM TG18-QC test pattern image in the normal manner (as you
would for a clinical image). Ensure the window-width (WW) is set to maximum and
the window-level (WL) is set to half of maximum. Use the same WW and WL
settings each time. See Table 13 for the WW and WL settings applicable to each
acquisition system image type.
Once the window width and level settings are correctly set, it is often
possible to “save” how the image is displayed so that next time the image is
called up the settings are already correct. (Consult your applications
training person for instructions.)
Table 13: Window Width and Level Settings for Viewing AAPM TG18-QC Images
Acquisition System Window-Width Window-Level
Agfa CR 32768 16384
Fuji CR 1024 512
GE 2000D, Essential 4096 2048
IMS Giotto Image SDL 4096 2048
Hologic Selenia 16384 8192
Kodak CR 4096 2048
Konica Regius CR 4096 2048
70
Siemens Inspiration, Novation 4096 2048
6. Evaluate subjectively the following aspects of the image (see Figure 6):
a) General image quality
i. Check for evidence of smearing.
ii. Examine the image for evidence of other artefacts
iii. Confirm that the vertical grayscale ramps that go from black to white along
the sides of the pattern (regions A on Figure 6) demonstrate a smooth and
continuous variation in brightness.
b) Geometric distortion:
i. Check that the lines on the pattern are straight.
ii. Check that the image is centered on the screen.
iii. Check that the boxes appear square.
c) Luminance:
i. The luminance squares frame the central portion of the pattern (regions B on
Figure 6). They are numbered 2 through 17. Check that each is a distinct
shade of gray, different from all the other patches.
ii. Examine the 0%-5% and the 95%-100% contrast squares (Figure 7)
located at the ends of the luminance square frame. Record if the patches are
visible on the relevant monitor QC charts (Chart 6 for radiologists’ review
workstations or Chart 7 for acquisition stations, as applicable).
d) Lettering (only required for primary display devices/radiologist’s workstations):

- Examine the text areas below the central region of the pattern (regions C on
Figure 6). Letters spelling “QUALITY CONTROL” are printed in progressively
fainter text over the backgrounds. Record the number of letters visible over the
following backgrounds on Chart 6.
i. Dark
ii. Mid-gray
iii. Light
Currently it may not be possible to install and display the AAPM TG-18 QC
pattern on all secondary display monitors. If that is the case at your site,
follow the manufacturer’s recommended monitor QC test for the monitor
71
until it becomes possible to perform this test. Consult your physicist for
more information.
Figure 6: TG18-QC pattern with vertical gray-scale bars (A), luminance (B), and
lettering (C) indicated.
72
Figure 7: The 95-100% contrast square from the TG18-QC Test Pattern
B. Radiologist’s Workstation Clinical Image Check
1. From the radiologist’s workstation used for interpretation, locate a random clinical
client file on the menu and open it for viewing. Load the same clinical image on all
monitors for viewing (Figure 8). DO NOT change the default WW and WL settings.
NOTE: You do not have to use the same clinical image each week for
this test. Simply choose a random image and place the same image on
each monitor.
2. Evaluate the following items and record a pass/fail for each on Chart 6:
3. Verify that the background (non-breast) areas appear black and not gray.
4. Verify that the background (non-breast) areas appear to have the same level of
blackness on all monitors.
5. Verify that corresponding areas of dense breast tissue appear to have the same
brightness on all monitors.
6. Verify that corresponding areas of dense breast tissue appear to have the same
contrast on all monitors
73
Figure 8: Radiologist’s workstation with the same clinical image displayed on
both monitors.
Viewing conditions for the secondary display devices should be as close as possible to
those used for interpretation so that proper assessment of image quality may be made
by the technologist.
Viewing conditions for the radiologist’s workstation should be as recommended by the

medical physicist.
There should be no noticeable artefacts in the TG18-QC image. This might include
diagonal lines, flicker, blotches, non-uniform gray scale ramps, curved “straight” lines
and bright or dark pixels. If artefacts are evident, contact the monitor service person.
All 16 luminance patches in the TG18-QC should be distinct from each other in shade. If
all 16 luminance patches are not distinct, it may be necessary to recalibrate the
monitors. If recalibration fails to correct the problem, contact the monitor service
person.
The smaller, 5% contrast squares (see Figure 7) should be visible in both the dark (0-
5%) and light (95-100%) squares. If the squares with a 5% luminance difference are
not visible, the monitors may need to be recalibrated. If recalibration fails to correct the
problem contact the monitor service person.
The letters “QUALITY CONT” should be visible in each of the three regions on the
primary display devices (radiologist’s workstations). If any of the letters in “QUALITY
74
CONT” in any of the three regions on the primary display devices (radiologist’s
workstations) are not visible, the monitors may need to be recalibrated, or the room
lighting level changed. If recalibration fails to correct the problem, contact the monitor
service person.
The images on all primary display monitors (i.e., radiologist’s workstations) should
appear to be visually identical (the same brightness and contrast). If the images do not
appear visually identical, the monitors may need to be recalibrated. If recalibration fails
to correct the problem, contact the monitor service person (PACS support or a qualified
service engineer).
A clinical image check should establish that the background is black, that image contrast
is adequate, and that the brightness or contrast settings of the two monitors are well
matched. If these criteria are not met the source of the problem must be identified and
corrective action taken, before any clinical examinations are interpreted from the review
workstation. (See Figure 9 for an example.) A qualified service engineer may be needed
to make brightness and contrast adjustments on radiologist’s workstation monitors and
to recalibrate monitors.
All corrective actions should be recorded on Chart 6 or Chart 7 as appropriate.
Immediately, before any further client images are interpreted on the review workstation,
before any further client images are acquired using the acquisition workstation, or
before the technologist’s workstation is used for client images.
NOTE: Failure of a review workstation monitor to pass this test does not
mean that client image acquisition must cease, only that interpretation of
client images using that monitor must cease until the problem is corrected.
Failure of the acquisition station monitor requires the cessation of client

imaging; unless the review workstation is located close enough to the
acquisition station, so that each image can be checked before the next is
taken.
75
(a)
(b)
Figure 9: Unacceptable monitors: (a) - significant differences noted in the
background blackness, brightness and contrast. (b) monitor on the
left has a maximum luminance 20% great than that on the right
76
Chart 6: Weekly Display Monitor QC – Review Workstation
Facility: Room:
Workstation Monitor
Mfr.: Mfr.:
Year:
Month
Day
Initials
Monitor L R L R L R L R L R L R
General Image Quality (P/F)
No smearing
No artefacts
Ramps cont.
Geometric Distortion (P/F)
Lines Straight
Pattern Centered
Boxes square
Luminance (P/F)
Patches Distinct
0-5% Visible
95-100% Visible
# of Letters Visible (at least 11 or “QUALITY CONT”)
Dark
Mid-gray
Light
Clinical Image Check (P/F)
Background
(non-breast)
area is black
Background
areas on 2
monitors match
Dense breast
tissues on 2
monitors match
Contrast on 2
monitors
matches
Overall Pass/Fail
Remarks:
Date: Action:
77
Chart 7: Weekly Display Monitor QC – Acquisition Monitor
Facility: Room:
Workstation
Monitor Mfr.:
Mfr.:
Year:
Month
Day
Initials
General Image Quality (P/F)
No smearing
No artefacts
Ramps cont.
Geometric Distortion (P/F)
Lines Straight
Pattern Centered
Boxes square
Luminance (P/F)
Patches Distinct
0-5% Visible
95-100% Visible
Overall Pass/Fail
Remarks:
Date: Action:
78
Test #9: Viewbox Cleanliness
Objective
To ensure that viewboxes are clean and uniform and that masking is available.
Frequency
Weekly (at least) - All viewboxes that are used for interpreting hard copy or screen-
film images (previous films or referrals)
Window cleaner (e.g., Windex or Glass Plus)

Soft towels
1. Clean viewbox surfaces using window cleaner and soft paper towels.
2. Assure that all marks have been removed.
3. Visually inspect the viewboxes for uniformity of luminance.
4. Assure that all viewbox masking equipment is functioning properly and easily.
5. Record performance of this task on Chart A.
Viewboxes are a vital link in the process of interpreting a mammogram yet receive little
attention even after extensive efforts have been invested in producing high-quality
mammograms.
Particular attention should be paid to the uniformity of the luminance of the viewbox and
the luminance level. Viewboxes used in mammography should have luminance
levels of at least 3,000 candela/m2 (nit).
If hardcopy laser-printed films are viewed on the same view-box, lower luminance may
be desirable, in which case a variable brightness control would be useful. It is essential
to mask the area around the mammograms to exclude extraneous light which reduces
image contrast and limits the maximum densities that can be seen without “bright-
lighting” each film.
It is essential to mask the area around the mammograms to exclude extraneous light
which reduces image contrast and limits the maximum densities that can be seen
without “bright-lighting” each film.
79
Fluorescent tubes decrease in brightness with time, although not rapidly (i.e., about
10% in 2,000 hours). It is advisable to replace fluorescent tubes every 18 to 24
months. All tubes should be replaced at one time. In addition, all of the
replacement tubes should be of the same type and colour. If it is necessary to replace
any fluorescent tubes due to decreased light output or for any other reason, such as
flickering, then all tubes should be replaced at the same time to assure uniformity in
colour and luminance.
Viewboxes should be free from dirt, grease pencil marks, marker etc. Any marks that
are not easily removed with window cleaner should be removed with a safe and
appropriate cleaner.
Viewboxes should appear uniformly bright and of the same hue. If viewboxes appear
non-uniform, all of the fluorescent lamps should be replaced as soon as possible. At the
same time as the lamps are replaced, the interior of the view-box and rear side of the
viewing panel should be cleaned.
Masking materials should be available and easy to use. If masking materials are missing,
they should be replaced. If viewbox masks are difficult to use, appropriate service or
modifications should be requested.
Viewboxes should be located so that they do not produce glare on softcopy reading
monitors.
Immediately; before any further client films are interpreted or reviewed for comparison
with current digital images.
80
3. MONTHLY QUALITY CONTROL TEST PROCEDURES
A uniform image should be taken using all applicable focal spots, filters and
magnification modes. This is to evaluate whether dirt has become lodged on the filter or
mirror, the flat-field calibration or detector characteristics has changed or if there is
deterioration in the detector plate. Results are recorded on Chart 7 (CR Full Field
Artefacts). The technologist must evaluate the safety and mechanical stability of the x-
ray unit on a monthly basis. This is accomplished using the monthly checklist of the
exam room (Chart 8, Monthly Mechanical Inspection). A test for laser printer
artefacts should also be performed, and the results recorded on Chart 9 (Laser Printer
Artefacts). Performance of the necessary monthly QC tests should be recorded on Chart
B. Every month the rate at which client films are repeated should be examined (Test
Procedure #13). This can be done with Chart 11 and Chart 12.
81
Test #10: Full Field Artefacts Test
Note that this test is similar to the artefact evaluation component of the weekly tests
described in Test #6 and the methodology described there is largely reproduced in this
section for completeness. However, on a monthly basis the test is extended to include all
applicable focal spots, filters and magnifications modes (only those that would be used
clinically) but the tests of MPV and SDNR are not required here.
Objective
To ensure there are no artefacts in the image which might mimic structures in the
breast, or which might increase the difficulty of interpretation.
Applicability
All
Frequency
Monthly or whenever changes have been made to the digital mammography

system that might affect the flat field performance.
OBSP Digital Mammography Uniform Phantom (DMUP) or uniform slab of PMMA that has
been supplied by the manufacturer for flat-field correction would also be acceptable. The
slab should be free of scratches or other imperfections that would cause artefacts. The
slab should preferably cover the entire area of the image receptor. The same test object
should be used in subsequent monthly tests.
Chart 8
1. Open the client QC Mammo at the acquisition workstation and give it an ID

number specific to the date (Use an ID number such as 9906UYYMMDD), with U
being the unit identifier.
2. Place the test object on the breast support centered laterally extending slightly
beyond the chest wall edge of the digital image receptor.
3. Do NOT place the disc on the phantom.
4. Apply compression force typically used clinically (e.g. 80 N). Record the
compression force used and thickness indicated at the top of Chart 8.
5. If there is a separate AEC sensor, confirm that it is under the test object. Keep this
in the same position every time the test is performed.
82
6. Acquire an image of the test object using the same technique settings that would
be used for a clinical exposure of a standard breast. Normally this is achieved by
using the automatic exposure mode. Otherwise, select target, filter, kV, grid,
density control position, operation mode (semiautomatic or automatic) as
appropriate. The DICOM “for processing” version of the image should be used for
this test. For all tests of CR systems, the systems should be set to the modes
indicated in Table 14.
For CR systems, it can be important to ensure that any anatomy or

histogram-based image processing algorithms be turned off, and that a
consistent linear look-up table is applied when sending the images to
the PACS system and/or the radiologist’s review workstation. Verify
how best to achieve this with your CR vendor or applications training
specialist.
Table 14: Settings and Exposure Indices for Testing CR Systems

Manufacturer/ Mode setting Exposure
system index
Fuji QC Test/Sensitivity S#
Semi
Philips QC Test/Sensitivity S#
Semi
Agfa systems diagnostic/flat lgM/EI*
field mammo
Carestream view: PATTERN, ROI tool
tonescale: linear, WW: average value
4096, WL: 2048
Konica Mammo/Test S#
7. Record the technique used to acquire the image on Chart 8. For CR systems the
exposure index should be recorded.
8. If patient images are interpreted in softcopy, view the “for processing” image on
the acquisition workstation if suitable analysis tools are available. Otherwise view
the image on the radiologist’s display workstation. Use the window width (WW)
and window level (WL) as recommended by your medical physicist. These settings
result in the background of the phantom being displayed with a mid-grey. The
same WW and WL settings (± 10) should be used each time an image is
evaluated. An appropriate choice of window width is critical to catch artefacts yet
not “fail” good images. Window width choice should be based on what is
appropriate/typical for breast images or for a phantom with breast-like features.
*
Agfa have introduced a new dose index called the Exposure Index (EI) which is linear with dose. Some
new CR readers have implemented this change whilst others retain the SAL.
83
9. With the same WW and WL as used above, evaluate the entire phantom image for
artefacts. Examine the entire phantom for both broad area artefacts, such as non-
uniformities, blotches, and streaks, and for detailed artefacts, such as black or
white pixels, clusters of pixels, lines, or dust particles. Broad area artefacts are
typically best seen while observing the phantom image as a whole, not in pieces.
Detailed artefacts are typically best seen while observing the phantom image at
full spatial resolution, where one pixel on the display matches one pixel in the
image, or even in magnified form (with a magnification greater than 1.0) Record
the absence or presence of artefacts at the bottom of Chart 7.
An artefact is considered significant if it may mimic or obscure

anatomic features.
10. Display the uniformity image with a zoom factor that displays full resolution
(1:1 pixel mapping). Reduce the WW until the texture (noise pattern) becomes
apparent. Pan over the entire image, examining the image for pixels that appear
much brighter or darker than the background (referred to as “bright” and “dark”
pixels) and for variations in the amount of noise and texture from place to place in
the image. The texture of the image should be uniform over the entire image or at
least be similar to the baseline. If this place-to-place variation changes over time,
areas where the noise appears to be less may indicate degradation in the detector
causing a loss of sharpness. At the same time, the presence of substantially
brighter or substantially darker pixels in the image, when compared with the
average, should be noted. This may indicate dead elements or other degradation
in the detector. Report this finding to the medical physicist and/or radiologist for
further investigation and consideration as to whether the problem is of the
magnitude and nature that is likely to cause reduction in diagnostic image quality.
It is not necessary to view the image on all available softcopy

monitors. This is a test of image acquisition, not display. Monitor
performance is assessed separately.
11. If client images are interpreted on hardcopy, print the images using the WW
and WL that would be used for a client image. View the image on a
mammographic quality viewbox, preferably the one used by the radiologist.
Evaluate the entire phantom image for artefacts, recording the absence or
presence of artefacts on Chart 7. Record at the bottom of Chart 7 whether the
phantom image was evaluated on hardcopy (H), softcopy (S), or both (B).
12. Repeat the above steps for clinically used filters and also, if applicable using
fine focus and magnification. For CR systems, repeat the above steps for all
cassettes using the most commonly used target and filter combination.
13. Record the outcome of the test on the monthly, quarterly and semiannual
checklist (Chart B).
84
The contrast must be set appropriately so that artefacts are not missed, or so that minor
imperfections are not over-emphasized.
There should be no conspicuous linear structures.
There should be no artefacts mimicking mass objects.
There should be no blotches or regions of altered noise appearance
There should be no observable grid lines or table top structure.
There should be no “bright” or “dark” pixels evident.
If results are unacceptable then the tests should be repeated if applicable. If the results
remain unacceptable it may be appropriate to contact the responsible medical physicist
for further advice in regard to implementing the recommendation listed below.
If any artefacts are visible which could mimic or obscure anatomic

information or if any patterns are seen, a recalibration or flat-fielding
of the digital detector is needed. After this has been done repeat the
test. If artefacts persist, contact your authorized service
representative.
Immediately; If this test fails, do not image patients until corrective action has been
taken.
85
Chart 8: Monthly Full Field Artefact Evaluation
Facility: Room:
Year:
Compression AEC Mode:

Force
Month
Day
Initials
Cassette ID
Exposure Index
Target
Filter
Mag. Factor
kV
mAs
Window Width
Window Level
No Undue
Artefacts
Hardcopy (H)/
Softcopy(S)/
Both(B)
Date: Remarks:
86
Test #11: Monthly Checklist of Exam Room
Objective
To verify the mechanical and electric operation of the mammography unit. To ensure that
the image acquisition information is correct
Frequency
Monthly, or after any service or maintenance on the mammographic x-ray system.
Thermometer, preferably mounted on the wall of digital mammography room

Chart 9 - Monthly Mechanical Inspection
1. Measure the temperature in the mammography acquisition room.
2. Visually inspect the unit for loose parts, cracks in the compression paddles,
compressor and bucky cleanliness and overall integrity.
3. Check that all hoses and cables are free from breaks, crimps, or knots. Hoses and
cables should not be under other heavy equipment.
4. Verify the angulation indicator is working correctly.
5. Verify the interlocks are working correctly.
6. Ensure the gantry moves smoothly.
7. Ensure that the field light is functioning.
8. Ensure that panel switches, indicator lights and meters are functioning.
9. Ensure the current technique chart is posted.
10. On the review workstation, display a recent clinical image, and verify that
the time and date as well as the facility identification are correct in the image
annotation.
11. If printed films are produced, ensure that appropriate information appears
on the films.
12. Check that the breast thickness indicator is accurate to ± 5 mm when using
a compression force typically used clinically (e.g. 80 N). Use the method
recommended by your medical physicist.
87
13. Confirm face guard is present or not damaged.
14. Confirm automatic compression release and manual compression release in

the advent of power failure both work
15. Confirm the integrity of the operator shield.
16. Ensure the cleaning solution for the breast support plate and compressor is
available.
17. Verify any other functions that are specified for monthly monitoring by the
equipment’s manufacturer.
18. Record the status of each item on Chart 8, and initial.
19. Record completion of the inspection on the monthly, quarterly and semi-
annual checklist (Chart B).
Some of the items on the mechanical inspection checklist are operator convenience
features. Many of the items, however, are essential for client safety and high-quality
diagnostic images. It may be necessary to add additional items to the list that are
specific to particular equipment or procedures. These should be included on the checklist
and in each evaluation.
Room temperature should be in the range recommended by the manufacturer. If the

room temperature is not in the range recommended by the manufacturer the air
conditioning service personnel should be called.
Items that are hazardous, inoperative, out of alignment or operate improperly should be
repaired by appropriate service personnel before any clients are imaged.
Items missing from the room should be replaced immediately.
Malfunctioning equipment should be reported to the service engineer for repair or

replacement as soon as possible.
If the time and date as well as the facility identification are not correctly displayed in the
image annotation on the interpretation workstation, correction by appropriate service
personnel must be undertaken before any further patients are imaged.
88
Timeframe for corrective action
Items requiring immediate Items requiring action within 30

action before any further days of first identified failure
patients are imaged
• Room temperature not • Angulation indicator not
controlled functioning
• Loose parts present, • Gantry motion not smooth
paddles damaged or Bucky • Panel lights faulty
unclean • Field light inoperative
• Hoses or cables kinked or • Current technique chart not
damaged posted
• Interlocks faulty • Breast thickness indicator
• Time, date and facility ID inaccurate
incorrect or not present on • Face guard absent or damaged
images • Operator radiation shield
• Automatic & manual damaged
compression release not • Overall integrity questionable
working
• Cleaning solution
unavailable
89
Chart 9: Monthly Mechanical Inspection
Facility: Room: Unit:
Year:
Month J F M A M J J A S O N D
Date
Initials
Room Temperature
No Loose Parts
Cleanliness
No Cracks in Paddle
Automatic compression
release
Compression release on
power failure
Overall integrity
Hoses and cabling
unobstructed
Angulation indicator
Locks (all)
Field light
Smoothness of motion
Breast thickness indicator
accuracy
Face guard integrity
Panel switches /lights /
meters
Technique charts
Time and date on images
correct
Facility ID on images
correct
Operator radiation shield
Cleaning solution
PASS = P
FAIL = F
Not Applicable = NA
IF failure of a test listed above, document resolution:
90
Test #12: Laser Printer Artefact Test
Objective
To ensure there are no objectionable artefacts on printed films.
Frequency
Monthly, or when the presence of artefacts is suspected - All sites interpreting

from hardcopy (film).
Uniform test image such as the “TG18-UNL80” (available from OBSP Physics on CD, see
Figure 10) or, uniform mid-grey image generated by the printer
Densitometer
Magnifying lens (4-5 x)
Chart 9 – Laser Printer Artefacts
Figure 10: The TG18-UNL80 test pattern.

1. Print the uniform test image with a window level that gives an optical density
between 1.5 and 2.0. The window width should be set to maximum.
2. Examine the resulting film on the radiologist’s viewbox using a magnifying glass.
Ensure the image is of uniform optical density, with no streaks, lines, specks or
blotches.
91
3. Record the test results on Chart 9.
4. Record the outcome of the test on the monthly, quarterly and semi-annual
The resulting film should be of uniform optical density.
There should be no streaks, lines, specks, blotches or other objectionable artefacts on

the film, which in the opinion of the radiologist could interfere with the interpretation of
a mammogram.
If the film quality is unacceptable then the test should be repeated. If the results
remain unacceptable it may be appropriate to contact the responsible medical physicist
for further advice in regard to implementing the recommendation listed below.
If significant artefacts appear, corrective action must be undertaken.

Service personnel should be called.
Timeframe for corrective action
Immediately; before any further client films are printed.
92
Chart 10: Laser Printer Artefacts
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date
Initials
OD
Uniform OD
No Streaks?
No Lines?
No Specks?
No Other Artefacts?
Overall Pass/Fail
PASS = P
FAIL = F
Not Applicable =
NA
Printer: Date:
93
Test #13: Retake Analysis
Objective
To determine the number and cause of repeated digital mammograms. Analysis of these
data should help identify ways to improve system performance, reduce digital image
retakes, associated increased client dose, and costs.
Frequency
Monthly. In order for the retake rates to be meaningful, a client volume of at least 250
clients is needed, if possible.
Note: The analysis may be carried out for each individual acquisition station,
rather than for the combined department as is done in screen-film
mammography.
Note: For CAR accreditation requirements a retake analysis of all

mammography images must be performed at least quarterly. This
requirement can be met by doing the monthly retake analysis for OBSP and
including all patient images (OBSP and non-OBSP).
A method to count or estimate the total number of clinical images acquired during the
test period.
Chart 11 - Digital Mammography Retake Record or retake log obtained from the
acquisition workstation provided it complies with this manual.
Chart 12 - Monthly Digital Mammography Retake Analysis
A repeated image is one that is taken for reasons of inadequate quality.

Repeats do not include additional views required to image selected tissue
seen on the first image. They also do not include images taken for the
purposes of including tissue that could not be positioned on the image
receptor due to size of the breast.
Repeats include images that are rejected at the acquisition workstation and
images that are aborted before the exposure is complete. Repeat causes
include problems with positioning, blurred images due to client motion, detector
underexposure or overexposure, unacceptable artefacts, x-ray equipment failures
(such as generator faults), software failures (e.g., acquisition software freezing or
crashing), blank images, no image ever appearing on the acquisition station,
although an exposure was made, and other miscellaneous problems.
94
1. Record each repeated exposure on Chart 11, entering the cause of repeated
exposure, date, etc. Some acquisition systems allow the causes of repeated
exposures to be logged by the acquisition software. This may be an acceptable
means of recording the majority of repeats, provided the log can be easily
retrieved for any specified date range and the causes provided match those shown
on Chart 11.
Note: repeated exposures taken on a different date (i.e., because the radiologist
remarked that the image was blurry) may not be logged by such software, and
thus the OBSP currently recommends maintaining a Chart 11 for such repeats,
even if repeat-logging software is used.
A “blank image” (cause 7) occurs when an exposure is made, and the resulting
image file is empty (all pixels the same value) such that the image displayed is all
one shade.
“No Image” (cause 8) occurs when an exposure is made, and no image at all
comes up on the screen – there is no image file; no digital record of the exposure
exists.
2. Use Chart 12 to summarize the number of repeats in each category.
3. Estimate the total number of clinical exposures taken during the quarter.
This can be done by subtracting the client number at the beginning of the quarter
from the client number at the end of the quarter and multiplying by the average
number of images per client (typically 4-5). This method assumes sequential client
numbering of all clients. It may also be possible to obtain the number of exposures
from a log maintained by the acquisition work-station (varies with manufacturer
and model). Be sure NOT to include images taken for quality control purposes.
4. Calculate the overall retake rate as the total of repeated exposures divided by
the total number of client exposures during the analysis period, multiplied by
100%.
5. Determine the percentage of retakes in each category by dividing the

retakes in that category by the total number of repeated exposures from all
categories.
6. Record completion of the Repeat Analysis on the monthly, quarterly and semi-
annual checklist (Chart B).
All images that are repeated should be included in the repeat analysis, not just those the
radiologist asked to have repeated. Some facilities may keep repeated images in the
95
client study along with good images, rather than rejecting them. These repeated images
must be included in the repeat analysis.
At a minimum, the retake analysis must be done quarterly. This process of

reviewing the rejected images provides mammographic technologists with an
educational benefit. Many higher workload facilities choose to conduct a retake analysis
monthly. Including examinations on at least 250 clients (approximately 1000 exposures)
allows for reasonable statistics to be calculated. Collecting rejected images from a larger
number of clients is encouraged because it will yield more reliable data when evaluating
causes for retakes. Facilities that do not examine 250 clients in a quarter should still
assess retake images at least quarterly to determine the primary causes of repeated
images and reap the educational benefit of the process.
There is a real danger that technologists may alter their routine procedures or criteria
for accepting images if they know their repeated images will be analyzed. This should be
avoided.
Many digital mammography acquisition stations include capabilities for logging the
causes for rejecting images in software and generating a summary report. This can
simplify the process of the retake analysis, however caution is needed. The logs
generated by the software may not catch all retakes – potentially missed areas may
include aborted exposures, retakes due to equipment malfunction, and retakes where
the original image is not rejected. Also, the reject logging software may not group the
causes for rejection in the same manner as suggested in this manual.
The overall repeat rate should ideally be 2% or less, but a rate of 5% or less is
probably adequate if the radiologist and medical physicist agree this is a reasonable
level. These rates should be based on an image volume of at least 250 clients to be
meaningful. A “Reason for Repeat” that is significantly higher than the others indicates
an area for potential improvement.
If the repeat rate exceeds the selected acceptance level of either 2% or 5%, or if the
repeat or reject rate changes from the previously measured rate by more than 2%, the
change should be investigated and corrective action taken if necessary. For example, if
the previous repeat rate was 1.8% and the new repeat rate is 4.2%, then the follow-up
described above is required. A repeat rate of below 0.5% can indicate the radiologists
are accepting/interpreting sub-standard images for the sake of expediency, since there
will always be some clients for whom positioning the breast and obtaining a proper
exposure is quite difficult.
Any corrective actions should be recorded on the bottom of the Repeat Analysis chart. In
addition, the effectiveness of the corrective actions should be assessed by performing
another repeat analysis after the corrective actions have been implemented.
96
If the primary cause of excessive repeated exposures is an equipment or detector
problem it should be brought to the attention of the service engineer.
If the primary cause of excessive repeated exposures is a positioning or other motion

problem, corrective actions such as additional training on positioning and compression
should be taken.
Within 30 days of the repeat analysis date.
97
Chart 11: Retake Analysis: Digital Repeat Record
Enter any repeated exposures that required the client to have additional dose
beyond that of the normal exam.
Facility: Room: Unit:
Date From:
Date To:
Initiated by:
# of
Study # Causes Date Physician Technologist Technologist
Times
Causes:
1 Positioning
2 Client Motion
3 Improper Detector Exposure
4 Artefact
5 X-Ray Equipment Failure
6 Software Failure
7 Blank Image
8 No Image
9 Other
98
Chart 12: Quarterly Digital Mammography Retake Analysis
Facility: Room Unit:
#
Date From: Date To:
Total Client Exposures in

Quarter:
Cause No. of Exposures Percentage of Repeats
1 Positioning
2 Client Motion
4 Artefact
5 X-Ray Equipment Failure
6 Software Failure
7 Blank Image
8 No Image
9 Other
Total # % Repeat Rate

Repeat Exposures (sum 1 through
9):
99
4. QUARTERLY QUALITY CONTROL TEST PROCEDURES
On systems with moving parts in the imaging chain (slot scanning, or CR laser readers
and printers), the resolution must be evaluated in order to catch problems which may
occur and degrade image quality (Test Procedure #14). The printed image quality should
be verified (Test Procedure #15) and the results recorded on Chart 13. Sites using wet
process printers should also measure the amount of fixer retained in their films (Test
Procedure # 16). Performance of all these tests can be recorded on Chart B.
100
Test #14: Resolution / MTF
Objective
To ensure the system is not causing any blur and that the contrast transfer is adequate
over the spatial frequency range used by the detector.
Frequency
Quarterly (at least), or whenever something seems wrong with the system
resolution - All systems which use scanned image acquisition (including CR systems).
Manufacturer recommended bar pattern or radiographic resolution test pattern

measuring up to at least 5 line pairs/mm (eg Fluke Biomedical bar patterns,
product numbers 07-515, 07-521, 07-523-2000, from Maquet-Dynamed)
OBSP Digital Mammography Uniformity Phantom (DMUP)
1. Open a client exam called QC MTF at the acquisition workstation and give it an ID
number specific to the date (9909UYYMMDD), with U being the unit identifier.
2. Position the resolution bar pattern, following the positioning described by the
manufacturer, or on the compression paddle, at a very slight angle to the chest
wall edge, with the paddle 4 cm above the breast support plate.
3. Acquire an image of the resolution bar pattern on top of your uniform phantom
using the same technique as used for the monthly artefacts test (Test #9).
4. Depending on the model of resolution test pattern used, you may need to rotate
the test pattern 90 degrees and acquire a second image in order to measure
resolution in both the horizontal and vertical directions.
5. You may use the manufacturer’s recommended test, or simply record the
minimum resolution seen on the resolution pattern in each direction. On a suitable
workstation view the high-contrast resolution pattern images with appropriate
zoom (see Figure 11; in this image the limiting resolution for the horizontal bars
is 6 line pairs/mm, and the limiting resolution for the vertical bars is 6 line
pairs/mm).
6. Window and level the image to best visualize the resolution test pattern.
7. Starting from the lowest frequency of the pattern (wide end of the wedge) note
the highest frequency pattern whose lines are distinctly visible. Note that the lines
may entirely blur out and then reappear at a higher frequency, with a reversal in
the light and dark bars in the image. This “spurious resolution”, demonstrated in
Figure 12 should not be interpreted as system resolution. Using this criterion,
101
record the highest frequency visible for each test image on the monthly, quarterly
and semi-annual checklist (Chart B).
Figure 11: Radiograph of a resolution test pattern. In this image the limiting
resolution for the horizontal bars is 4.5 line pairs/mm, and the limiting
resolution for the vertical bars is 4.5 line pairs/mm.
102
Figure 12: Aliasing. This image was taken on the magnification stand, using the large
focal spot to show the effect of aliasing. There should be 5 bars, and 4 spaces.
The image gets blurry as the bars get closer together, and then it looks like
bars can be seen again. This aliasing causes “spurious” resolution, as there
are 4 bars seen, when really there should be 5.
8. Record the performance and overall pass or fail of the test on the monthly,
quarterly and semi-annual checklist (Chart B).
Precautions and caveats
The limiting resolution is the first time the pattern goes blurry, and does not include the
aliased bars that can be seen beyond that point.
Performance Criteria and corrective action
The limiting resolution should fall within the “acceptable” range for the machine type.
If the limiting resolution drops below the acceptable range, repeat the test to verify
there is a problem.
NOTE: If the test fails on the second attempt, contact your authorized
service representative. No clients should be imaged until the problem is
corrected.
103
Immediately; before any further client images are acquired.
104
Test #15: Printed Image Quality Test
Objective
To ensure the printed image quality is consistently high.
Applicability
This test applies only to site printing hardcopy.
Frequency
Quarterly, or when reduced printed image quality is suspected.
The modified TG18-QC pattern (see Figure 13) Use those that are specific to the digital
mammography units in the facility (provided by OBSP Physics).
Magnifying Glass (4-5 x)
Ruler
Chart 12 – Printed Image Quality
1. Annotate the modified TG18-QC pattern image with rulers measuring the length of
the horizontal and vertical 5 cm rulers (arrow E, Figure 13). This should only
need to be done the first time the image is used, if the annotated imaged is
“locked” and not deleted from the workstations.
2. Print the TG18-QC test pattern appropriate for each type of digital mammography
unit used to generate images for interpretation from both the acquisition station
and the radiologist’s review workstation(s).
3. Examine the resulting films carefully on the radiologist’s view-box, using the
magnifying glass.
4. Record the visibility of the different test objects (see Figure 13 and Figure 14)
on Chart 12.
5. Measure the length of the 5 cm long calibration lines in horizontal and vertical
directions and record on Chart 12.
6. Record the outcome of the test on the monthly, quarterly and semi-annual
105
Figure 13: Modified TG18-QC image with test objects indicated. A -0-5% contrast
square, B 95-100% contrast square, C- horizontal and vertical line pairs, D-
squares going from black to white, E- 5 cm lines
The 0-5% contrast squares and 95-100% contrast squares should be distinguishable.
The finest horizontal and vertical lines should be visible on all four corners (see Figure
14).
The squares of different shades from black to white should be distinct.
Lines should appear straight and even, without apparent distortions.
There should be no distracting artefacts.
The 5 cm lines should be between 4.7 and 5.3 cm long on the printed image.
106
If the printed film quality is unacceptable then the test should be repeated if applicable.
If the results remain unacceptable it may be appropriate to contact the responsible
medical physicist for further advice in regard to implementing the recommendation listed
below.
If these criteria are not met, the printer should be serviced to correct the
problem immediately if there is no other means for primary interpretation
If this test fails do no print films until corrective action has been taken.
Immediately; before any further client films are printed if there is no other means for
primary interpretation.
Figure 14: Detail of horizontal and vertical line pairs from TG18-QC test pattern.
107
Chart 13: Printed Image Quality
Printer:
Printed
From:
Date:
Initials:
0-5% Square
95-100% Square
Horizontal Line Pairs
Vertical Line Pairs
Grey Patches
Lines Straight
No Artefacts
Length of 5 cm
Horizontal Ruler
(between 4.7-5.3 cm)
Length of 5 cm Vertical
Ruler (between 4.7-5.3
cm)
Overall Pass / Fail
PASS = P
FAIL = F
Not Applicable = NA
108
Test #16: Analysis of Fixer Retention
Objective
To determine the quantity of residual fixer (hypo) in processed film as an indicator of

keeping quality. Residual hypo indicates insufficient washing and considerably degrades
image stability.
Frequency
Quarterly (every 3 months) – all sites printing hardcopy with wet processing
Hypo estimator comparison tool (e.g., Kodak Hypo Estimator, Publication No. N-405, or
equivalent) as used for screen-film processors.
Hypo test solution.
1. Process one sheet of unexposed film in the photographic processor.
2. Place one drop of the hypo test solution on the emulsion (less shiny) side of the
film.
3. Allow the solution to stand for two minutes.
4. Blot off the excess solution.
5. Place the film on a sheet of white paper.
6. Compare the stain with a hypo estimator strip (Figure 15) by observing the
radiographic film on a sheet of white paper. The comparison should be made with the
estimator over the film sample to help compensate for differences in the colour of the
base of the film and with the hypo estimator strip in its sleeve for protection.
7. Record the results of the test on the Monthly, Quarterly and Semi-annual Checklist
(Chart B).
The comparison should be made immediately after the excess test solution has been
removed from the film. Direct sunlight causes the spot to darken rapidly and a prolonged
delay between the blotting of the solution and comparison also allows the spot to
darken.
The test hypo estimator solution has a shelf-life of about two years, provided it is stored
in a dark, airtight bottle away from light.
109
Both acetic acid and silver nitrate are dangerous and must be handled with caution. If
either of these chemicals comes in contact with your skin, wash the area with cold water
immediately. For more information, consult the Material Safety Data Sheets (MSDS)
provided by the manufacturer or supplier.
The hypo estimator provides estimates of the amount of residual hypo in the film in
units of grams per square meter. The estimated amount of residual hypo should be
0.05 grams per meter (5 micrograms per square cm) or less.
If the stain indicates there is >0.05 grams per square meter residual hypo in the
film, the test should be repeated. If the same result is obtained, then corrective action is
necessary.
The processor wash water tank should be checked to assure it is full of water, if
appropriate. The wash water flow rate should be verified to determine it meets the
specifications of the processor manufacturer.
The fixer replenishment rate should be checked to determine it is close to the

recommended rate as the efficiency of the wash water in removing fixer from the film is
dependent on the correct fixing of the film.
If these items appear to be correct, a technical representative of the film manufacturer

should be consulted to assist in resolving the problem of excessive fixer retention.
Within 30 days of the test date.
Figure 15: Hypo Estimator Comparison Tool. Step 1 indicates an acceptable

amount of retained fixer.
110
5. SEMI-ANNUAL QUALITY CONTROL TEST PROCEDURES
Test #17: Compression Force
Objective
To assure that the mammography system can provide adequate compression in the
manual and powered mode and that the equipment does not allow too much
compression to be applied.
The compression device must be easily adjustable and stable when locked into its
desired position so that the compression plate does not wobble. It is desirable that
compression can be released remotely from the control console after exposure, and also
in the event of a power failure. If compression is achieved by hydraulically or
pneumatically powered devices, their safety-limit controls must be checked carefully to
avoid accidental over compression. Adequate compression is essential for high-quality
mammography. Compression reduces the thickness of tissue that must be penetrated by
radiation, thereby reducing scattered radiation and increasing contrast, while reducing
radiation exposure to the breast. Compression improves image sharpness by reducing
the breast thickness, thereby minimizing focal spot blurring of structures in the image,
and by minimizing client motion. In addition, compression makes the thickness of the
breast more uniform, resulting in more-uniform image densities and an image which is
easier to interpret.
As the result of inadequate compression is not beneficial to the client, her cooperation
should be sought before the examination. Once the benefit of compression is explained
fully, she is usually willing to tolerate a few seconds of discomfort to help ensure that the
technical quality of the mammographic examination is as high as possible. Adequate
compression may be uncomfortable for some women, and may even be painful for those
who are very sensitive. Extreme care should be taken with all women when applying
compression to ensure that adequate compression can be reached with the least amount
of discomfort. To minimize discomfort, women with tender breasts should be booked so
that their menstrual cycle will not interfere with the application of proper compression.
Frequency
Initially, then Semi-annually (every 6 months), and when reduced compression is

suspected
Bathroom scale
The scale should be a flat, conventional, analog type. Household digital scales sample the
data and may not respond properly as additional pressure is applied slowly to the scale.
Digital scales designed specifically to measure compression force may be used.
Several towels
111
Power Mode
1. Place a towel on the cassette holder (to protect the cassette holder), then place
the bathroom scale on the towel with the dial or read-out positioned for easy
reading. Locate the center of the scale directly under the compression device
(Error! Reference source not found.).
2. Place one or more towels on top of the scale to prevent damage to the
compression device.
3. Using the initial power drive, activate the compression device and allow it to
operate until it stops automatically.
4. Read and record the compression force on the monthly, quarterly and semi-annual
5. Release the compression device.
Manual Mode
Some units will allow the operator to apply manual pressure beyond this limit. This is not
recommended, but may be done at the discretion of the Technologist.
1. Using the initial power drive, move the compression device downward until it
stops. Then use the manual compression adjustment to increase the
compression force until it stops.
2. Read and record the compression force on the monthly, quarterly and semi-annual
3. Release the compression device.
NOTE: 1 decaNewton (daN) = 10 Newton = 2.2 lbs force.
If the safety mechanism is not properly adjusted, it may be possible to damage the
compression device and associated components. If the compression exceeds 200 N (20
daN or approximately 45 pounds) in the power drive mode, immediately release the
compression device and ask a service engineer to make the appropriate adjustments.
Some units will allow the operator to apply manual pressure beyond this limit. This is not
recommended, but may be done at the discretion of the Technologist.
112
Figure 16: Positioning of bathroom scale to perform compression force
measurement.
In the initial power driven mode, a compression force of 8 to 15 daN (18 - 34 lbs)
must be available and further powered compression should not exceed 20 daN (45
lbs).
Under manual adjustment of compression, a compression force of at least 15 daN (34

lbs) should be achievable, but should not exceed 30 daN (67 lbs).
If the performance criteria are not met in the manual or the power driven modes, a
service engineer should make the appropriate internal adjustments of compression
force.
Immediately; before any further clients are imaged.
113
IV. REVISION CHANGES FROM 2.6
New tests:
• #4 - Daily flatfield image
• #5 - Daily visual inspection for artefacts (CR)
• #6 – Daily image plate erasure (CR)
Significantly revised tests:
• #7 – Weekly phantom image quality (new phantom, now using processed image)
• #17 – Semi-Annual compression force test
Separated Daily Checklist and Monitor viewing conditions into two tests.
New section – “Changes to the Mammographic Imaging System” details what to do for
CAR and OBSP when something is changed in the system (ie new tube, new detector,
new software)
End-of-Month QC requirements clarified and updated
Blank Equipment Downtime and Technical Problem Report added.
X-Ray Safety, Policy and Procedures section added and updated.
Updated the section on phantoms for digital QC.
Added information about DICOM tags needed for IHE compliance, and what IHE is.
Changed the requirements for Dmax for laser printer sensitometry.
Instructions for how to perform the monthly artefact evaluation test have been
expanded and edited.
Some additions have been made to the monthly checklist of exam room. A table listing
what items require immediate action versus correction within 30 days has been added.
A number of minor spelling changes as well as formatting of charts, and removal of

redundant charts. Updated photographs have been added.
Edited MTF/Resolution test to remove mention of MTF squares or software provided by

physics and instead to suggest bar patterns of a recommended scale range and an
example supplier and the model numbers.
114
V. REFERENCES
1. American Association of Physicists in Medicine, Task Group 18. Assessment of

Display Performance for Medical Imaging Systems (Pre-print draft version 9.0).
AAPM, 2002
2. Bloomquist AK, Yaffe MJ, Pisano ED, Hendrick RE, Mawdsley GE, Bright S, Shen SZ,
Mahesh M, Nickoloff EL, Fleischman RC, Williams MB, Maidment ADA, Beideck DJ,
Och J, Seibert JA. Quality Control for Digital Mammography in the ACRIN DMIST
Trial - Part I. Med. Phys. 2006
3. Destouet JM, Bassett LW, Yaffe MJ, Butler PF, Wilcox PA. The American College of
Radiology Mammography Accreditation Committee – 10 Years of experience since
MQSA. J. American College of Radiology. 2, 585-594, 2005
4. Haus AG, Yaffe MJ (ed). Syllabus: a categorical course in physics: technical aspects
of breast imaging. Chicago: Radiologic Society of North America, 1993
5. R. E. Hendrick et al., American College of Radiology (ACR) Mammography Quality
Control Manual for Radiologists, Medical Physicists and Technologists, (American
College of Radiology, Reston, VA, 1999)
6. National Electrical Manufacturer’s Association, DICOM Imaging and Communication
in Medicine (DICOM) Part 14: Grayscale Standard Display Function, PS 3.14-2004,
(National Electrical Manufacturer’s Association, Rosslyn, VA, 2004)
7. Pisano, E.D., Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S, Conant EF,
Fajardo LL, Bassett L, D'Orsi C, Jong R, Rebner M. Diagnostic accuracy of digital
versus film mammography for breast cancer screening - The results of the
American College of Radiology Imaging Network (ACRIN) Digital Mammographic
Imaging Screening Trial (DMIST). NEJM, 353, 1773-1783, 2005
8. E. Pisano, R. E. Hendrick, S. Masood and C. Gatsonis, American College of
Radiology Imaging Network - ACRIN 6652 - Digital vs. Screen-Film Mammography,
ACRIN 2001
9. E. Samei, et al, Assessment of Display Performance for Medical Imaging Systems,
Pre-print Draft (version 9.0). American Association of Physicists in Medicine, Task
Group 18, 2002
10. Yaffe MJ, Bloomquist A, Mawdsley GE, Pisano, Hendrick RE, Fajardo LL, Boone JM,
Kanal K, Mahesh M, Fleischman RC, Och J, Williams MB, Beideck DJ, Maidment
ADA. Quality control for digital mammography: Part II Recommendations from the
ACRIN DMIST trial. Med. Phys. 2006
115
VI. APPENDIX – SAMPLE CHARTS
116
DIGITAL MAMMOGRAPHY TECHNIQUE CHART
(CHART C)
No Implants
Compressed Breast Mammographic AEC Aim Value

Target Filter kVp mAs
Thickness (cm) Density Setting (S#, EI or ADU)
2 cm average CNT Mo Mo 25 30 700
4 cm average CNT Mo Rh 28 80 700
6 cm average CNT Rh Rh 28 200 700
8 cm average CNT Rh Rh 30 225 700
Implants
Compressed Breast Mammographic AEC Aim Value

Target Filter kVp mAs
Thickness (cm) Density Setting (S#, EI or ADU)
2 cm average Man Mo Mo 25 30 700
4 cm average Man Mo Rh 28 80 700
6 cm average Man Rh Rh 28 200 700
8 cm average Man Rh Rh 30 225 700
117
Monthly QC Report Cover Sheet
Facility Name: Anywhere X‐Ray and Mammography
Address: 123 Somestreet
Anywhereville, ON, M0M 0M0
Phone: 416‐123‐4567
Email address: JaneDoe@anywhereXray.com
Excel File Submission
Prepared by: Jane Doe
Date: 2010‐May‐31
Attention: OBSP Physics Consulting Group
Email Address: obspp@sri.utoronto.ca
Number of Files: 1
Re: x Monthly QC for May
Equipment Downtime/Service Report
Other
If images are not read on site (no Review Work Station), please list locations where OBSP
images are read below:
NA
Message: Here is our month end QC.
Please contact the HEAD QC TECHNOLOGIST as soon as possible if you do not receive all pages.
Name: Jane Doe
Chart A: Digital Mammography Quality Control Checklist
Daily and Weekly Tests
Room: 1 Month: May Year: 2010

Manufacturer: GE Model: Essential
CR Reader Manufacturer: NA CR Plates: NA
Checkmark (√) = Pass/Adequate; x = Fail; initial when complete
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Test
Initials JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD
1 Monitor Cleaning √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
2 Daily Checklist (daily) √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
Laser Printer Sensi‐
3
tometry‐wet (daily)
Daily Flatfield image
4 √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
(daily)
Visual inspection for
5
artefacts (CR, daily)
Image plate erasure
6
(CR, daily)
Phantom Image
7 √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
Quality (weekly)
Display Monitor QC
8 √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
(weekly)
Viewbox Cleanliness
9 √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
(weekly)
119
120
Chart B: Digital Mammography Quality Control Checklist
Monthly, Quarterly and Semi‐Annual Tests
Room: 1 Year: 2010 Minimum Resolution: NA
Test
Month JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Pass (P) / Fail (F)
Initials JD JD JD JD JD
Laser Printer
2 Sensitometry ‐ dry P P P P P
(monthly)
Full‐Field Artefacts
10 P P P P P
(monthly)
Monthly Checklist
11 P P P P P
(monthly)
Laser Printer
12 P P P P P
Artefacts (monthly)
Resolution/MTF
Horizontal Bars
(scanning‐quarterly)
13 Resolution/MTF
Vertical Bars
(scanning‐quarterly)
Overall Pass/Fail
Repeat Analysis
14 P P P P P
(quarterly)
Printed Image
15 P P P P P
Quality (quarterly)
Analysis of Fixer
16
Retention
Compression Force
17 30 lb
(semi‐annual)
Radiologist Review
JJ JJ
(quarterly)
Medical Physicist Review
AT
(semi‐annually)
Version 3.0
120
CHART 1: DAILY CHECKLIST
Facility: Anywhere X‐Ray and Mammography Room: 1
Month: May Year: 2010
Checkmark (√) = Pass/Adequate; x = Fail; initial when complete
Day ‐‐> 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Initials JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD
No Loose Parts √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
Overall Integrity √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
Cleanliness √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
No Cracks in Paddles √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
Hoses and Cabling
Unobstructed √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √
CR‐Reader Cleanliness
Imaging Plate Erasure
Date: Comments:
Version 3.0
121
CHART 2: LASER PRINTER SENSITOMETRY
Laser Printer: Kodak Film: Laser Mammo Emul#: 1234567 Workstation: PACS1
4.20 2.00
4.00
1.90
3.80
1.80
DMax
DD
3.60
1.70
3.40
3.20 1.60
3.00 1.50
1‐Apr‐10
1‐Feb‐10
1‐Mar‐10
1‐Jan‐10
1‐May‐10
1‐Apr‐10
1‐Jan‐10
1‐Feb‐10
1‐May‐10
1‐Mar‐10
Last 30 Measurements Last 30 Measurements
1.50 0.30
1.40
0.25
1.30
MD
BF
1.20
0.20
1.10
1.00 0.15
1‐Apr‐10
1‐Jan‐10
1‐Feb‐10
1‐May‐10
1‐Mar‐10
1‐Apr‐10
1‐Jan‐10
1‐Feb‐10
1‐May‐10
1‐Mar‐10
Last 30 Measurements Last 30 Measurements
Version 3.0
Box #16 ‐
TG‐18 QC Box #18 Box #16 Box #11 Box #5 Box #5 Box #1
WW: WL:
Gray‐Scale
Step #: Step #: Step #: Step #: DD1‐DD2 Lightest When new limits are set mid‐m
Step Wedge
into the columns as follows ‐ D
Op Levels 4.00 2.24 1.27 0.46 1.78 0.19 4096 2048 Base + Fog column Q on the row
Date Dmax DD1 MD DD2 DD B+F Remarks:
4‐Jan‐10 4.02 2.24 1.27 0.46 1.78 0.18
1‐Feb‐10 4.00 2.25 1.26 0.45 1.80 0.17
1‐Mar‐10 3.98 2.23 1.28 0.44 1.79 0.20
1‐Apr‐10 4.01 2.24 1.27 0.47 1.77 0.19
3‐May‐10 4.00 2.25 1.25 0.50 1.75 0.19
123
CHART 3: SETTING OPERATING LEVELS FOR LASER PRINTER
Date operating levels valid from: 14‐Dec‐09
TG‐18 QC Pattern Window Width: 4096 Window Level: 2048
Box#/ Dates
Step 10‐Dec‐09 11‐Dec‐09 12‐Dec‐09 13‐Dec‐09 14‐Dec‐09 Average Operating Level
Maximum Density 18 4.00 3.95 3.99 4.01 4.05 4.00 4.00
DD1 16 2.22 2.26 2.22 2.26 2.22 2.24
Mid‐Density 11 1.25 1.30 1.26 1.30 1.25 1.27 1.27
DD2 5 0.47 0.45 0.49 0.45 0.45 0.46
Base+Fog 1 0.19 0.18 0.19 0.20 0.20 0.19 0.19
DD 1.77
Reason for setting new operating levels:
Printer recalibrated by service.
Version 3.0
CHART 4 - DAILY FLAT FIELD PHANTOM
Facility: Anywhere X-Ray and Mammography
Manufacturer: GE Room / Unit: 1
Model: Essential Phantom SN#: 0001
CR Manuacturer: NA CR Plates: NA
Uniform phantom baseline Viewing Parameters (Processed Image)

Exposure mode (AEC/AOP) CNT Window Width 400
Target/Filter Mo/Rh Window Level 700
kV 27
Compression thickness (mm) 40
Compression force (daN) 8
Year 2010
Month May
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 23 27 28 29 30 31
Initial JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD JD
mAs 80 80 81 79 78 80 78 79 80 81 80 81 79 78 80 80 79 79 79 80
Artefacts Softcopy P P P P P P P P P P P P P P P P P P P P
Acceptable Hardcopy P P P P P P P P P P P P P P P P P P P P
Date: Remarks:
125
Version 3.0
31‐May‐10 31‐May‐10
24‐May‐10 24‐May‐10
17‐May‐10 17‐May‐10
10‐May‐10 10‐May‐10
3‐May‐10 3‐May‐10
26‐Apr‐10 26‐Apr‐10
19‐Apr‐10 19‐Apr‐10
12‐Apr‐10
12‐Apr‐10
5‐Apr‐10
Last 30 Measurements
5‐Apr‐10
29‐Mar‐10
29‐Mar‐10
22‐Mar‐10
22‐Mar‐10
15‐Mar‐10
15‐Mar‐10
8‐Mar‐10
8‐Mar‐10
1‐Mar‐10
1‐Mar‐10
22‐Feb‐10
22‐Feb‐10
15‐Feb‐10
15‐Feb‐10
8‐Feb‐10
8‐Feb‐10
1‐Feb‐10
1‐Feb‐10
25‐Jan‐10
25‐Jan‐10
18‐Jan‐10
Model: Essential
CHART 5: WEEKLY PHANTOM
11‐Jan‐10 18‐Jan‐10
4‐Jan‐10 11‐Jan‐10
950
900
850
800
1200
1150
1100
1050
1000
4‐Jan‐10
1
1
1
1
1
1
0
0
0
0
0
Signal
31‐May‐10 31‐May‐10
24‐May‐10 24‐May‐10
17‐May‐10 17‐May‐10
10‐May‐10 10‐May‐10
NA
3‐May‐10 3‐May‐10
26‐Apr‐10 26‐Apr‐10
19‐Apr‐10 19‐Apr‐10
12‐Apr‐10 12‐Apr‐10
5‐Apr‐10 5‐Apr‐10
Manuf: GE
29‐Mar‐10 29‐Mar‐10
CR Manuf:
22‐Mar‐10 22‐Mar‐10
15‐Mar‐10 15‐Mar‐10
8‐Mar‐10 8‐Mar‐10
Facility: Anywhere X‐Ray and Mammography
1‐Mar‐10 1‐Mar‐10
22‐Feb‐10 22‐Feb‐10
15‐Feb‐10 15‐Feb‐10
8‐Feb‐10 8‐Feb‐10
1‐Feb‐10 1‐Feb‐10
25‐Jan‐10 25‐Jan‐10
18‐Jan‐10 18‐Jan‐10
11‐Jan‐10 11‐Jan‐10
4‐Jan‐10
Room: 1
4‐Jan‐10
12.0
11.0
10.0
9.0
8.0
7.0
6.0
120
115
110
105
100
95
90
85
80
mAs SDNR
Version 3
Disk Background Background SDNR

TG‐18 QC mAs WW: WL:
Signal (A) Signal (B) St. Dev. (C) (B‐A)/C
Op Levels 98 900 990 10.0 9.0 Artefacts 100 400.0 700.0

Date mAs Disk Sig Backgd. Sig. Std. Dev. SDNR (Y/N) Remarks
4‐Jan‐10 98 899 990 10.0 9.1 N
11‐Jan‐10 97 895 970 8.3 9.0 N
18‐Jan‐10 96 900 1000 11.0 9.1 N
25‐Jan‐10 97 905 991 8.7 9.9 N
1‐Feb‐10 98 901 989 9.6 9.2 N
8‐Feb‐10 99 900 990 10.0 9.0 N
15‐Feb‐10 100 899 970 8.0 8.9 N
22‐Feb‐10 98 899 1000 11.1 9.1 N
1‐Mar‐10 98 895 995 10.5 9.5 N
8‐Mar‐10 99 900 990 9.5 9.5 N
15‐Mar‐10 97 905 970 7.5 8.7 N
22‐Mar‐10 98 901 1000 11.1 8.9 N
29‐Mar‐10 99 900 991 10.1 9.0 N
5‐Apr‐10 98 899 989 9.9 9.1 N
12‐Apr‐10 97 899 990 10.1 9.0 N
19‐Apr‐10 97 895 970 8.5 8.8 N
26‐Apr‐10 99 900 1000 10.9 9.2 N
3‐May‐10 98 905 995 10.0 9.0 N
10‐May‐10 98 901 999 10.8 9.1 N
17‐May‐10 98 900 990 9.9 9.1 N
25‐May‐10 97 899 980 9.0 9.0 N
31‐May‐10 99 900 990 10.0 9.0 N
127
CHART 6: WEEKLY DISPLAY MONITOR QC ‐ REVIEW WORKSTATION

Workstation Mfr: GE Monitor Mfr: Barco
Year: 2010
Month Jan Feb Mar Ap May

Day 4 1 1 5 3
Monitor Left Right Left Right Left Right Left Right Left Right Left Right
General Image Quality (Pass(P)/Fail(F)/Marginal(M))
No Smearing P P P P P P P P P P
No Artefacts P P P P P P P P P P
Ramps cont. P P P P P P P P P P
Geometric Distortion
Lines straight P P P P P P P P P P
Pattern Centered P P P P P P P P P P
Boxes square P P P P P P P P P P
Luminance
Patches distinct P P P P P P P P P P
0‐5% P P P P P P P P P P
95‐100% P P P P P P P P P P
# of Letters Visible (at least 11 or "QUALITY CONT")
Dark 11 11 11 11 12 12 12 12 11 11
Mid‐Gray 11 12 12 11 12 12 12 12 12 12
Light 11 11 11 11 12 12 12 11 12 12
Clinical Image Check
Background (non‐
P P P P P P P P P P
breast) area is black
Background areas on
P P P P P
2 monitors match
Dense breast tissues
P P P P P
on 2 monitors match
Contrast on 2
P P P P P
monitors matches
Overall Pass/Fail P P P P P P P P P P
Remarks
Date: Action:
128
CHART 7: WEEKLY DISPLAY MONITOR QC ‐ ACQUISITON MONITOR

Workstation Mfr: GE Monitor Mfr: Barco
Year: 2010
Month Jan Feb Mar Apr May

Day 4 1 1 5 3
General Image Quality (Pass(P)/Fail(F)/Marginal(M))
No Smearing P P P P P
No Artefacts P P P P P
Ramps cont. P P P P P
Geometric Distortion
Lines straight P P P P P
Pattern Centered P P P P P
Boxes square P P P P P
Luminance
Patches distinct P P P P P
0‐5% P P P P P
95‐100% P P P P P
Overall Pass/Fail P P P P P
Remarks
Date: Action:
Under "Genera l Ima ge Qua l i ty" enter "Y" or "N" to i ndi ca te pres ence or a bs ence of s mea ri ng or other a rtefa cts .
Enter "Y"i f the greys ca l e ra mps a ppea r conti nuous , "N" i f they do not.
Under "Geometri c Di s torti on" enter "Y" or "N" to i ndi ca te i f the l i nes a nd borders a ppea r s tra i ght, i f the pa ttern i s
centered a nd i f the boxes a ppea r s qua re.
Under "Lumi na nce" enter "Y" or "N" to i ndi ca te the vi s i bi l i ty of ea ch i tem.
Under "Letteri ng" record the number of l etters vi s i bl e a t ea ch l umi na nce l evel . Version 3.0
129
CHART 8 ‐ MONTHLY FULL‐FIELD ARTEFACT EVALUATION
Facility: Anywhere X‐Ray and Mammograp Room: 1

Year: 2010
Compression Force 8 daN AEC Mode: CNT/manual
Month Mar Mar Mar Apr Apr Apr May May May
Day 1 1 1 5 5 5 3 3 3
Initials JD JD JD JD JD JD JD JD JD
Pass (P) / Fail (F) / Marginal (M)
Cassette ID
Exposure Index
Target Mo Mo Rh Mo Mo Rh Mo Mo Rh
Filter Mo Rh Rh Mo Rh Rh Mo Rh Rh
Mag. Factor 1 1 1 1 1 1 1 1 1
kV 25 27 28 25 27 28 25 27 28
mAs 100 60 50 100 60 50 100 60 50
Window Width 500 500 500 500 500 500 500 500 500
Window Level 700 800 800 700 800 800 700 800 800
No Undue Artefacts P P P P P P P P P
Hardcopy (H) /Softcopy (S) / Both (B)
Type of copy B B B B B B B B B
Date Remarks
Version 3.0
130
CHART 9: MONTHLY MECHANICAL INSPECTION
Facility:Anywhere X‐Ray and Mammography Room: 1
Unit: GE Essential Year: 2010
Date 4 1 1 5 3
Pass (P) / Fail (F) / Marginal (M) / Not Available (NA)
Room temperature P P P P P
No Loose Parts P P P P P
Cleanliness P P P P P
No Cracks in Paddle P P P P P
Automatic
compression P P P P P
release
Compression
release on power P P P P P
failure
Overall Integrity P P P P P
Hoses and Cabling
P P P P P
Unobstructed
Angulation
P P P P P
Indicator
Locks (all) P P P P P
Field Light P P P P P
Smoothness of
P P P P P
Motion
Breast thickness
P P P P P
indicator accurate
Face guard integrity P P P P P
Panel switches/
P P P P P
lights/meters
Technique charts P P P P P
Time and date on
P P P P P
images correct
Facility ID on
P P P P P
images correct
Operator radiation
P P P P P
shield
Cleaning solution P P P P P
Version 3.0
131
CHART 10: MONTHLY LASER PRINTER ARTEFACT EVALUATION
Facility: Anywhere X‐Ray and Mammography Year: 2010

Printer: Kodak
Date 4 1 1 5 3
OD 1.50 1.47 1.52 1.50 1.48
Uniform OD P P P P P
No Streaks? P P P P P
No Lines? P P P P P
No Specks? P P P P P
No Other Artefacts? P P P P P
Overall Pass/Fail P P P P P
Version 3.0
132
CHART 11: DIGITAL MAMMOGRAPHY RETAKE RECORD
(Enter any repeated exposures that required the patient
to have additional dose beyond that of the normal exam)

Unit: GE Essential
Date From: 1‐May‐2010
Date To: 31‐May‐2010
Number of Initiated by:
Study # Causes Date Technologist
Times Physician Technologist
201 1 1 3‐May‐10 x JD
212 1 1 7‐May‐10 x JD
220 1 1 10‐May‐10 x JD
231 2 1 17‐May‐10 x JD
243 2 1 18‐May‐10 x JD
248 1 1 31‐May‐10 x JD
Causes:
1 Positioning
2 Patient Motion
4 Artefact
5 X‐Ray Equipment Failure
6 Software Failure
7 Blank Image
8 No Image
9 Other Version 3.0
133
CHART 12: QUARTERLY RETAKE ANALYSIS

Date From: 1‐May‐2010 Unit: GE Essential
Date To: 31‐May‐2010
Total Patient Exposures in Quarter: 250
Cause No. of Exposures Percentage of Repeats

1 Positioning 4 66.7%
2 Patient Motion 2 33.3%
4 Artefact
5 X‐Ray Equipment Failure
6 Software Failure
7 Blank Image
8 No Image
9 Other
Total % Repeats
Repeat Exposures (1‐9) 6 2.4%
Version 3.0
134
CHART 13: QUARTERLY PRINTED IMAGE QUALITY TEST
Printer: Kodak Year: 2010

Printed From: PACS1
Date 4‐Jan 5‐Apr

Initials JD JD
Length of 5 cm
Horizontal Ruler
4.9 4.9
(between 4.7 and 5.3
cm)
Length of 5 cm
Vertical Ruler
5.0 4.9
(between 4.7 and 5.3
cm)
0‐5% Square P P
95‐100% Square P P
Horizontal Line Pairs P P
Vertical Line Pairs P P
Grey Patches P P
Lines Straight P P
No Artefacts P P
Overall Pass/Fail P P
Version 3.0
135

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Ontario Breast Screening Program

Digital Mammography Quality

Authors: G.E. Mawdsley, A.K. Bloomquist, M.J. Yaffe

Mammographic Physics Consulting Group

The latest version of this manual can be downloaded from:

II. IMPORTANT POINTS 26

III. DIGITAL MAMMOGRAPHY QUALITY CONTROL TESTS 42

This QC Manual for the mammographic technologist has procedures with

And from the OBSP Collaborative Webspace: http://www.obsp.webexone.com

The mammographic technologist must understand that the CAR accreditation

The X-ray Inspection Service

As in screen-film mammography, DM QC is only effective if the procedures are

Images are generally provided to PACS systems in a “For Presentation” or

Table 3: Mammographic Technologist’s QC Test Images and Suggested

CHANGES TO THE MAMMOGRAPHIC IMAGING SYSTEM

Specifically, if new equipment is installed, the mammography machine is

In general, for any proposed change(s):

• Clinical as well as phantom images must be submitted when the

• Physicist’s reports submitted to the CAR must be signed by a

Table 4: Required Action for Specific Changes to the Imaging System

Changes to the Imaging System

One New ---------------------------- Copy of license & N/A N/A

All ---------------------------- Clinical Images, N/A N/A

MAMMOGRAPHY QC TEST IMAGE AND RECORD RETENTION

Table 5: OBSP Requirements for Mammography QC Test Image

Information to be submitted includes:

• Monthly QC Report Cover Sheet – requires an email address and

• Chart 6 and Chart 7 – Display monitor QC summary (replaces processor

• Chart 12 – Retake analysis for digital images

The monthly QC submission must also include clear notes documenting

If you are submitting QC electronically, emailing the Excel spreadsheet, do not

Nature of Problem (and diagnosis by technologist):

Service Company (name): _________________________________________

Service action taken:

Length of time to complete service: ______Charge for service: __________

Other Centres Affected? (Y/N) _______

a) When a New Revision of the OBSP QC Manual has been Published

All of the Mammography Technologists (including part-time) and every

b) When a Mammography Technologist/Radiologist is Newly Hired

The new Mammography Technologist and/or Radiologist must review the

NOTE: Changes to personnel must be reported to the CAR (refer to “Changes

The Mammography Technologist must be registered with the CMRTO.

• they are newly hired

• a new revision of the OBSP QC Manual is published and distributed

Views: For screening, bilateral Craniocaudal and bilateral mediolateral oblique

When overexposure occurs:

• Inform Radiation Protection Officer, who is to contact the Director of X-

• Before imaging another client, determine cause of problem and if it

The door of the mammography room must be closed during exposure.

A copy of the OBSP Quality control manual(s) must be kept in the

A copy of the HARP Act and Regulations should be on site (available at

Dosimeters: Mammography Technologists are not required to wear dosimeters

Pregnant technologists will be treated no differently than other technologists,

CR cassettes will be stored in a shielded area within the mammography room,

Equipment problems are to be repaired as soon as possible and the appropriate

• Burnt-out collimator lamp: call for "non-urgent" service; position clients

• QC action limits exceeded: determine cause of problem following

Length of time to complete service: Charge for service: ____