Reject analysis is an accepted standard of practice for quality assurance in conventional radiology. The need for reject analysis has been challenged by the introduction of computed radiography (CR) because of low reported reject rates and because criteria for improperly exposed images were lacking. Most CR systems include quality control (QC) workstations that are capable of modifying the appearance of images before release, and also of deleting poor images before they are analyzed. Texas Children's Hospital has been using computed radiography since October 1995, and now conducts essentially filmless imaging operations using a large-scale picture archival and communications system (PACS) with fourteen CR units. The QC workstation is a key element of our CR operation; however, the extensive software tools of the workstation are limited in terms of avoiding repeated examinations. Neither the QC workstation nor the PACS itself is designed to support reject analysis, so our task was to design a system that accommodates identification, isolation, and archiving of repeated examinations, making use of our electronic imaging systems. We had already developed transcription codes for our radiologist's examination critique, so we adopted these as codes for rejected images. The technologist at the QC workstation appends the critique code to patient demographic information, modifies other fields to indicate that the image is rejected, and archives as usual. Modified routing tables prevent the release of rejected images but ensure they are available for review. Our frequency and reasons for repeated examinations are comparable to other reports of reject analysis in the literature. The most frequent cause of a repeated examination is mis-positioning. The process of developing the method for capturing repeat, collecting the data, and analyzing it is only one-half of the battle; to achieve an improvement in services, it is necessary to feed back the results to management and staff and to implement training as indicated. It is our intention to share our results with PACS and CR vendors in the hope that they will incorporate some mechanisms for reject analysis into the design of their systems.

The most frequently asked question without a correct answer is: "Just how many people does it take to operate a picture archiving and communication system IPACS)7" At Texas Children's Hospital, our consensus is that we do not yet know. As soon as we felt we had adequate staffing to provide timely response for routine services, we found that including the Intensive Care Units (ICUs) increased our demand for urgent response beyond our capacity. The addition of inpatient bedside imaging to PACS also increased the demand for round-the-clock and weekend PACS services. Our answer to the staffing question changes every year, in accordance with changes in the scope of services that our PACS is expected to provide. Our administration drew up a 5-year plan for PACS implementation, concentrating on purchase and installation of equipment, but neglected to estimate requirements for full-time equivalents IFTEs) for PACS. Our administration reasonably assumed that existing employees would be galvanized into PACS personnel. It is now clear that new FTEs need to be created strictly for the PACS service. Our 5-year plan also did not anticipate significant changes in the extent of our healthcare enterprise. Our PACS accommodates limited remote service: providing a PACS Analyst to travel to the site when a problem is not resolved remotely is another demand on staffing. Our PACS service was formed using staffing numbers based on assumptions about the minimum number of employees needed to perform routine duties, field trouble calls, conduct training, and work on special projects, such as adding new acquisition modalities or troubleshooting longstanding problems. This staffing was based on a single shift operation, with on-call coverage for second, third, and weekend shifts. The number of employees also considered absences for vacation, sick leave, and training. The service has administrative overhead that should be covered by a secretary. Someone is also needed to supervise the team. Once the number of personnel is determined, detailed definition of qualifications and responsibilities is required. Each job description must accurately reflect what is expected of the employee, but must be constructed in such a way to be graded appropriately by Human Resources, without excluding potentially desirable applicants. In addition to competitive pay, RATHER THAN PROACTIVELY obtaining a staff for the picture archival and communications system (PACS), many sites begin to amass a staff in response to customer complaints of delays in getting their patients' images and diagnostic reports. Our PACS evolved from an ultrasound niche-PACS beta site to a hospital-wide filmless operation. Other factors that affect the staffing of a totally digital radiology service are projected expansions of hospital operations and additions of remote sites whose images will be interpreted at a central location. The x-ray department is often the first service converted to digital using computed radiography (CR). The first criterion of installing a PACS is the need for ...

No abstract

Texas Children's Hospital is a pediatric tertiary care facility in the Texas Medical Center with a large-scale, Digital Imaging and Communications in Medicine (DICOM)-compliant picture archival and communications system (PACS) installation. As our PACS has grown from an ultrasound niche PACS into a full-scale, multimodality operation, assuring continuity of clinical operations has become the number one task of the PACS staff. As new equipment is acquired and incorporated into the PACS, workflow processes, responsibilities, and job descriptions must be revised to accommodate filmless operations. Round-the-clock clinical operations must be supported with round-the-clock service, including three shifts, weekends, and holidays. To avoid unnecessary interruptions in clinical service, this requirement includes properly trained operators and users, as well as service personnel. Redundancy is a cornerstone in assuring continuity of clinical operations. This includes all PACS components such as acquisition, network interfaces, gateways, archive, and display. Where redundancy is not feasible, spare parts must be readily available. The need for redundancy also includes trained personnel. Procedures for contingency operations in the event of equipment failures must be devised, documented, and rehearsed. Contingency operations might be required in the event of scheduled as well as unscheduled service events, power outages, network outages, or interruption of the radiology information system (RIS) interface. Methods must be developed and implemented for reporting and documenting problems. We have a Trouble Call service that records a voice message and automatically pages the PACS Console Operator on duty. We also have developed a Maintenance Module on our RIS system where service calls are recorded by technologists and service actions are recorded and monitored by PACS support personnel. In a filmless environment, responsibility for the delivery of images to the radiologist and referring physician must be accepted by each imaging supervisor. Thus, each supervisor must initiate processes to verify correct patient and examination identification and the correct count and routing of images with each examination.

Texas Children's Hospital, a definitive care pediatric hospital Iocated in the Texas Medical Center, has been constructing a large-scale picture archival and communications system (PACS) including ultrasound (US), computed tomography (CT), magnetic resonance (MR), and computed radiography (CR). Developing staffing adequate to meet the demands of filmless radiology operations has been a continuous challenge. Overall guidance for the PACS effort is provided by a hospitallevel PACS Committee, a department-level PACS Steering Committee, and an Operations Committee. Operational Subcommittees have been formed to address service-specific implementations, such as the Emergency Center Operations Subcommittee. These committees include membership by those affected by the change, as well as those effecting the change. Initially, personnel resources for PACS were provided through additional duties of existing imaging service personnel. As the PACS effort became more complex, fulltime positions were created, including a PACS Coordinator, a PACS Analyst, anda Digital Imaging Assistant, Each position requires a job description, qualifications, and personnel development plans that are difficult to anticipate in an evolving PACS implementation. These positions have been augmented by temporary full-time assignments, position reclassifications, and cross-training of other imaging personnel. Imaging personnel are assisted by other hospital personnel from Biomedical Engineering and Information Services. UItimately, the PACS staff grows to include all those who must operate the PACS equipment in the normal course of their duties. The effectiveness of the PACS staff is limited by their level of their expertise. This report discusses our methods to obtain training from outside our institution and to develop, conduct, and document standardized in-house training. We describe some of the products of this work, including policies and procedures, clinical competency criteria, PACS inservice topics, and an informal PACS newsletter. As the PACS system software and hardware changes, and as our implementation grows, these products must to be revised and training must be repeated.