The Division of Mammography Quality Standards (DMQS) performed an analysis of inspections performed under the Enhancing Quality Using the Inspection Program (EQUIP) initiative from January 1, 2017, through June 30, 2017. During this first year of inspections that include the EQUIP questions, facilities will not receive citations related to the new EQUIP questions. However, inspectors are responsible for recording facility responses to the EQUIP questions and any deficiencies are noted on the post inspection report. These are then discussed during the inspection close-out session so that facilities are aware of what would have been cited if citations were in effect. This provides facilities with the opportunity to address these deficiencies prior to inspection citations being issued, beginning with inspections performed on or after January 1, 2018.
As of June 30, 2017, there have been 4,166 annual MQSA inspections performed under the EQUIP initiative. Overall, 44% of those inspections had one or more EQUIP deficiencies. The chart shows a breakdown of how many deficient inspections were recorded for each EQUIP sub-question. The highest number of deficient inspections was related to sub-questions 2(a) and 2(b), which cover the periodic image quality review.
Number of Deficient Inspections
Percent of Total Inspections
Question 1(a) - There is no system in place that includes a mechanism for providing ongoing IP feedback on image quality
Question 1(b) - There is no system in place that includes a mechanism for documenting any needed corrective action and the effectiveness of any corrective action taken
Question 2(a) - There is no mechanism in place for regular reviews of image quality attributes of a sample of mammograms performed by each active RT and a sample of mammograms accepted for interpretation by each active IP
Question 2(b) - There is no documentation of review since the last inspection
Question 3(a) - There is no system in place for LIP oversight, including review of the frequency of performance of all required tests
Question 3(b) - There is no system in place for LIP review to determine whether appropriate corrective actions were performed when needed
We at DMQS anticipated that Question 2 might be the most difficult for facilities to meet, mainly due to the fact that while many facilities engage in daily feedback, not all of them take the opportunity to do an assessment of image quality for the facility as a whole, including all technologists and interpreting physicians in that assessment. This type of assessment allows the facility an overall look at the quality of the images it produces, as well as a look at the less-often-assessed quality of images that its interpreting physicians are accepting for interpretation. Image quality is a responsibility that should be shared by both technologists and interpreting physicians. Supplementing the daily feedback process with this type of assessment can potentially lead to systemic remedies that improve a facility’s image quality. Although we encourage facilities to do this assessment more frequently, it must be done and documented at least once a year. Note that the EQUIP questions are designed to check that processes are in place for this image quality review, not specific review details. Facilities are free to design processes that best fit their individual situations and practices. This flexibility allows for many different ways to successfully meet Question 2, as well as the other EQUIP questions, and thereby satisfy the EQUIP inspection questions.
Please take time to engage with your inspector during this educational year to learn how EQUIP can help your facility maintain image quality. Beginning with inspections performed on or after January 1, 2018, Level 2 citations will be issued to facilities who have not successfully implemented the processes covered by the EQUIP inspection questions. Facilities may contact the MQSA Facility Hotline at 800-838-7715 or by e-mail at MQSAhotline@versatechinc.com for questions about EQUIP. DMQS also has posted extensive EQUIP informational resources including articles, videos, and FAQs on the MQSA website.