Insufficient breast positioning is commonly considered the No. 1 cause for technical failure in mammograms and can cause issues in both full-field digital mammography (FFDM) and digital breast tomosynthesis (DBT). With that in mind, a team of researchers spent more than three years on a quality improvement (QI) project to improve breast positioning at their facility, writing about the project’s impact in American Journal of Roentgenology.

From June 2013 to December 2016, the authors led a “team-based performance improvement initiative” to see if they could improve the overall quality of mammographic positioning within their department. Technologists and radiologists worked side by side to establish quality measures based on American College of Radiology (ACR) positioning criteria, audited a minimum of 35 mammograms each week and used dashboards to display technologist performance. One individual was also designated as the group’s “mammography positioning coach,” helping technologists develop and maintain high-quality positioning skills.

So did the initiative make an impact? According to the team’s data, it most certainly did. While a baseline mammogram audit from June 2013—just as the QI project was about to begin—found that 67 percent of exams met ACR positioning criteria. After training began, but before the project was over, another audit found that 80 percent of exams met the ACR criteria. And in December 2016, which the QI project was complete, that number jumped again to 91 percent.

“Our results indicate that dedicated QI methods may be used to successfully improve mammographic positioning and sustain that level of performance,” wrote David Larson, MD, MBA, vice chair of education and clinical operations in the department of radiology at the Stanford University School of Medicine, and colleagues. “We identified several factors that we believe contributed to the success of the improvement project.”

One of those factors, the authors explained, was the project’s weekly audits, which allowed technologists to see how their exams performed based on the established ACR criteria. Another key factor the authors identified was the mammography positioning coach.

“The positioning coach spends about 80 percent of her time as a working mammography technologist and 20 percent of her time auditing cases, providing feedback, directly observing, and teaching,” the authors wrote. “We consider the time spent as a working technologist to be critical to maintain skill, understand the nuances of the facility and equipment, and earn the respect of the other technologists. The coach also solicits feedback from the radiologists and incorporates specific performance improvement needs into her efforts.”

Larson et al. also noted that their initiative cost approximately $30,000 to develop, $42,000 to launch and another $25,000 annually.

“Virtually all of the estimated cost was dedicated to supporting the positioning coach,” they wrote. “Time spent coaching constituted approximately 3.5 percent of all technologist time (0.5 FTE / 14.5 FTE) for the first year and 1.4 percent of all technologist time (0.2 FTE / 14.2 FTE) on an ongoing basis.”