OBJECTIVE: To evaluate the effects of the Enhancing Quality Using the Inspection Program (EQUIP) on quality control (QC) and quality assurance (QA) at an academic medical center.
METHODS: EQUIP audit logs for technologist image quality review as well as mammography unit QA and QC formed the basis for study data. One randomly selected screening mammogram was evaluated by the lead interpreting physician (LIP) using EQUIP criteria for each technologist for each imaging site worked, initially semiannually and then monthly. One randomly selected screening mammogram interpreted by each interpreting physician (IP) for each imaging site was evaluated on a semiannual basis. Quarterly, the LIP reviewed QA and QC logs for each mammography unit with deficiencies further investigated.
RESULTS: Of 214 965 eligible screening mammograms performed, 5955 (2.8%) underwent EQUIP image quality review. Five were found to be technically inadequate (0.08%, 5955/214 965). The LIP identified 20 significant interpretive differences compared with the clinical interpretation resulting in 10 biopsies and 7 previously undetected malignancies, with supplemental cancer detection rate of 1.2/1000 cases reviewed. Two hundred ninety mammography unit QA/QC reviews identified 31 potential deficiencies, 29 of which were due to human documentation error (93.4%).
CONCLUSIONS: EQUIP review of both IP and technologists\' quality and mammography unit QA/QC logs as performed identified few deficiencies. EQUIP policies should be evaluated at each institution and modified to best utilize resources and provide opportunities for meaningful quality improvement. Although not an EQUIP focus, supplemental cancer detection was observed as might be expected with double reading.

The new Enhancing Quality Using the Inspection Program (EQUIP) law places more responsibility for quality assurance on the interpreting radiologists and the lead interpreting physician (LIP). Compliance with the law will require addressing three specific questions related to quality assurance and clinical image corrective action, continued compliance, and ensuring LIP oversight. This process enables the radiologist to exemplify added value through physician leadership, team integration, and improved patient care.

OBJECTIVE: Analyze mammography quality and deficiencies, including variability in quality assessment among subspecialized breast radiologists, after implementing the Enhancing Quality Using the Inspection Program (EQUIP).
METHODS: After IRB approval, this single institution study retrospectively queried data prospectively entered into our automated reporting software after implementing EQUIP (October 2017-March 2019). Screening and diagnostic combination (digital mammography with tomosynthesis) mammograms were reviewed by seven breast radiologists. Quality was assessed as excellent, good, adequate, or problems found. Of those with problems found, the deficiency and corrective action were evaluated. The interpreting radiologist, EQUIP radiologist, and performing technologist were recorded. P values were calculated using Fisher exact test and chi-square analyses.
RESULTS: Of 17 312 mammograms, 529 (3%) underwent EQUIP review. Of 43 (8%) with problems found, 23 (53%) did not include sufficient tissue, 9 (21%) had motion degradation, 3 (7%) had artifacts, 2 each (4.7% each) had the nipple not in profile or skin folds, and 4 (9%) were categorized as \"other.\" Nine (9/529, 1.7%) required recall for repeat imaging. The lead interpreting physician (LIP) was more likely to categorize mammograms as technically inadequate compared to other radiologists (P < 0.00001), and there were also statistically significant differences in how the remaining radiologists stratified cases (P < 0.00001) even when excluding the LIP.
CONCLUSIONS: Insufficient tissue was the most common problem identified in the EQUIP-reviewed mammograms with deficiencies. Significant variability was present among radiologist EQUIP designations. Ongoing review of clinical image quality with EQUIP allows for opportunities to provide corrective feedback.

OBJECTIVE: To evaluate the ability of a long-term technologist coaching program to sustain gains in mammography quality made by a previously implemented quality improvement (QI) initiative.
METHODS: Mammography quality metrics from July 2014 to June 2020 were reviewed. Numbers of screening mammograms performed/audited, monthly average mammogram overall quality pass rates, changes in facilities/staffing, and technical recall rates were evaluated. Performance metrics at baseline (July 2013), during the improvement (July 2014 to January 2015), postimprovement (February 2015 to August 2015), and sustained coaching periods (after initiation of the technologist coaching model, from September 2015 to June 2020) were compared.
RESULTS: During the postimprovement and sustained coaching periods, 93% (501/541) and 90% (8902/9929) of audited mammograms, respectively, met overall passing criteria, achieving or exceeding the QI goal of 90%, and results for both periods were significantly higher than that during the improvement period (74%, 1098/1489), at P < 0.0001 and P < 0.0001, respectively. The technical recall rates during the improvement and postimprovement periods were 2.6% (85/3321) and 1.7% (54/3236), respectively; the rate during the sustained coaching period was significantly lower than these, at 1.2% (489/40 440) (P < 0.0001 and P = 0.0232, respectively). Sustained quality passing rates and lower technical recall rates were observed despite statistically significantly increases in screening volumes.
CONCLUSIONS: A technologist coaching program resulted in sustained high mammographic quality for almost 5 years.

UNASSIGNED: To identify causes of technical repeats, determine whether differences exist between mobile and fixed mammography units, and evaluate the rate of improvement on repeat imaging.
UNASSIGNED: IRB approval was obtained for retrospective review of Enhancing Quality Using the Inspection Program (EQUIP) logs of screening mammography technical repeats performed from March 2017 to December 2018 at a hospital breast imaging center and from April 2017 to December 2018 on mobile mammography units. Frequency tables and Fisher\'s exact tests were used for statistical analysis.
UNASSIGNED: Technical deficiencies were reported in 483 cases and reviewed by two or three auditors. Auditors identified no technical deficiencies in 31 cases, which were excluded. The remaining 452 cases were assigned a technical recall category: motion, positioning/excluded tissue, skin folds, artifacts, undercompression, or contrast (under/overexposure). Motion was the most common technical recall category (253/452, 56.0%). Positioning/excluded tissue was the second most common reason (150/452, 33.2%). Statistically significant differences in technical deficiencies were identified between mammograms performed on mobile versus fixed mammography units for motion (94/143, 65.7% vs 159/309, 51.5%, respectively, P = 0.0058), skin folds (16/143, 11.2% vs 15/309, 4.8%, respectively, P = 0.02), and positioning/excluded tissue (30/143, 21% vs 120/309, 38.8%, respectively, P = 0.00016). Most recalls improved with repeat imaging (auditor 1: 451/483, 93% and auditor 2: 387/483, 80%).
UNASSIGNED: Motion and positioning/excluded tissue are the most common reasons for screening mammography technical recalls. The reasons for technical recall differ between patients imaged on mobile and fixed mammography units, likely because of differences in each location\'s patient population.

Reducing the global treatment gap for mental health conditions in low- and middle-income countries (LMICs) requires not only an expansion of clinical psychology training but also assuring that graduates of these programs have the competency to effectively and safely deliver psychological interventions. Clinical psychology training programs in LMICs require standardized tools and guidance to evaluate competency. The World Health Organization (WHO) and UNICEF developed the \"Ensuring Quality in Psychological Support\" (EQUIP) platform to facilitate competency-based training in psychosocial support, psychological treatments, and foundational helping skills, with an initial focus on in-service training for non-specialists. Our goal was to design the first application of EQUIP to implement competency-based training into pre-service education for clinical psychology trainees. With Makerere University in Uganda as a case study, we outline an approach to develop, implement, and evaluate a competency-based curriculum that includes seven steps: (1) Identify core clinical psychology competencies; (2) Identify evaluation methods appropriate to each competency; (3) Determine when competency evaluations will be integrated in the curriculum, who will evaluate competency, and how results will be used; (4) Train faculty in competency-based education including conducting competency assessments and giving competency-based feedback; (5) Pilot test and evaluate the competency-based education strategy with faculty and students; (6) Modify and implement the competency-based education strategy based on pilot results; and (7) Implement ongoing evaluation of the competency-based curriculum with continuous quality improvement. This approach will be formally evaluated and established as a foundation for pre-service training in other low-resource settings.

OBJECTIVE: The Enhancing Quality Using the Inspection Program (EQUIP) initiative was launched to improve clinical image quality. The purpose of this study was to determine if the implementation of the EQUIP reporting system resulted in an increased number of extra views performed at the technologists\' discretion during screening mammography.
METHODS: Following IRB approval at a single comprehensive cancer center, patients who underwent screening mammography with combination full-field digital mammography plus digital breast tomosynthesis during a 6-month period before (January 2017 to June 2017) and after (January 2018 to June 2018) EQUIP implementation were identified. For each patient, both screening mammograms were retrospectively reviewed by 1 of 3 subspecialized breast radiologists (3-10 years of experience). The following data were recorded: demographics, breast density, surgical history, technologist, number and type of extra views, final BI-RADS assessment, radiologist-assigned indication for the view, and radiologist-assigned necessity of the view. McNemar\'s test for paired data was computed with p value of <0.05 considered statistically significant.
RESULTS: Of 820 patients, 370 (45%) had additional views in 2018 compared to 317 (39%) in 2017. After EQUIP, patients were 38% more likely to have additional views (OR = 1.38, 95% CI = 1.11-1.73). The total number of additional views in 2018 was 636 compared to 530 in 2017 (20% increase). Among patients with extra views in both years, the number of additional views per patient did not significantly increase post EQUIP implementation (OR = 1.18, 95% CI = 0.73-1.92). The most common extra view was exaggerated craniocaudal lateral, and the most common reason cited by the reviewing radiologist was lateral fibroglandular tissue at the edge of the images. Most of the extra views performed in 2018 were not performed in 2017 and over half were deemed unnecessary. Eight of eleven technologists demonstrated an increased frequency of screening mammograms with extra views performed post EQUIP.
CONCLUSIONS: Following EQUIP implementation, screening mammography patients were significantly more likely to have extra views performed at the technologists\' discretion. Our findings emphasize the importance of ongoing technologist education and radiologist feedback.

OBJECTIVE: To determine the feasibility of objectively critiquing mammography images and quantitatively assessing technologist performance, and to determine whether results can be compared to analyze performance.
METHODS: The authors assessed mammography examinations performed by 3 experienced technologists using a quality improvement method to track factors that affect image quality. A total of 147 examinations were evaluated prior to the technologists receiving standardized positioning training, and an equal number of examinations were evaluated 2 months after the training. During the evaluations, data was collected that described the quality of the examinations and the technologists\' behavior during the pre-exposure, acquisition, and postexposure process that affected image quality.
RESULTS: The authors selected 7 out of more than 140 prominent examples to demonstrate a methodology to evaluate image quality, to use the results to empower the technologist to improve their performance in areas that indicate positioning and compression weakness, and to track the technologist\'s improvement over time. Technologist 1 demonstrated the most dramatic improvement between the pre- and posteducational evaluations in the length of the pectoral muscle on the mediolateral oblique projection. Technologist 3 improved inclusion of the inframammary fold region by 18% between evaluations. Posteducational evaluations also demonstrated a decrease in the percent of examinations that passed posterior nipple line measurements. Compression force did not significantly change.
CONCLUSIONS: Identifying specific technologist actions that positively or negatively affect the quality of mammography examinations and then providing this information to the technologist with a suggested plan of corrective action can improve mammography service.
CONCLUSIONS: This clinical validation study for mammography quality improvement demonstrated that technologist performance affecting image quality can be measured when examination and threshold variables are controlled.

Enhancing quality using the inspection program (EQUIP) augments the FDA/MQSA program ensuring image quality review and implementation of corrective processes. We compared technical recalls between digital breast tomosynthesis (DBT) and full-field digital mammography (FFDM). Prospectively recorded technical recalls of consecutive screening mammograms (10/2013 - 12/2017) were compared for imaging modality [FFDM, DBT + FFDM, DBT + synthesized mammography (SynM)], images requested, and indication(s) (motion, positioning, technical/artifact). Chi-squared tests evaluated statistical significance between proportions. Of 48,324 screening mammograms, 277 (0.57%) patients were recalled for 360 indications with 371 repeated views. DBT exams had significantly less recalls compared to FFDM ( X 2 = 25.239 ; p = 0 < 0.001 ). 98 (27.2%) recalls were for motion, 192 (53.3%) positioning, and 70 (19.4%) technique/artifacts. Theses indications for technical recall were compared for FFDM, DBT + FFDM, and DBT + SynM. There were significant differences in the indications for technical recall prior to and after implementing DBT + SynM ( X 2 = 18.719 ; p < 0.001 ). Technical recalls declined significantly with the inclusion of DBT (SynM/FFDM) compared to FFDM alone. Recalls for motion demonstrated the greatest decrease. Positioning remains a dominant factor for technical recall regardless of modality, supporting the opportunity for continued technologist education in positioning to decrease technical recalls.

OBJECTIVE: The purpose of this project was to achieve sustained improvement in mammographic breast positioning in our department.
METHODS: Between June 2013 and December 2016, we conducted a team-based performance improvement initiative with the goal of improving mammographic positioning. The team of technologists and radiologists established quantitative measures of positioning performance based on American College of Radiology (ACR) criteria, audited at least 35 mammograms per week for positioning quality, displayed performance in dashboards, provided technologists with positioning training, developed a supportive environment fostering technologist and radiologist communication surrounding mammographic positioning, and employed a mammography positioning coach to develop, improve, and maintain technologist positioning performance. Statistical significance in changes in the percentage of mammograms passing the ACR criteria were evaluated using a two-proportion z test.
RESULTS: A baseline mammogram audit performed in June 2013 showed that 67% (82/122) met ACR passing criteria for positioning. Performance improved to 80% (588/739; p < 0.01) after positioning training and technologist and radiologist agreement on positioning criteria. With individual technologist feedback, positioning further improved, with 91% of mammograms passing ACR criteria (p < 0.01). Seven months later, performance temporarily decreased to 80% but improved to 89% with implementation of a positioning coach. The overall mean performance of 91% has been sustained for 23 months. The program cost approximately $30,000 to develop, $42,000 to launch, and $25,000 per year to maintain. Almost all costs were related to personnel time.
CONCLUSIONS: Dedicated performance improvement methods may achieve significant and sustained improvement in mammographic breast positioning, which may better enable facilities to pass the recently instated Enhancing Quality Using the Inspection Program portion of a practice\'s annual Mammography Quality Standards Act inspections.