Fluoroscopic Guided Lumbar Puncture PQI: Module A — Radiation Safety

Template Contributors: Ryan B Peterson, MD; Kimberly Applegate, MD, MS; Ivan Dequesada, MD; Srikanth Boddu, MD; and Amanda Corey, MD

This template is designed to assist you in meeting Part IV of the maintenance of certification (MOC) requirements. Persons who are participating in the MOC program must select a practice quality improvement project that is relevant to their practice and that produces measurable results suitable for repeated measurements.

This template focuses on radiation safety, specifically reducing radiation exposure to patients and staff.  Your sample population may include inpatients and/or outpatients.

This template will take you step-by-step so you can develop your own PQI project.


  1. Review the Practice Audit Instructions and complete the Practice Audit Survey by conducting an audit of 15 charts. You may use the Example Survey to organize your review of charts.
  2. Compare your current practice to national parameters by reading the provided Practice Audit Discussion Points and National Parameters/Consensus documents
  3. Record fluoroscopic times and BMI for each patient in the audit and calculate a mean fluoroscopic time and BMI for your study group.
  4. Compare your results to the benchmark fluoroscopic times as related to patient BMI in Practice Audit Survey Discussion Table 1
  5. Complete the appropriate education interventions (for radiologists, referring physicians and technologists)
    1. Education Intervention: For the Radiologist
    2. Education Intervention: For the Technologist
  6. Create and implement an action plan (Action Plan Template), including selecting one or more specific clinical intervention(s).
    Example interventions include:
    1. New lead aprons
    2. Annual lead apron inspection
    3. Monitor use of radiation protective eye-wear
    4. Radiology technologist in-service training on radiation safety
    5. Review and adaptation of department policies regarding dosimeter usage
    6. Radiation physicist support
    7. Implement alternative to monitor patient dose (ie individual dosimeter badges)
  7. Conduct a 6-month post-intervention follow-up chart review of 15 new patient exams. Document patient fluoroscopy times and BMI for 15 new patient exams and compare those to standard benchmarks and prior survey.
  8. Repeat steps #5 and #6 if clinical intervention resulted in no change or a change that did not meet the goals you set as part of the action plan
  9. Complete the Post Test
  10. Check answers with Post Test Answer Sheet
  11. Record your PQI project in myABR and keep a copy of your action plan, chart review results and conclusions reached in the event of an MOC audit

The ABR designates performance improvement activities in this project as meeting the standard for a PQI project as defined in Part IV of the MOC requirements as it includes an assessment of current practice, the implementation of an intervention, a re-evaluation and documentation of the impact of the change. This template allows the user to meet these criteria.

This is a template that can be modified as necessary to fit your practice.

Designation Statement
This material was fully qualified as a PQI template by the American Board of Radiology (ABR) on 12/16/14.

Target Audience
Radiologists and other professionals performing fluoroscopic guided lumbar punctures.

Goals and Objectives
The goal of this template is to:

  1. Reduce patient and healthcare professionals radiation exposure during fluoroscopic guided lumbar punctures.
  2. Provide radiologists and other health professionals with a comprehensive guide in the development of PQI project that will fulfill MOC requirements.

Nothing to disclose

PQI Template Checklist

☐ Review practice audit instruction
☐ Perform practice audit survey
☐ Review “Practice Audit Discussion Points”
☐ Review “National Parameters and Consensuses”
☐ Compare benchmark fluoroscopic times
☐ Review “Education Interventions for Radiologists & Technologists”
☐ Create and implement an “Action Plan”
☐ Perform 6-month post intervention chart review/practice audit survey
☐ Complete “Post Test” and check answers
☐ Record PQI project in myABR