Good practice guide for clinical radiologists

Transcription

1 Good practice guide for cliical radiologists Secod editio Board of Faculty of Cliical Radiology The Royal College of Radiologists

2 Foreword As doctors ad radiologists, we have a primary duty to esure that we provide safe, patiet-cetred services which improve the outcomes to the patiets ad public that we serve. We must always be strivig to improve ad develop these services drive by healthcare developmets ad public expectatio. This best practice guidace is a essetial resource to help you i this process ad describes what are your idividual resposibilities as well as those of the orgaisatio i which you work. These good practice guidelies are clearly set out with useful liks to more detailed documets drawig together all the available ad relevat iformatio. From a patiet s perspective, it is importat that this is ot a aspiratioal documet but oe that ca be referred to by ay radiologist as beig relevat to their day-to-day professioal role ad resposibilities. The Good Practice Guidelies were origially prepared i 1999 by Paul Dubbis, the the Dea of the RCR. The origial guidelies were the basis for this update. The RCR ackowledges the work of Paul Dubbis i producig the origial documet ad it is a credit to his work that most of the origial documet is still applicable. This documet replaces BFCR(99)11 Good Practice Guide for Cliical Radiologists which is ow withdraw. The guidelies have bee updated by the curret members of the Professioal Support ad Stadards Board (PSSB) with cotributios from David Kessel. Thaks ad ackowledgmet go to all those ivolved. We are sure this documet will be welcomed as a authoritative guide for all for the beefit of both professioals ad patiets. Dr Peter Cavaagh Dea of the Faculty of Cliical Radiology The Royal College of Radiologists Lay foreword As lay members of the Professioal Support ad Stadards Board (PSSB), we welcome this updated documet as a guide for good practice for radiologists whether NHS or private practice-based. We believe it will sigificatly cotribute to the improved cliical care of patiets. The guidelies demostrate the cotiuig commitmet of The Royal College of Radiologists (RCR) towards improvig stadards i radiology. At a time of chage withi the practice of radiology ad the medical professio geerally the guidelies help set out a template for achievig high stadards withi the specialty. They put ito cotext how the resposibilities of a idividual radiologist fit ito the differet tiers of resposibility withi the professio. They also offer reassurace to practitioers i a melee of regulatios ad statutory requiremets, clarifyig cotractual arragemets ad maagemet arragemets betwee trusts ad professioals. Cliical Radiology Patiets Liaiso Group The Royal College of Radiologists Good practice guide for cliical radiologists 3

3 1 Itroductio The purpose of this documet is to summarise for cliical radiologists existig advice o good practice from The Royal College of Radiologists (RCR) ad the priciples which uderpi good radiological practice. The accoutability of doctors ad stadards of healthcare provisio remai i the spotlight of public, media ad political cocers. Careerlog maiteace of cliical stadards of practice is required for all doctors rather tha the reliace of stadards determied at the time of etry ito practice. Stregtheed aual appraisal ad revalidatio is evisaged to facilitate this for all doctors. 1 Patiets attedig a departmet of cliical radiology are etitled to expect the highest possible stadard of service. Patiets have a right to expect that moder healthcare systems will have established frameworks to esure the quality of healthcare provisio. The available resources will affect the stadard of care that ca be delivered. The medical professio, patiet groups, govermet bodies ad the professios allied to medicie are all committed to cotiuig improvemets i the stadards of medical care. 2,3 Cliical radiologists ad the teams i which they work ad lead must be appropriately qualified, traied ad experieced, ad be adequately resourced i terms of staffig ad equipmet. The RCR supports the priciples of the delivery of a high-quality imagig service ad cotiues to produce guidace o the developmet ad maiteace of high stadards of cliical care. The RCR produces guidace documets o cotemporary issues. These are developed after takig advice from members ad Fellows, other professioal groups ad patiet orgaisatios. The recet developmet of the radiology departmetal accreditatio scheme which is delivered by the Uited Kigdom Accreditatio Scheme (UKAS) as the Imagig Services Accreditatio Scheme (ISAS) is a recet example of the work of the RCR i collaboratio with the Society ad College of Radiographers (SCoR). Good practice i cliical radiology requires cotiual assessmet of the imagig services that are provided with, as required, revisio ad reewal of the processes which deliver this service. Usig the framework for good medical practice provided by the Geeral Medical Coucil (GMC), 4 atioal guidace ad RCR stadards, the documet is costructed aroud the idividual radiologist ad their role ad resposibilities withi radiological departmets. The documet is based aroud the curret Uited Kigdom healthcare model of NHS hospital trust care provisio but is applicable to other healthcare models such as private orgaisatios. The documet is divided ito four sectios: The atioal guidace what is out there to direct us The hospital ad departmetal resposibilities that is, the shared resposibilities of the orgaisatio ad service Idividual resposibilities what you as a idividual are resposible for regardless of your place of work Maitaiig good practice how the GMC guidace relates to you as a radiologist. A ote o termiology Throughout this documet, the term trust is used to ecompass ay hospital provider of services. 4 Good practice guide for cliical radiologists

4 2 Natioal guidace Ecouragig ad maitaiig good cliical practice is at the core of the GMC guidace for idividual medical practitioers. The ew GMC framework for revalidatio 5 will become the stadard for assessmet of medical practitioers. The output from the stregtheed aual appraisal process will establish criteria required for revalidatio of idividual doctors. To retai their licece to practise, doctors will eed to demostrate to the GMC that they are up to date ad fit to practise. This will ivolve providig supportig iformatio to show that they are practisig i accordace with relevat professioal stadards. Cliical goverace Cliical goverace is a framework through which NHS orgaisatios are accoutable for cotiuously improvig the quality of their services ad safeguardig high stadards of care by creatig a eviromet i which excellece of cliical care will flourish. Idividual practitioers are resposible for developig ad maitaiig stadards of cliical care withi their local healthcare orgaisatios through the process of cliical goverace. The statutory duty to maitai ad ehace the quality of cliical care rests with the chief executive of the healthcare orgaisatio. All orgaisatios are required to establish a framework for the co-ordiatio ad implemetatio of policies to improve the quality of care. Radiology departmets should have their ow defied cliical goverace framework ad processes which fit withi the overall orgaisatioal structure. Clear lies of resposibility with established leadership via a idetified seior cliicia, usually the medical director of a NHS trust, or equivalet, leadig a multidiscipliary team for cliical goverace should be i place. Regulatio of health ad social care i Eglad is carried out by the Care Quality Commissio. Its equivalet i Wales is the Health Ispectorate, i Scotlad the Scottish Commissio for the Regulatio of Care ad i Norther Irelad by the Regulatio ad Quality Improvemet Authority. Self-assessmet forms part of the assessmet process for CQC registratio as a iitial measure of healthcare quality. It is valuable i reviewig the adequacy of local healthcare provisio. Documetatio of this self-assessmet should lead to critical aalysis of local radiological service provisio ad steps ca the be take to improve o ay deficiecies idetified. Careful self-assessmet of the stregths ad weakesses of the orgaisatio should lead to a programme of cotiuous improvemet. This practice should be applied to all cliical ad o-cliical areas. For radiology departmets, this should be led by the cliical director ad supported by local audit ad risk assessmets. Poor performace may be idetified by iteral assessmets. Departmetal assessmet or review (for example, via the ISAS accreditatio process or via the RCR Service Review committee) 6 ca help to idetify potetial solutios ad remedies for the cliical radiology departmet. Idividual cliical cosultat radiologist performace should be assessed as part of the five-year GMC revalidatio cycle with aual appraisal. Idividual cliical performace which is perceived to be poor at a local level may require exteral cliical assessmet which ca be achieved via cosultatio with the Natioal Cliical Assessmet Service (NCAS). Natioal Istitute for Health Research (NIHR) ad the Natioal Istitute for Health ad Cliical Excellece (NICE) The Natioal Istitute for Health Research (NIHR) via the NIHR Health Techology Assessmet programme ad the Natioal Istitute for Health ad Cliical Excellece (NICE), promote idepedet guidace o the best cliical ad cost-effective cliical practice ad treatmets i Eglad ad Wales. Appraisal of the best practice withi existig treatmet optios, assessmet of ew health itervetios ad advice o how to implemet chages i cliical practice form key aspects of their roles. The Natioal Quality Board (NQB) is a multi-stakeholder board established i 2009 to champio quality ad esure aligmet i quality throughout the NHS i Eglad. Its role is to provide strategic oversight ad leadership i quality across the NHS. The board is chaired by Sir Bruce Keogh, the NHS Medical Director. The board plas the publicatio of approximately 150 atioal quality stadards over the ext five years. These stadards will iclude relevat details of radiological practice relatig to each cliical stadard; for example, demetia, Good practice guide for cliical radiologists 5

5 eoatal care ad veous thromboembolic disease. As these stadards are published, radiology departmets will eed to udertake self-assessmet to establish if their curret provisio of service is appropriate for the ewly defied stadard. Scottish Itercollegiate Guidelies Network (SIGN) The Scottish Itercollegiate Guidelies Network (SIGN) develops evidece-based cliical practice guidelies for the NHS i Scotlad. SIGN has represetatives from all of the UK Royal Colleges ad Faculties i Scotlad. SIGN guidelies are derived from systematic review of the medical literature. They are desiged as a vehicle for acceleratig the traslatio of ew kowledge ito cliical practice, to reduce variatios i practice ad to improve patiet outcomes. Natioal service frameworks (NSFs) Natioal service frameworks (NSFs) set atioal healthcare stadards ad their aim is to deliver high-quality healthcare to all patiets irrespective of geographical locatio. They form part of the cetral Govermet s NHS Choices programme. NSFs set clear quality requiremets for cliical care based o the best available evidece ad offer guidace ad support to help healthcare orgaisatios to achieve these stadards. They establish specific performace targets agaist which progress withi a defied timescale ca be measured. The Geeral Medical Coucil The Geeral Medical Coucil (GMC) has issued guidace for Good Medical Practice which forms the basis for the practice of all doctors. 4 Good medical practice sets out the priciples ad values o which good practice is fouded; these priciples together describe medical professioalism i actio. The basic teet of the advice ad guidace from the GMC is: Patiets must be able to trust doctors with their lives ad health. To justify that trust you must show respect for huma life ad you must: Make the care of your patiet your first cocer Protect ad promote the health of patiets ad the public Provide a good stadard of practice ad care Treat patiets as idividuals ad respect their digity Work i partership with patiets Be hoest ad ope ad act with itegrity. The advice requires doctors to: Keep their professioal kowledge ad skills up to date Recogise ad work withi the limits of their competece Maitai trust ad cofidetiality i their professioal relatioships with patiets Maitai trust ad probity i their professioal relatioships with colleagues, employig bodies ad others Provide cotiuity of care Esure the safe itroductio of skills mix to ehace access to cliical services, while maitaiig stadards 7 Be persoally accoutable for their professioal practice ad to be always prepared to justify idividual decisios ad actios. 8 The GMC is itroducig revalidatio as the method for assessig the performace of all doctors o a five-year cyclical basis to esure fitess to practise. This will be based o a satisfactory aual appraisal process for each year of the five-year cycle ad the overall judgemet of a resposible officer. The GMC has iteral procedures for assessig the cliical ad professioal performace of doctors whe there is reaso to believe that this may be seriously deficiet. The GMC has powers to require a doctor to udergo further traiig, to restrict their practice, or to susped them from practice if deficiecies are ot remedied. Discipliary ad disability procedures All healthcare providers such as trusts are required to have their ow clearly defied policies for dealig with persoal ad professioal miscoduct. Processes for dealig with cocers stemmig from physical or metal disability ad addressig the prevetio of harm to patiets as a result of the physical or metal disability of a doctor should be i place withi the trust. Foudatio trusts have their ow policies ad procedures for these issues ad their service ad fiacial goverace arragemets are curretly ispected ad assessed by Moitor. 6 Good practice guide for cliical radiologists

6 3 Hospital ad departmetal resposibilities 3.1 Settig stadards Departmets of cliical radiology have a resposibility to esure that their practice achieves the highest possible stadards. These stadards iclude cliical care, quality of images ad image iterpretatio, results of itervetios measured by outcome data as well as issues such as waitig times, facilities, patiet experiece ad speed of issue of the report. 9 Most of these stadards will be iflueced by the workforce ad equipmet resources available. The itroductio ad achievemet of accreditatio of imagig services should lead to a cosistet high stadard of departmetal practice across the Uited Kigdom. ISAS, which is admiistered by UKAS, the sole atioal accreditatio orgaisatio approved by the UK Govermet, provides the opportuity for departmetal accreditatio ad was developed by collaboratio betwee the RCR ad the SCoR. Data for clear stadards for may of the ivestigatios ad therapeutic itervetios performed withi radiology departmets is icomplete. The RCR cotiues to cotribute to the developmet of stadards as iformatio becomes available from research ad audit data. The RCR has recetly udertake iteral restructurig ad iitiated the Professioal Stadards ad Support Board (PSSB) i recogitio of the importace of this subject ad the chagig medical eviromet withi the Uited Kigdom. Service stadards Each departmet should esure that there are systems i place to: Justify cliically each imagig examiatio based o atioal ad local guidelies 10 Esure that the most appropriate available imagig modality is used 11 Esure that all studies are formally reported by a accredited radiologist or appropriately delegated, except where a explicit policy for o-reported examiatios exists 9,12 Esure that traiees work uder supervisio ad to a level appropriate to their level of traiig ad expertise Esure appropriate respose times: radiological examiatios ca oly cotribute to effective patiet maagemet if they are performed i a timely fashio. Target respose times for differig imagig procedures ad differet levels of cliical urgecy are required. The ability of departmets to achieve target respose times depeds upo the availability of adequate resources of equipmet ad persoel Achieve effective ad timely commuicatio of the report 9,13 Evaluate adverse icidets Esure appropriate applicatio of health ad safety guidace (COSHH). Techical stadards The performace of ivestigatios withi radiology departmets is depedet o the use of high-quality equipmet which is appropriate to the task. It is essetial, if quality is to be maitaied, that issues relatig to equipmet performace are kept uder cotiuous review. Particular attetio should be give to: Maiteace of equipmet Calibratio of equipmet Adequacy of a equipmet replacemet programme Applicatio of the as low as reasoably practical (ALARP) priciple Adequate dosimetry for all equipmet with radiatio potetial, with audit of radiatio dose to staff ad patiets Moitorig the umber of exposures recorded for idividual examiatios Observace of the advice issued by the Natioal Radiological Protectio Board (NRPB) which is ow part of the Health Protectio Agecy ad the Euratom Directive 14 Rejectio aalysis of images. The majority of UK imagig is ow based o digital imagig ad this has resulted i a sigificat reductio i the umber of images rejected for techical reasos i recet years. Careful review of radiographic exposure factors, maiteace ad calibratio of all equipmet ivolved i digital image productio is required to maitai this importat factor i radiatio protectio. Stadards of performace If uiformly high stadards of practice are to be maitaied, these must be iformed by guidelies: Writte guidelies should be available for all procedures udertake Good practice guide for cliical radiologists 7

7 The idicatios for the procedure should be explicit The methodology for the procedure must be outlied The ature of ay recordigs or observatios must be recorded The preferred method of commuicatio of the report should be stated. Commuicatio of the report is a key performace elemet of ay radiological examiatio. The traditioal paper report is ow icreasigly supplemeted or replaced by electroic trasmissio. Electroic report delivery is best achieved with a direct automated lik to the relevat digital images ad a electroic system of stadardised report ackowledgemet from the cliical team who requested the examiatio. The use of paper reports is likely to cotiue for a umber of years as electroic systems are itroduced to facilitate report ackowledgemet. Audit of paper report systems should be udertake to establish that Natioal Patiet Safety Agecy (NPSA) guidelies are beig fulfilled. 9,13,15 Diagostic accuracy There are still few atioally agreed figures for diagostic accuracy for ay imagig ivestigatio. Accuracy rates which appear i the literature are ofte achieved oly uder optimum coditios of staffig ad equipmet. Noetheless, the cliical radiologist should strive to achieve stadards of accuracy similar to those published i the literature. Natioally agreed miimum stadards are available for oly a limited umber of areas of cliical practice. Examples iclude atioal screeig programmes for breast cacer ad abdomial aortic ultrasoud screeig. The atioal breast screeig programme (NHSBSP) was established i 1988, with the defied aim of reducig the mortality due to breast cacer by 25%. The establishmet of the screeig programme, staffig levels ad the processes of audit have bee based o the eed to achieve specific performace stadards. Recet chages i the breast screeig programme iclude the extesio of the age rage of wome eligible for breast screeig to those aged 47 to 73 i This will be completed i The NHS Abdomial Aortic Aeurysm Screeig Programme has recetly published its expected miimum stadards for diagostic accuracy. 16 The details of how this ultrasoud-based screeig programme will be implemeted were established after a review of the atioal breast screeig programme ad reflect a adaptatio of this model of screeig practice. Itervetioal radiology Itervetioal radiology procedures have trasformed treatmets across may areas of medicie. Despite the miimally ivasive ature of these techiques, they are ot without risk. Itervetioal radiologists are boud to demostrate that their performace meets miimum stadards. Every cliical radiologist has a resposibility to cotribute to the developmet of the evidece base, to be aware of existig stadards ad to examie their ow performace regularly ad i particular if stadards fall below the miimum expected. I accordace with the priciples of cliical goverace, all radiologists who udertake itervetioal procedures should cotiually review their practice to esure that it meets accepted criteria where they exist withi the established literature. It is particularly importat to cosider all complicatios ad problems lookig for prevetable ad systematic causes from which lessos which ca be leared. Every doctor should maitai a permaet record of practice which should be available for periodic iteral ad exteral review. The record should iclude the volume of work ad outcomes of procedures. This record of performace should regularly be audited agaist target stadards. 8,17,18 The RCR provides guidace o quality assurace i itervetioal techiques which is directly relevat to practice withi the UK. 19 These guidelies do ot cover every itervetio. More comprehesive Stadards of Practice have bee developed i Europe ad the USA. These are published by the Cardiovascular ad Itervetioal Radiology Society Europe (CIRSE) 20 ad the Society of Itervetioal Radiology (SIR). 21 These stadards have bee researched extesively ad are based o available evidece. However, differeces i practice ad certificatio mea that these may require modificatio for practice withi the UK. 22 Moitorig itervetioal radiological performace A effective meas of moitorig performace is through submissio of data to atioal registries ad databases. These are co-ordiated through several societies such as the British Society of Itervetioal Radiology (BSIR) ad the Vascular Society of Great Britai ad Irelad (VSGBI). These registries provide a cotiually evolvig picture of outcomes from itervetioal procedures. 22,23 Data from these registries reflect cotemporary stadards of practice i the UK ad is essetial for bechmarkig. This is the basis for the developmet of atioal stadards which iform the RCR guidelies. 8 Good practice guide for cliical radiologists

8 Arragemets for supportig cosultats i data capture should be icluded withi the idividual cosultat job pla. Idividuals ca extract their data from registries ad use this to demostrate that their performace meets accepted stadards. This is particularly helpful i support for those itervetioal radiologists who may work i relative isolatio ad who therefore may have limited scope for objective review of practice. Threshold stadards for procedure-related complicatios Examples of recommeded upper limits for complicatios arisig from diagostic ad itervetioal vascular procedures ca be see i Appedix 1. These are based o evidece from registries ad from published literature. The RCR will cotiue to commissio the developmet of stadards for vascular ad itervetioal techiques takig advice from special iterest groups esurig that the stadards are applicable to practice withi the UK. These stadards will iclude: Appropriateess ad/or idicatios Safety or complicatio rate Miimum efficacy rates. The stadards withi cliical radiology will cotiue to evolve to reflect chages i practice ad the available evidece base. 24 These will take ito accout chagig idicatios for ivestigatios ad itervetios ad the itroductio of ew techiques. 25 Resposibility for radiatio protectio/safety Legal resposibility for radiatio protectio Legal resposibility for radiatio protectio lies with the employer. The extet to which this resposibility is delegated to idividual radiologists varies ad i particular depeds upo the degree to which they are ivolved i the maagemet of the radiology departmet. Noetheless, all cliical radiologists carry a resposibility for the protectio from uecessary radiatio of: Patiets Themselves Other members of staff Members of the public, icludig relatives ad carers. Legislatio Good practice ivolves more tha compliace with legislatio; evertheless radiologists must be familiar with the implicatios to their practice of the regulatios relatig to ioisig radiatio. This is particularly importat to those holdig Admiistratio of Radioactive Substaces Committee (ARSAC) liceces for the admiistratio of radio-pharmaceuticals. Guidace o stadards of cliical practice withi uclear medicie departmets have also bee published by the British Nuclear Medicie Society (BNMS) ad the Europea Associatio of Nuclear Medicie (EANM). 26,27 Resposibility before the exposure The overridig priciple is to maitai radiatio doses as low as reasoably practicable (the ALARP priciple). Each radiologist should be cofidet that procedures are i place to esure that examiatios usig ioisig radiatio are oly carried out whe there is adequate cliical justificatio as required by the Ioisig Radiatio (Medical Exposure) Regulatios 2000 (IRMER). 10 The Royal College of Radiologists Referral Guidelies: Makig the best use of radiology, 7th editio 11 should be used as a guide to justificatio i radiology. Vettig of request forms, locally agreed guidelies ad protocols for delegatio will form part of the processes required here. If exposures are beig made which appear to cotravee accepted guidelies, the radiologist must take steps to rectify the situatio. 10,14 Radiologists must uderstad the priciples uderlyig the protectio of the fetus. 28,29 Where a cliical radiologist is resposible for radiouclide imagig, they should provide appropriate advice to the carers ad relatives of patiets udergoig scitigraphy. Nursig mothers who receive radioactive isotopes should be advised of the limitatios that these impose o breastfeedig. Resposibility durig the exposure A radiologist should wear ad retur their persoal dose moitors i accordace with local practice, ad ecourage others to do the same. The cliical radiologist performig the examiatio will be resposible for esurig that the study is carried out i such a way that the dose to the patiet is kept to the miimum ecessary to achieve the desired cliical result. I additio, idividuals will be expected to adopt Good practice guide for cliical radiologists 9

9 practices which esure that their ow exposure ad that of others i the room is miimised. This resposibility is delegated to the radiographic staff performig examiatios which do ot ivolve the cliical radiologist directly. Resposibility after the exposure There will be occasios whe a radiologist becomes aware that protocols/guidelies have bee breached after the evet. I this case, they would be expected to take steps to esure that the appropriate procedures are adhered to i the future. There are also occasios where a female patiet is iadvertetly exposed to radiatio durig early pregacy. I this situatio where there has bee o sigificat exposure of the fetus, the cliical radiologist should offer prompt reassurace ad appropriate advice. However, whe there is doubt, there should be a clearly defied process for ivolvemet of the radiatio protectio adviser, a estimatio of the dose ivolved, a accurate assessmet of risk ad the appropriate advice offered. Resposibility for safety of o-ioisig radiatio Cliical radiologists should maitai up-to-date kowledge of the risks associated with imagig modalities ivolvig o-ioisig radiatio; for example, ultrasoud 30 ad magetic resoace imagig. Although these procedures are curretly idetified as low- or o-risk procedures, it remais prudet to apply the ALARP priciple to all diagostic exposures. Resposibility for istallatio of up-to-date equipmet Advaces i equipmet developmet withi cliical radiology cotiue. They occur i respose to cliical eed, research ad developmet by maufacturers, ad chagig maagemet patters primarily i order to: Provide more accurate ad cliically useful diagostic iformatio prior to medical or surgical itervetio Icrease the speed of trasmissio of iformatio withi ad betwee hospitals ad the wider commuity Replace ivasive ivestigative procedures with o-ivasive tests Substitute o-ioisig imagig procedures for those usig ioisig radiatio Further develop image-guided techiques to replace ad ehace existig medical ad surgical treatmets. All departmets should develop: Clearly defied quality assurace systems with established delegated resposibility ad clear lies of commuicatio Robust programmes for timely equipmet replacemet ad developmet Plas for commissioig ad upgradig of iformatio techology systems, picture archivig ad teleradiology. 31,32 Equipmet replacemet programmes eed to reflect the fact that electroic equipmet has a fiite lifetime. The expected useful lifetime depeds upo: Age ad itesity of use Availability of spare parts Image quality Equipmet maiteace Equipmet upgrades Radiatio dose. The replacemet ages for imagig equipmet have bee defied by the RCR with the above factors i mid: Ultrasoud Accidet ad emergecy X-ray equipmet Radiouclide equipmet Itervetioal procedural equipmet Mobile X-ray equipmet Computed tomographic equipmet MRI equipmet Stadard X-ray equipmet 5 years 7 years 7 years 7 years 10 years 7 years 7 years 10 years 10 Good practice guide for cliical radiologists

10 Picture archivig ad commuicatio systems (PACS) ad teleradiology systems require particular attetio withi the radiology equipmet replacemet programme due to their cost, size, importace ad frequet rapid advaces withi their field. The RCR has actively supported the expasio of the provisio of PET-CT equipmet withi the UK. 33 This service is curretly maily procured as a atioal cotract with a private cotractor. There will be a requiremet for additioal capital ad reveue fudig if this importat imagig modality is to be more fully itegrated ito practice withi NHS trust ad foudatio trust radiology departmets. 34 The availability of fiite capital resources for radiology equipmet replacemet programmes as part of overall orgaisatio budgetig may ecessitate cosideratio of other methods of equipmet fiacig ad procuremet such as leasig. Public resposibility There are limited resources available for healthcare. It is, therefore, importat that cliical radiologists exercise care ad resposibility i maagig the resources available to them effectively ad ecoomically. Noetheless, if factors withi the workig eviromet threate the safety of patiets, the security of diagosis or the radiatio safety of co-workers, cliical radiologists have a duty ad resposibility to take appropriate actio. This might mea withdrawal of a particular service or codemig a particular agig piece of equipmet. Orgaisatio, leadership, maagemet ad admiistratio If you lead the team, you must take resposibility for esurig that the team provides care which is safe, effective ad efficiet. Geeral priciples A cliical radiology departmet should provide a imagig ad itervetioal service of high quality withi a defied budget. Where appropriate there should be traiig facilities to the stadards required by the RCR. 35 Effective ad efficiet admiistratio is facilitated by good leadership. This should be provided by a desigated service leader who should be a cliical radiologist ad who will be resposible for maagig the activities of the departmet. Cliical radiology departmets vary i size ad service provisio but frequetly are large departmets i terms of staff umbers, physical size ad budget. No sigle perso ca achieve all of the leadership fuctios ad be ivolved persoally i every group withi the departmet. The service leader should have a robust set of groupigs or committees dealig with the differet areas, fuctios or activities of the departmet. The service leader will have clearly defied lie maagemet resposibility to the trust board. They should be appoited for a defied ad agreed period sufficiet to allow for the proper developmet ad cotiuity of maagemet processes. To maage effectively, they should have the support of other cliical radiologists withi the departmet, other professioal groups ad the medical school whe appropriate. Resposibilities of the service leader Busiess plaig Areas of key maagemet ad leadership activity iclude: Developmet of the departmet s busiess pla ad i-service plaig Iput ito the trust s cotractig process ad service plaig, icludig the prioritisatio of demads ad workload agreemets The developmet ad maiteace of adopted policies, guidelies ad protocols icludig the risk maagemet strategy The traiig of radiologists ad other staff groups withi the departmet. The establishmet of service level agreemets liked to cost ad volume cotracts of activity is recommeded to facilitate the maagemet of workload i a orderly, efficiet ad cliically resposible maer. Preplaig of work volume should eable departmets to maage the flow of patiets ad to respod to chages i cliical practice. The practice of medicie is iseparable from risk. 4 Cliical radiologists are resposible for balacig the risk of ay ivestigatio or itervetioal procedure agaist the risk of leavig the coditio udiagosed or utreated. Risk maagemet requires the recogitio that risk exists, idetificatio of factors which icrease risk ad implemetatio of policies which reduce such these factors, such as the World Health Orgaizatio (WHO) Surgical checklist adapted for radiological practice. 36 The reductio of risk to patiets ad staff to the lowest level achievable withi existig resources should be the focus of maagerial activity. Traiig of all staff groups withi cliical radiology departmets requires a appropriate structure ad resource to promote safe ad effective delivery of this essetial part of ay radiological service. Good practice guide for cliical radiologists 11

11 Budgets The operatioal cotrol of the fiaces of a departmet of cliical radiology will be the joit resposibility of the busiess maager ad the service leader. It is the resposibility of the service leader to prepare ad preset a well-argued ad evidece-based case for adequate resources, ad to keep withi agreed budgets. Staff maagemet The service leader must esure that there is a equitable distributio of work withi the departmet with efficiet rosterig to meet the required activities. 37 This icludes the proper maagemet of aual, study ad professioal leave. All cosultats are required to have a job pla specifyig their cotractual obligatios. These should be reviewed ad agreed aually, providig a opportuity for cosultats to assess their ow programmes ad workloads ad to pla their persoal professioal developmet. Appraisal based upo the job pla is a valuable method of assessig the performace ad effectiveess of idividual radiologists. Satisfactory aual appraisal will be required for GMC revalidatio requiremets over a five-year cycle for cliical radiologists. The service leader has a resposibility for other staff withi the departmet, through the support of the radiology busiess maager ad other seior radiographic, ursig ad other allied professioal maagers. Regular ad effective staff appraisal/evaluatio forms a importat part of staff maagemet ad uderpis the professioal developmet of all members of the departmet, servig to ehace service delivery to patiets. PACS ad teleradiology The cotiued developmet ad expasio of electroic data trasmissio ad storage requires robust plaig for existig PACS ad future upgradig. The priciple of sharig imagig data across etworks for safe ad effective patiet maagemet requires service leaders to review ad update routiely their ow iteral ad exterally etworked teleradiology arragemets. The RCR has published guidace o this importat subject which provides further detail. 32 Maagerial resposibilities The cotributio of cliical radiology to the work of the trust requires recogitio as a core cliical service. The departmet must be represeted at seior level i trust maagemet structures ad at a similar level to other cliical specialties. The importace ad hece ifluece of the service leader for radiology withi the trust maagemet structure should ot be udervalued. Critical decisios relatig to the orgaisatio ad delivery of cliical radiology services should reflect the service leader s kowledge of service provisio, traiig ad maiteace of stadards. Plas for cliical service recofiguratio withi or betwee trusts may be directed towards improvig the quality of ad/or reducig the cost of the cliical service provisio. Cliical radiologists must be ivolved from the outset i ay such discussios with represetatio by the service leader. Support Service leaders eed protected time ad appropriate support to perform their maagerial tasks adequately. A separate cotract for this part of their work should be draw up ad a agreed job descriptio formulated. Service leaders should be supported by, ad work closely with, busiess ad radiography maagers. Ready access to fiacial, persoel ad maagemet expertise, secretarial ad iformatio techology support are all required to facilitate effective cliical maagemet of a radiology departmet. Requests for a ivestigatio A request to a cliical radiology departmet for a imagig ivestigatio represets a request for a opiio from a cliical radiologist. These requests are usually but ot exclusively received from other medical practitioers withi the hospital, i the commuity or i geeral practice. Direct access to a wide rage of imagig ad advice o optimum imagig strategies is essetial to the proper practice of all cliicias icludig geeral practitioers. 38 The cliical radiologist is resposible for the medical care of the patiet while i the departmet of cliical radiology. They are resposible for the appropriate imagig ivestigatio, the coduct of the examiatio, the maagemet of complicatios ad the provisio of the report. 4,8 12 Good practice guide for cliical radiologists

12 Requests for cliical radiological examiatios will usually be made o a stadard radiology request form. This eables effective ad efficiet commuicatio of the relevat cliical iformatio. It is the resposibility of the referrig cliicia to complete the form properly, but it is the resposibility of the cliical radiologist (ad through delegatio, the radiographer) to esure that the cliical iformatio received is adequate ad appropriate for the performace of a particular ivestigatio. The form also affords the collectio of data such as the umber of films, cotrast details where appropriate, exposure ad dose. Electroic referral ad reportig of imagig examiatios are icreasigly supplatig the paper request form. The same priciples for the justificatio of ivestigatios clearly apply i this circumstace. Electroic order commuicatios systems facilitate accurate patiet demographic details ad structured questioig of the cliical details relevat to a particular imagig ivestigatio from the referrer. 39 Departmetal protocols should be i place to deal with requests from healthcare practitioers who are ot medically qualified. 40 Commuicatio of iformatio ad the radiologist s report I providig care, radiologists must keep clear, accurate ad cotemporaeous patiet records which report relevat cliical fidigs, the decisios made, the iformatio give to patiets ad ay drugs or other treatmet prescribed. Radiologists ad all cliicias must keep colleagues well iformed whe sharig the care of patiets. A accurate healthcare record will eable the patiet to receive effective cotiuig care, eables the healthcare team to commuicate successfully, ad allow aother doctor or professioal member of the team to assume care of the patiet at ay time. It eables the patiet to be idetified without risk or error, facilitates the collectio of data for research, educatio ad audit ad ca be used i legal proceedigs. The writte radiology report costitutes the legal record of the imagig ivestigatio. It is, therefore, vital that the iformatio cotaied withi the record is accurate, explicit, uderstadable ad iformative. It should be uambiguous with a level of cofidece either clearly implied or explicitly stated. Where ucertaity exists, this should be made clear withi the text of the report. The report should iclude clear patiet idetificatio, the ame of the cliical radiologist ad the secretarial support where appropriate ad record advice or iformatio give to the patiet at the ed of the examiatio. It should iclude documetary evidece of drugs/cotrast used durig the procedure ad advice o post-procedural care. (Note: May departmets will record details of drug admiistratio separately i the patiet s cliical case otes. Similarly, certai procedures which are the subject of departmetal writte protocols requirig the routie use of drugs for the procedure such as a muscle relaxat for barium eema examiatios would ot require separate documetatio withi the report.) Iformatio with respect to patiet dose exposure ad the umber of films will usually be recorded separately, most commoly o the request form. Robust methods of prompt ad accurate trascriptio ad secure trasmissio of the writte report whether by post, courier or electroic methods is vital. The writte radiology report is essetial for the commuicatio of iformatio betwee the cliical radiologist ad other groups ivolved i the care of the patiet. It represets the cetrepiece of commuicatio ad is a legally importat documet. Rapid meas of commuicatio should be used as a adjuct to the writte report i situatios of cliical urgecy. These should iclude brief etries i the patiet s medical otes, direct or telephoe coversatios with other medical staff or, where appropriate seior ursig staff. Occasioally it will be ecessary to commuicate importat iformatio directly to a geeral practice surgery via a seior admiistrative/clerical assistat. While it is ot the resposibility of the cliical radiologist to esure the competece of staff withi other departmets/practices, it is their resposibility to esure that the iformatio has bee received precisely, uambiguously ad if commuicated to o-medical staff, is fully uderstood. NPSA recommedatios ad specific guidace o sigificat uexpected radiological fidigs provide valuable iformatio ad/or guidace o idividual, departmetal ad trust resposibilities i this area. 9,13 Electroic order commuicatio systems have the potetial to record whe, where ad by whom writte reports have bee read. Ideally cliically urget writte reports should be highlighted as requirig immediate attetio ad actio by the referrer. Referrers should be ecouraged to record that they have received, read ad uderstood the cotet of the report ad acted appropriately i respose to the urget report. These actios have the potetial to improve sigificatly the cliical care of patiets ad efforts to advace electroic commuicatio form a effective method of reducig cliical risk to patiets. 15 Good practice guide for cliical radiologists 13

13 4 Idividual resposibilities I providig care, the radiologist must recogise ad work withi the limits of idividual professioal competece; be competet whe makig diagoses; ad be willig to cosult with others. The duty of care to the patiet requires detailed up-to-date kowledge i specialist ad subspecialist areas. A major aspect of the work of cliical radiologists relates to the optimisatio of cliical imagig strategies for differet cliical coditios. Radiologists eed to esure that their skills are appropriate for the areas of cliical radiology i which they practise ad that they remai up to date i their kowledge of relevat medical coditios. The RCR has published guidace i a umber of areas, of which the followig are examples: Guidace o the use of cross-sectioal imagig i the iitial ivestigatio ad stagig of commo maligacies 41 Guidace o the provisio of itervetioal radiology 19 Guidace o the provisio of ewer techiques such as image-guided ablatio ad radiofrequecy ablatio. 42,43 The skills of the idividual cliical radiologist must be appropriate to the task. A cosequece of icreasig subspecialisatio withi cliical radiology is that all radiologists will have particular skills but that these will ot cover all areas of radiological practice. Recommedatios from the RCR ad other bodies cocerig specialist kowledge ad expertise for the performace of various diagostic ad therapeutic procedures give guidace o cliical areas such as ocological, paediatric ad obstetric imagig. I recogitio of the eed for specific subspecialty traiig, the RCR has established subspecialty curricula i breast imagig, radiouclide radiology, euroradiology ad itervetioal radiology. Itervetioal radiology was recogised as a subspecialty of radiology i Stadards for traiig i itervetioal radiology are set out i the itervetioal radiology traiig curriculum which was available from Traiees startig from 2010 owards will follow the ew curriculum. Traiees who started before 2010 will be able to follow either the special iterest curriculum or the ew curriculum. It is recommeded that those about to start subspecialty traiig i Year 4 should follow the ew curriculum while recogisig that this may affect their date of eligibility for a certificate of completio of traiig (CCT). May cliical radiologists will develop skills i itervetioal procedures. Some of these are withi the core curriculum ad expected of all radiologists. Other competeces are acquired at Levels 1 ad 2 ad oly expected of those who will practise itervetioal radiology. Specific traiig rotatios are provided for the developmet of practical skills withi the curriculum. Adverse reactios Cliical radiologists have a resposibility for the care of the patiet which requires that reasoable precautios are take to esure that possible adverse reactios ca be idetified ad maaged to a appropriately high stadard. For example, all cliical radiologists should be able to recogise ad respod quickly to adverse reactios to itraveous ad other cotrast media. A departmetal protocol based o RCR advice should be displayed promietly withi the departmet. There should be a regular review of the maagemet strategies employed ad regular updatig of staff with the maagemet protocols. 45 Cliical radiologists eed to be aware of drug reactios that are relevat to their practice. The RCR issues advice i respose to reports of drug iteractios ad co-ordiates this iformatio with data from other professioal bodies. Cliical radiologists who perform itervetioal procedures requirig sedatio ad/or aalgesia should maitai a awareess of the pharmacological actios of these agets, of ay drug iteractios ad potetial complicatios ad be prepared to maage the iitial care of such complicatios. Although serious adverse reactios are rare i cliical radiology departmets, oetheless cliical radiologists have a resposibility to maitai their skills i basic life support ad resuscitatio. Out-of-hours work The eed to work withi the limits of professioal competece is particularly relevat to out-of-hours work. 39 Extesio of the ormal workig day to routie eveig ad routie weeked sessio workig ad emergecy o-call situatios eed to be cosidered i this cotext. Cosequet upo progressive subspecialisatio of idividual cliical radiologists, the breadth of skill ad experiece that would be available durig the ormal workig day is ot available out of hours. Cosequetly, the RCR recommeds: 14 Good practice guide for cliical radiologists

14 Emergecy o-call cosultat staff must be readily idetifiable o a rota ad must be readily ad easily cotactable A radiologist should oly carry out those procedures out of hours that they have previous experiece of ad are competet to perform withi ormal workig hours Oly those examiatios which affect immediate patiet maagemet should be performed as emergecy o-call imagig studies Each departmet should agree a portfolio of examiatios that ca be safely ad reliably offered out of hours by the cliical radiologists o the o-call rota Itervetioal radiology procedures performed out of hours require careful plaig with assessmet of the risk beefit i each case. The RCR has published advice o potetial models of service which discuss these issues 19 Supervisio of juior o-call staff must be real ad ot just titular. 37 Professioal relatioships with patiets Successful relatioships betwee doctors ad patiets deped upo trust. The cliical radiologist usually works as part of a team withi a departmet. Several members of the team may iteract with the patiet. I may cases, the first, or the oly, cotact with the patiet may be with a radiographer. Commuicatio with patiets should therefore address a umber of issues. Qualificatios ad expertise A essetial part of commuicatio betwee the departmet of cliical radiology ad the patiet is to esure that patiets kow which procedures are carried out by which staff. Such iformatio should be commuicated idividually to the patiet ad augmeted by writte iformatio either give to the patiet or displayed promietly withi the departmet. Social skills ad the patiet-friedly eviromet The process of welcomig the patiet ad makig them feel at their ease is vital i the doctor patiet relatioship. This depeds ot oly o the persoal maer of the idividual practitioer, but also o the appropriateess of the eviromet for waitig, examiatio ad commuicatio of iformatio. Iformatio provided by cliical radiologists Most examiatios are ot performed by cliical radiologists ad the iformatio of the report is commuicated to the resposible medical practitioer rather tha directly to the patiet. Where a procedure is performed by a radiologist, it is ot ureasoable for the patiet to expect that the provisioal or prelimiary results of the examiatio be give to them at the time of the examiatio. Cliical radiologists should exercise careful judgemet, usig their skills as medical practitioers, to select the best method of commuicatig iformatio to patiets. Factors cotributig to this decisio will be the patiet s prior kowledge of their coditio, the availability of follow-up support ad iformatio as well as the expectatios of the idividual patiet ad referrig cliicia. There should be time withi the programme of a cliical radiologist to esure that iformatio is preseted i a sympathetic ad uderstadable form ad i a eviromet that is sesitive to patiet axieties. The cotet of such discussios held with the patiet should also be reported to the resposible medical practitioer. Cliical radiologists should receive traiig i commuicatio skills, icludig the process ad timig of breakig bad ews. Iformatio about risks ad risk beefit May procedures withi departmets of cliical radiology carry a risk. These iclude radiatio risks as well as specific risks associated with itervetioal procedures. Patiets require ot oly details of the process of the examiatio, ay expected discomfort ad its duratio but also the risks of morbidity ad of mortality. This data must be provided to the patiet i a clear ad uderstadable form. Although most departmets have leaflets about procedures, these are ot a replacemet for verbal commuicatio. Cliical radiologists eed to be prepared to provide this iformatio, ofte usig compariso with examples of risk from everyday life. It is importat that the cliical radiologist ca preset this iformatio i a maer which reflects the balace of risk ad the potetial beefit to the patiet of the ivestigatio or therapeutic procedure as well as the potetial risk of avoidace of the procedure. Iformatio about diagosis ad treatmet optios This is particularly appropriate to itervetioal procedures. Alterative procedures ad/or treatmets should be clearly ad precisely preseted to the patiet ad they should be give the opportuity to discuss them. Good practice guide for cliical radiologists 15

15 Coset Successful relatioships betwee doctors ad patiets deped upo trust. 4 Patiets must be give iformatio, i a way they ca uderstad, to eable them to exercise their right to make iformed decisios about their care. Effective commuicatio is the key to eablig patiets to make iformed decisios. The etity of patiet-iitiated o-iformed coset eeds to be cosidered ad, wherever possible, this outcome should be avoided by careful ad cosiderate discussio with the patiet. This may require the use of third parties such as relatives or frieds of the patiet or other cliical staff to improve the commuicatio of iformatio. The GMC has issued guidace o coset by patiets to examiatios or treatmet which is based o certai critical priciples. The RCR has adapted the advice of the GMC i relatio to imagig procedures. 46 Iformatio about risk ad risk beefit is particularly importat for itervetioal procedures with a high risk of morbidity ad mortality ad for techiques ivolvig high radiatio doses. Cofidetiality ad access to patiet records Patiet cofidetiality forms a cetral part of all aspects of medical care. Patiets eed to be cofidet that the maiteace of cofidetiality is a priority withi a departmet of cliical radiology, but eed to be aware also that certai staff will require access to their records. 31 Itimate examiatios Departmets should have writte protocols for itimate examiatios. The RCR has published guidace to esure that procedures are carried out i the most appropriate settigs, ackowledgig the eed for privacy, digity ad respect for idividual beliefs. This advice stresses the eed for proper iformatio prior to ad durig the examiatio. 47 Professioal relatioships with colleagues Healthcare is icreasigly delivered i multidiscipliary teams ad you are expected to work costructively withi teams ad to respect the skills ad cotributios of colleagues. Cliical radiologists work closely with may other professioals. The ability to work harmoiously withi a departmet is essetial for optimum patiet care. While cliical radiologists may lead the cliical team, a eviromet must be created where opiios are sought ad valued ad the cotributio of all groups to the workig of a departmet is respected. Workig i teams does ot chage your persoal accoutability for your professioal coduct ad the care you provide. You must esure the safety of patiets from risk of harm at all times. You must participate i regular reviews ad audits of the stadards ad performace of the team, takig steps to remedy ay deficiecies. You must support colleagues who have problems with performace, health or coduct. Usig the skills of all healthcare professioals appropriately is a priority for the delivery of healthcare i a timely fashio while maitaiig stadards of care. Role extesio has bee used to improve accessibility of diagostic procedures to patiets ad the RCR supports this where it provides sigificat advatage for the patiet ad recommeds that this is delivered i a structured way to esure that the stadard of care delivered is ot compromised. 7 Delegatio ad referral You may delegate medical care to other medical colleagues or to other healthcare professioals. Although you will ot be accoutable for the decisios ad actios of those to whom you delegate, you will still be resposible for the overall maagemet of the patiet ad accoutable for your decisio to delegate. Referral ivolves trasferrig some or all of the resposibility of patiet care, such as whe requestig a specialist opiio o a imagig examiatio or requestig a procedure that is outside your competece. Durig referral ad delegatio you are expected to commuicate effectively with colleagues, both withi ad exteral to your team. The RCR has produced advice o delegatio to esure the competece of the perso to whom the task is delegated ad has defied the roles ad resposibilities withi this process. The RCR advises that issuig a descriptio of fidigs as a descriptive process ca also be delegated. However, the RCR also advises that issuig a medical iterpretatio ad/or opiio that is, the medical report ca oly be provided by a appropriately traied registered medical practitioer the cliical radiologist. 9,12,48 16 Good practice guide for cliical radiologists

16 Probity You must ot defraud patiets or the service or orgaisatio you work for. The cotract with the trust ad the persoal job pla clearly set out the duties of each cliical radiologist. It is a discipliary offece to fail to meet these obligatios. There are clear guidelies provided by the GMC publicatio Good Medical Practice 4 relatig to fiacial ad commercial dealigs, coflicts of iterest ad hospitality. Cliical radiologists have a duty to be aware of these strictures ad the potetial for compromise of their idepedece as a source of professioal advice. Research You have a absolute duty if egagig i research to coduct research with hoesty ad itegrity. Cliical radiologists who are ivolved i biomedical research ivolvig huma beigs have the same resposibilities as all scietists. This resposibility demads that the coduct of research is subject to certai iviolable priciples: Adherece to the priciples defied i the Helsiki Declaratio ad its subsequet revisios 49 Approval of the research by a appropriate research ethics committee Assurace that recruitmet is based o free will ad that there are o iducemets or pressure brought to bear o participats That proper iformed coset is obtaied Where ecessary, ARSAC approval is obtaied Commuicatio with patiets is maitaied throughout the study to esure that the patiets remai fully iformed Patiet cofidetially is respected Arragemets to remove patiets from the study or to termiate the study if this is i their best iterest. Good practice guide for cliical radiologists 17

17 5 Maitaiig good practice Cliical audit You must work with colleagues to moitor ad maitai your awareess of the quality of the care you provide. I particular you must: Take part i regular ad systematic medical ad cliical audit, recordig data hoestly. Where ecessary, you must respod to the results of audit to improve your practice; for example, by udertakig further traiig Respod costructively to assessmets ad appraisals of your professioal competece ad performace. Audit is the systematic critical aalysis of the quality of medical or cliical care icludig the procedures for diagosis ad treatmet, the use of resources ad the resultig outcomes ad quality of life for the patiet. It is a essetial part of cliical practice, strogly supported by the GMC ad a cotractual obligatio for doctors. Audit is fudametal to the process of cliical goverace. Good data maagemet with appropriate iformatio techology must be i place for cliical audit to be effective. Cliical audit withi departmets Withi a cliical radiology departmet, it is ecessary to audit the structure, process ad outcome of healthcare itervetios. The audit programme This should be a regular activity both as a essetial part of cliical care ad as part of the traiig provided withi a departmet of cliical radiology for all staff members. Local orgaisatio A amed cliical radiologist should be resposible for the implemetatio of audit. The ame of the audit lead should be made kow to the RCR to facilitate atioal audit. Clear lies of commuicatio ad resposibility should exist betwee cliical radiology audit ad orgaisatio-wide audit. All radiologists are required to participate i audit activity. There should be regular meetigs held throughout the year with a programme published i advace. Errors/discrepacies ad complicatios sessios are of specific value withi the overall programme to allow the departmet to address sigificat educatioal issues ad/or cliical problems. 52 Choice of audit topics Audit topics should reflect high-volume ad high-risk procedures but should also reflect the cocers, difficulties ad potetial problems experieced by patiets ad staff withi the departmet ad the wider hospital eviromet. Complaits ad cliical icidet reportig may be useful i determiig particular topics to be addressed. Structure; for example, the suitability, quality ad adequacy of departmetal equipmet ad staffig levels. These factors ifluece outcome ad audit ca be used to support ivestmet i ew resources. Process; for example, waitig time moitorig for examiatios may allow assessmet of the process. Outcome; this is clearly importat i all aspects of medicie. This ca be most difficult to assess i may areas of cliical radiology. Outcome audit is well established i two areas of cliical radiology. Breast screeig The NHS Breast Screeig Programme as part of its quality assurace methodology has specific stadards of cliical audit practice. The priciples of such audit are applicable to other areas of cliical radiological practice icludig symptomatic breast imagig. Itervetioal radiology This is frequetly associated with sigificat risk of morbidity ad mortality. Audit should assess: Appropriateess or idicatios Safety or complicatio rate Miimum efficacy rates. 18 Good practice guide for cliical radiologists

18 Regular review of relatively commo procedures such as vascular itervetio 18 ad percutaeous ephrostomy 24 ca be achieved by systematic data etry ito established itervetioal registries. Review of such data will allow idetificatio of sigificat deviatio from accepted stadards ad allow a pla for remedial actio. Referral patters, equipmet ad other facilities as well as idividual performace may all require cosideratio i such plaig. Audit with other groups Audit should ivolve other departmets ad specialties ad exted outside the hospital, where appropriate. Optimisig care pathways for particular pathologies ad cliical presetatios ca be facilitated by iter-specialty audit. Collaborative audit with GPs should be udertake. Resources required for effective cliical audit Time doctors should be spedig the equivalet of 0.5 supportig programmed activity (SPA) per week o audit activities. This should iclude time spet collectig the data, time completig the audit ad the formal meetig structure. Support clerical staff must be available to help with audit activities such as the collectio ad collatio of iformatio. RCR audit committee the restructurig of the RCR committee has further advaced the role ad importace of audit withi the RCR. Natioal audits iitiated by the committee help to establish bech-markig for idividual departmets ad highlight both good practice ad deficiecies withi cliical radiology. AuditLive ( is a valuable iteractive resource for all departmets ad idividual radiologists to access via the RCR website. Cofidetiality The maiteace of cofidetiality of outcome icidets, complicatios, errors ad omissios is essetial if local audit is to be beeficial ad if atioal comparisos are to be achieved. Cofidetiality is also ecessary if cliical radiologists are to perceive audit ad review as a process by which their practice is iformed ad ehaced, rather tha threateed. Nevertheless, the resposibility to moitor structure, process ad outcome of the work of the departmet clearly rests with all cliical radiologists. Cliical radiologists have a idividual ad joit resposibility to idetify patters of poor care, to establish clear-cut mechaisms for remedial actio ad to ivolve other cliicias, health workers, maagers ad exteral bodies whe ad where appropriate. Cotiuig professioal developmet (CPD) You must keep your kowledge ad skills up to date throughout your workig life. If you have special resposibilities for teachig, you must develop the skills, attitudes ad practices of a competet teacher. CPD is a process of lifelog learig for all doctors. It represets a cotiuum of learig from medical school to retiremet. 51 CPD focuses o the maiteace ad improvemet of specific medical kowledge ad skills. Each of the medical Royal Colleges has developed CPD schemes which are based o the acquisitio of credits grated for udertakig exterally accredited activities such as attedace at exteral courses ad scietific meetigs (Category 1) ad for local ad idividual activities (Category 2). CPD is a itegral part of the revalidatio process for all doctors. The developmet of persoal CPD plas for idividual doctors should take ito accout the eeds of the doctor, the imagig departmet ad the employig trust. Part of this overall plaig process for the imagig departmet should iclude the resources required to udertake CPD for each cliical radiologist. Fudig of CPD Employers, amely the healthcare trust, are resposible for cliical goverace ad should assume resposibility for fudig CPD. Time for CPD As CPD is a requiremet for all idividual cliical radiologists, sufficiet time durig the workig week eeds to be set aside to allow CPD to take place. The RCR positio is that 1.5 SPAs per week are a miimum for CPD withi the cliical radiologist s cosultat job pla. Moitorig CPD The idividual cliical radiologist eeds to record their CPD activity. Durig a five-year cycle this documetatio will iclude retaiig evidece of exteral accreditatio (for example, certificates of course attedace) for Category 1-type activities ad retaiig evidece of learig for Category 2-type activities. This will form part of the revalidatio process for each cliical radiologist. The aual review of job Good practice guide for cliical radiologists 19

19 pla provides a opportuity to discuss the ability to fulfil CPD activities. Professioal developmet plas ca the be developed for future idividual requiremets. Evolutio of CPD The RCR believes that attedace at formal meetigs ad courses is a valuable learig experiece allowig exchage of ideas, views ad kowledge. This type of activity will cotiue to form a importat part of CPD. However, self-directed learig icludig electroically commuicated distace learig ad reflective practice are also playig a icreasigly importat part of cotemporary CPD. The types of activities which are also valuable i CPD iclude: Visitig other hospitals or cetres of excellece withi the UK or abroad Learig or improvig maagemet skills Improvig teachig skills ad iterview techiques Improvig patiet commuicatio skills Improvig skills i research ad writig. It is clear that CPD is a core requiremet of cliical goverace. All doctors should participate i lifelog learig. Idividual failure to participate i CPD will become uacceptable to trusts, the GMC, the medical isurers ad the public. Revalidatio Revalidatio is the process by which licesed doctors will be required to demostrate to the GMC, o a regular basis, that they remai up to date ad fit to practise. Revalidatio will be based o a local evaluatio of doctors performace through appraisal. Doctors will be expected to participate i aual appraisal i the workplace ad will eed to maitai a folder or portfolio of supportig iformatio to brig to their appraisals as a basis for discussio. Iformatio from the appraisal will be provided to their local Resposible Officer (usually the medical director) who will make a recommedatio to the GMC, ormally every five years, o whether to revalidate a doctor. Supportig iformatio requiremets for revalidatio The GMC published their documet Supportig iformatio for appraisal ad revalidatio 52 i April This outlied the six types of supportig iformatio that all doctors will be expected to provide ad discuss at appraisal at least oce i each five-year revalidatio cycle. The categories are: a) Cotiuig professioal developmet b) Quality improvemet activity c) Sigificat evets d) Feedback from colleagues e) Feedback from patiets (where applicable) f) Review of complaits ad complimets. I additio, the followig geeral iformatio will also have to be provided: i. Persoal details ii. iii. iv. Scope of work Record of aual appraisals Persoal developmet plas ad their review v. Probity vi. Health. The RCR is workig with the Academy of Medical Royal Colleges to produce a specialty-specific supportig iformatio framework by populatig each of these categories with the requiremets for cliical radiologists. This is published o the RCR website revalidatio To help radiologists provide the supportig iformatio for revalidatio, the RCR has developed a series of tools ad templates which could be used as a practical meas of collectig ad documetig supportig iformatio. These tools are etirely optioal, but desiged to be helpful ad save time. They ca be dowloaded from the RCR website 20 Good practice guide for cliical radiologists

20 Timescales Followig a test of readiess i 2012, the GMC ited to implemet revalidatio by the ed of 2012, although the details of how it will be rolled out are still uclear. Doctors i difficulty, remediatio ad retraiig I the case of those i whom revalidatio caot be recommeded, there will have to be a process of further assessmet, ad i the case of potetial removal from the medical register it is likely that the full fitess to practise procedure would apply before this occurred. There are existig mechaisms available to deal with coduct that falls short of acceptable practice ad radiologists should ote advice from the GMC that doctors should act without delay if you have good reaso to believe that you or a colleague may be puttig patiets at risk. 4 NHS discipliary procedures are available to deal with problems relatig to: Geeral employmet law ad cotractual obligatios Persoal coduct Professioal coduct Professioal competece. I the case of cocer about a idividual s practice, referral ca also be made to the Natioal Cliical Assessmet Service where evaluatio of idividual persoal ad professioal performace ca be carried out. Various remedial procedures, for example, specific retraiig may be suggested as part of a actio pla. At preset, the arragemet for remediatio for those doctors whose revalidatio is called ito questio is uclear ad the RCR is curretly lookig at how it might assist those who eed specific help ad guidace. The RCR Service Review Committee has ow over te years experiece i the systematic review of cliical departmets of radiology which provides a valuable resource for the RCR, its Fellows ad members. 6 The RCR, through its service review mechaism, ca be requested to look i detail at imagig departmets where problems have bee idetified. The service review is carried out by a team of experieced cliical radiologists at the request of seior trust maagemet. The team ca evaluate all aspects of service delivery icludig departmetal workloads, job plaig, support staff, maagemet ad orgaisatioal arragemets, equipmet, quality of reportig, CPD, skills mix, iformatio techology, commuicatio, o call ad cotiuity of care. The fial report delivered to the trust idetifies ad defies ay areas where practice falls short of expected stadards ad gives advice o how to achieve improvemets. Good practice guide for cliical radiologists 21