Good practice guide for clinical radiologists Second edition Board of Faculty of Clinical Radiology The Royal College of Radiologists Foreword As doctors and radiologists, we have a primary duty to ensure that we provide safe, patient-centred services which improve the outcomes to the patients and public that we serve. We must always be striving to improve and develop these services driven by healthcare developments and public expectation. This best practice guidance is an essential resource to help you in this process and describes what are your individual responsibilities as well as those of the organisation in which you work. These good practice guidelines are clearly set out with useful links to more detailed documents drawing together all the available and relevant information. From a patient’s perspective, it is important that this is not an aspirational document but one that can be referred to by any radiologist as being relevant to their day-to-day professional role and responsibilities. The Good Practice Guidelines were originally prepared in 1999 by Paul Dubbins, the then Dean of the RCR. The original guidelines were the basis for this update. The RCR acknowledges the work of Paul Dubbins in producing the original document and it is a credit to his work that most of the original document is still applicable. This document replaces BFCR(99)11 Good Practice Guide for Clinical Radiologists which is now withdrawn. The guidelines have been updated by the current members of the Professional Support and Standards Board (PSSB) with contributions from David Kessel. Thanks and acknowledgment go to all those involved. We are sure this document will be welcomed as an authoritative guide for all – for the benefit of both professionals and patients. Dr Peter Cavanagh Dean of the Faculty of Clinical Radiology The Royal College of Radiologists Lay foreword As lay members of the Professional Support and Standards Board (PSSB), we welcome this updated document as a guide for good practice for radiologists whether NHS or private practice-based. We believe it will significantly contribute to the improved clinical care of patients. The guidelines demonstrate the continuing commitment of The Royal College of Radiologists (RCR) towards improving standards in radiology. At a time of change within the practice of radiology – and the medical profession generally – the guidelines help set out a template for achieving high standards within the specialty. They put into context how the responsibilities of an individual radiologist fit into the different tiers of responsibility within the profession. They also offer reassurance to practitioners in a melee of regulations and statutory requirements, clarifying contractual arrangements and management arrangements between trusts and professionals. Clinical Radiology Patients’ Liaison Group The Royal College of Radiologists Good practice guide for clinical radiologists 3 1 Introduction The purpose of this document is to summarise for clinical radiologists existing advice on good practice from The Royal College of Radiologists (RCR) and the principles which underpin good radiological practice. The accountability of doctors and standards of healthcare provision remain in the spotlight of public, media and political concerns. Careerlong maintenance of clinical standards of practice is required for all doctors rather than the reliance of standards determined at the time of entry into practice. Strengthened annual appraisal and revalidation is envisaged to facilitate this for all doctors.1 Patients attending a department of clinical radiology are entitled to expect the highest possible standard of service. Patients have a right to expect that modern healthcare systems will have established frameworks to ensure the quality of healthcare provision. The available resources will affect the standard of care that can be delivered. The medical profession, patient groups, government bodies and the professions allied to medicine are all committed to continuing improvements in the standards of medical care.2,3 Clinical radiologists and the teams in which they work and lead must be appropriately qualified, trained and experienced, and be adequately resourced in terms of staffing and equipment. The RCR supports the principles of the delivery of a high-quality imaging service and continues to produce guidance on the development and maintenance of high standards of clinical care. The RCR produces guidance documents on contemporary issues. These are developed after taking advice from members and Fellows, other professional groups and patient organisations. The recent development of the radiology departmental accreditation scheme which is delivered by the United Kingdom Accreditation Scheme (UKAS) as the Imaging Services Accreditation Scheme (ISAS) is a recent example of the work of the RCR in collaboration with the Society and College of Radiographers (SCoR). Good practice in clinical radiology requires continual assessment of the imaging services that are provided with, as required, revision and renewal of the processes which deliver this service. Using the framework for good medical practice provided by the General Medical Council (GMC),4 national guidance and RCR standards, the document is constructed around the individual radiologist and their role and responsibilities within radiological departments. The document is based around the current United Kingdom healthcare model of NHS hospital trust care provision but is applicable to other healthcare models such as private organisations. The document is divided into four sections: n The national guidance – what is out there to direct us n The hospital and departmental responsibilities – that is, the shared responsibilities of the organisation and service n Individual responsibilities – what you as an individual are responsible for regardless of your place of work n Maintaining good practice – how the GMC guidance relates to you as a radiologist. A note on terminology Throughout this document, the term ‘trust’ is used to encompass any hospital provider of services. 4 Good practice guide for clinical radiologists 2 National guidance Encouraging and maintaining good clinical practice is at the core of the GMC guidance for individual medical practitioners. The new GMC framework for revalidation5 will become the standard for assessment of medical practitioners. The output from the strengthened annual appraisal process will establish criteria required for revalidation of individual doctors. To retain their licence to practise, doctors will need to demonstrate to the GMC that they are up to date and fit to practise. This will involve providing supporting information to show that they are practising in accordance with relevant professional standards. Clinical governance Clinical governance is a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence of clinical care will flourish. Individual practitioners are responsible for developing and maintaining standards of clinical care within their local healthcare organisations through the process of clinical governance. The statutory duty to maintain and enhance the quality of clinical care rests with the chief executive of the healthcare organisation. All organisations are required to establish a framework for the co-ordination and implementation of policies to improve the quality of care. Radiology departments should have their own defined clinical governance framework and processes which fit within the overall organisational structure. Clear lines of responsibility with established leadership via an identified senior clinician, usually the medical director of an NHS trust, or equivalent, leading a multidisciplinary team for clinical governance should be in place. Regulation of health and social care in England is carried out by the Care Quality Commission. Its equivalent in Wales is the Health Inspectorate, in Scotland the Scottish Commission for the Regulation of Care and in Northern Ireland by the Regulation and Quality Improvement Authority. Self-assessment forms part of the assessment process for CQC registration as an initial measure of healthcare quality. It is valuable in reviewing the adequacy of local healthcare provision. Documentation of this self-assessment should lead to critical analysis of local radiological service provision and steps can then be taken to improve on any deficiencies identified. Careful self-assessment of the strengths and weaknesses of the organisation should lead to a programme of continuous improvement. This practice should be applied to all clinical and non-clinical areas. For radiology departments, this should be led by the clinical director and supported by local audit and risk assessments. Poor performance may be identified by internal assessments. Departmental assessment or review (for example, via the ISAS accreditation process or via the RCR Service Review committee)6 can help to identify potential solutions and remedies for the clinical radiology department. Individual clinical consultant radiologist performance should be assessed as part of the five-year GMC revalidation cycle with annual appraisal. Individual clinical performance which is perceived to be poor at a local level may require external clinical assessment which can be achieved via consultation with the National Clinical Assessment Service (NCAS). National Institute for Health Research (NIHR) and the National Institute for Health and Clinical Excellence (NICE) The National Institute for Health Research (NIHR) via the NIHR Health Technology Assessment programme and the National Institute for Health and Clinical Excellence (NICE), promote independent guidance on the best clinical and cost-effective clinical practice and treatments in England and Wales. Appraisal of the best practice within existing treatment options, assessment of new health interventions and advice on how to implement changes in clinical practice form key aspects of their roles. The National Quality Board (NQB) is a multi-stakeholder board established in 2009 to champion quality and ensure alignment in quality throughout the NHS in England. Its role is to provide strategic oversight and leadership in quality across the NHS. The board is chaired by Sir Bruce Keogh, the NHS Medical Director. The board plans the publication of approximately 150 national quality standards over the next five years. These standards will include relevant details of radiological practice relating to each clinical standard; for example, dementia, Good practice guide for clinical radiologists 5 neonatal care and venous thromboembolic disease. As these standards are published, radiology departments will need to undertake self-assessment to establish if their current provision of service is appropriate for the newly defined standard. Scottish Intercollegiate Guidelines Network (SIGN) The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence-based clinical practice guidelines for the NHS in Scotland. SIGN has representatives from all of the UK Royal Colleges and Faculties in Scotland. SIGN guidelines are derived from systematic review of the medical literature. They are designed as a vehicle for accelerating the translation of new knowledge into clinical practice, to reduce variations in practice and to improve patient outcomes. National service frameworks (NSFs) National service frameworks (NSFs) set national healthcare standards and their aim is to deliver high-quality healthcare to all patients irrespective of geographical location. They form part of the central Government’s NHS Choices programme. NSFs set clear quality requirements for clinical care based on the best available evidence and offer guidance and support to help healthcare organisations to achieve these standards. They establish specific performance targets against which progress within a defined timescale can be measured. The General Medical Council The General Medical Council (GMC) has issued guidance for Good Medical Practice which forms the basis for the practice of all doctors.4 Good medical practice sets out the principles and values on which good practice is founded; these principles together describe medical professionalism in action. The basic tenet of the advice and guidance from the GMC is: Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must: – Make the care of your patient your first concern – Protect and promote the health of patients and the public – Provide a good standard of practice and care – Treat patients as individuals and respect their dignity – Work in partnership with patients – Be honest and open and act with integrity. The advice requires doctors to: n Keep their professional knowledge and skills up to date n Recognise and work within the limits of their competence n Maintain trust and confidentiality in their professional relationships with patients n Maintain trust and probity in their professional relationships with colleagues, employing bodies and others n Provide continuity of care n Ensure the safe introduction of skills mix to enhance access to clinical services, while maintaining standards7 n Be personally accountable for their professional practice and to be always prepared to justify individual decisions and actions.8 n The GMC is introducing revalidation as the method for assessing the performance of all doctors on a five-year cyclical basis to ensure fitness to practise. This will be based on a satisfactory annual appraisal process for each year of the five-year cycle and the overall judgement of a responsible officer. The GMC has internal procedures for assessing the clinical and professional performance of doctors when there is reason to believe that this may be seriously deficient. The GMC has powers to require a doctor to undergo further training, to restrict their practice, or to suspend them from practice if deficiencies are not remedied. Disciplinary and disability procedures All healthcare providers such as trusts are required to have their own clearly defined policies for dealing with personal and professional misconduct. Processes for dealing with concerns stemming from physical or mental disability and addressing the prevention of harm to patients as a result of the physical or mental disability of a doctor should be in place within the trust. Foundation trusts have their own policies and procedures for these issues and their service and financial governance arrangements are currently inspected and assessed by Monitor. 6 Good practice guide for clinical radiologists 3 Hospital and departmental responsibilities 3.1 Setting standards Departments of clinical radiology have a responsibility to ensure that their practice achieves the highest possible standards. These standards include clinical care, quality of images and image interpretation, results of interventions measured by outcome data as well as issues such as waiting times, facilities, patient experience and speed of issue of the report.9 Most of these standards will be influenced by the workforce and equipment resources available. The introduction and achievement of accreditation of imaging services should lead to a consistent high standard of departmental practice across the United Kingdom. ISAS, which is administered by UKAS, the sole national accreditation organisation approved by the UK Government, provides the opportunity for departmental accreditation and was developed by collaboration between the RCR and the SCoR. Data for clear standards for many of the investigations and therapeutic interventions performed within radiology departments is incomplete. The RCR continues to contribute to the development of standards as information becomes available from research and audit data. The RCR has recently undertaken internal restructuring and initiated the Professional Standards and Support Board (PSSB) in recognition of the importance of this subject and the changing medical environment within the United Kingdom. Service standards Each department should ensure that there are systems in place to: n n n n n n n n Justify clinically each imaging examination based on national and local guidelines10 Ensure that the most appropriate available imaging modality is used11 Ensure that all studies are formally reported by an accredited radiologist or appropriately delegated, except where an explicit policy for non-reported examinations exists9,12 Ensure that trainees work under supervision and to a level appropriate to their level of training and expertise Ensure appropriate response times: radiological examinations can only contribute to effective patient management if they are performed in a timely fashion. Target response times for differing imaging procedures and different levels of clinical urgency are required. The ability of departments to achieve target response times depends upon the availability of adequate resources of equipment and personnel Achieve effective and timely communication of the report9,13 Evaluate adverse incidents Ensure appropriate application of health and safety guidance (COSHH). Technical standards The performance of investigations within radiology departments is dependent on the use of high-quality equipment which is appropriate to the task. It is essential, if quality is to be maintained, that issues relating to equipment performance are kept under continuous review. Particular attention should be given to: n n n n n n n n Maintenance of equipment Calibration of equipment Adequacy of an equipment replacement programme Application of the ‘as low as reasonably practical’ (ALARP) principle Adequate dosimetry for all equipment with radiation potential, with audit of radiation dose to staff and patients Monitoring the number of exposures recorded for individual examinations Observance of the advice issued by the National Radiological Protection Board (NRPB) which is now part of the Health Protection Agency and the Euratom Directive14 Rejection analysis of images. The majority of UK imaging is now based on digital imaging and this has resulted in a significant reduction in the number of images rejected for technical reasons in recent years. Careful review of radiographic exposure factors, maintenance and calibration of all equipment involved in digital image production is required to maintain this important factor in radiation protection. Standards of performance If uniformly high standards of practice are to be maintained, these must be informed by guidelines: n Written guidelines should be available for all procedures undertaken Good practice guide for clinical radiologists 7 n n n n The indications for the procedure should be explicit The methodology for the procedure must be outlined The nature of any recordings or observations must be recorded The preferred method of communication of the report should be stated. Communication of the report is a key performance element of any radiological examination. The traditional paper report is now increasingly supplemented or replaced by electronic transmission. Electronic report delivery is best achieved with a direct automated link to the relevant digital images and an electronic system of standardised report acknowledgement from the clinical team who requested the examination. The use of paper reports is likely to continue for a number of years as electronic systems are introduced to facilitate report acknowledgement. Audit of paper report systems should be undertaken to establish that National Patient Safety Agency (NPSA) guidelines are being fulfilled.9,13,15 Diagnostic accuracy There are still few nationally agreed figures for diagnostic accuracy for any imaging investigation. Accuracy rates which appear in the literature are often achieved only under optimum conditions of staffing and equipment. Nonetheless, the clinical radiologist should strive to achieve standards of accuracy similar to those published in the literature. Nationally agreed minimum standards are available for only a limited number of areas of clinical practice. Examples include national screening programmes for breast cancer and abdominal aortic ultrasound screening. The national breast screening programme (NHSBSP) was established in 1988, with the defined aim of reducing the mortality due to breast cancer by 25%. The establishment of the screening programme, staffing levels and the processes of audit have been based on the need to achieve specific performance standards. Recent changes in the breast screening programme include the extension of the age range of women eligible for breast screening to those aged 47 to 73 in 2010. This will be completed in 2012. The NHS Abdominal Aortic Aneurysm Screening Programme has recently published its expected minimum standards for diagnostic accuracy.16 The details of how this ultrasound-based screening programme will be implemented were established after a review of the national breast screening programme and reflect an adaptation of this model of screening practice. Interventional radiology Interventional radiology procedures have transformed treatments across many areas of medicine. Despite the minimally invasive nature of these techniques, they are not without risk. Interventional radiologists are bound to demonstrate that their performance meets minimum standards. Every clinical radiologist has a responsibility to contribute to the development of the evidence base, to be aware of existing standards and to examine their own performance regularly and in particular if standards fall below the minimum expected. In accordance with the principles of clinical governance, all radiologists who undertake interventional procedures should continually review their practice to ensure that it meets accepted criteria – where they exist within the established literature. It is particularly important to consider all complications and problems looking for preventable and systematic causes from which lessons which can be learned. Every doctor should maintain a permanent record of practice which should be available for periodic internal and external review. The record should include the volume of work and outcomes of procedures. This record of performance should regularly be audited against target standards.8,17,18 The RCR provides guidance on quality assurance in interventional techniques which is directly relevant to practice within the UK.19 These guidelines do not cover every intervention. More comprehensive Standards of Practice have been developed in Europe and the USA. These are published by the Cardiovascular and Interventional Radiology Society Europe (CIRSE)20 and the Society of Interventional Radiology (SIR).21 These standards have been researched extensively and are based on available evidence. However, differences in practice and certification mean that these may require modification for practice within the UK.22 Monitoring interventional radiological performance An effective means of monitoring performance is through submission of data to national registries and databases. These are co-ordinated through several societies such as the British Society of Interventional Radiology (BSIR) and the Vascular Society of Great Britain and Ireland (VSGBI). These registries provide a continually evolving picture of outcomes from interventional procedures.22,23 Data from these registries reflect contemporary standards of practice in the UK and is essential for benchmarking. This is the basis for the development of national standards which inform the RCR guidelines. 8 Good practice guide for clinical radiologists Arrangements for supporting consultants in data capture should be included within the individual consultant job plan. Individuals can extract their data from registries and use this to demonstrate that their performance meets accepted standards. This is particularly helpful in support for those interventional radiologists who may work in relative isolation and who therefore may have limited scope for objective review of practice. Threshold standards for procedure-related complications Examples of recommended upper limits for complications arising from diagnostic and interventional vascular procedures can be seen in Appendix 1. These are based on evidence from registries and from published literature. The RCR will continue to commission the development of standards for vascular and interventional techniques taking advice from special interest groups ensuring that the standards are applicable to practice within the UK. These standards will include: n n n Appropriateness and/or indications Safety or complication rate Minimum efficacy rates. The standards within clinical radiology will continue to evolve to reflect changes in practice and the available evidence base.24 These will take into account changing indications for investigations and interventions and the introduction of new techniques.25 Responsibility for radiation protection/safety Legal responsibility for radiation protection Legal responsibility for radiation protection lies with the employer. The extent to which this responsibility is delegated to individual radiologists varies and in particular depends upon the degree to which they are involved in the management of the radiology department. Nonetheless, all clinical radiologists carry a responsibility for the protection from unnecessary radiation of: n n n n Patients Themselves Other members of staff Members of the public, including relatives and carers. Legislation Good practice involves more than compliance with legislation; nevertheless radiologists must be familiar with the implications to their practice of the regulations relating to ionising radiation. This is particularly important to those holding Administration of Radioactive Substances Committee (ARSAC) licences for the administration of radio-pharmaceuticals. Guidance on standards of clinical practice within nuclear medicine departments have also been published by the British Nuclear Medicine Society (BNMS) and the European Association of Nuclear Medicine (EANM).26,27 Responsibility before the exposure The overriding principle is to maintain radiation doses ‘as low as reasonably practicable’ (the ALARP principle). Each radiologist should be confident that procedures are in place to ensure that examinations using ionising radiation are only carried out when there is adequate clinical justification as required by the Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER).10 The Royal College of Radiologists’ Referral Guidelines: Making the best use of radiology, 7th edition11 should be used as a guide to justification in radiology. Vetting of request forms, locally agreed guidelines and protocols for delegation will form part of the processes required here. If exposures are being made which appear to contravene accepted guidelines, the radiologist must take steps to rectify the situation.10,14 Radiologists must understand the principles underlying the protection of the fetus.28,29 Where a clinical radiologist is responsible for radionuclide imaging, they should provide appropriate advice to the carers and relatives of patients undergoing scintigraphy. Nursing mothers who receive radioactive isotopes should be advised of the limitations that these impose on breastfeeding. Responsibility during the exposure A radiologist should wear and return their personal dose monitors in accordance with local practice, and encourage others to do the same. The clinical radiologist performing the examination will be responsible for ensuring that the study is carried out in such a way that the dose to the patient is kept to the minimum necessary to achieve the desired clinical result. In addition, individuals will be expected to adopt Good practice guide for clinical radiologists 9 practices which ensure that their own exposure and that of others in the room is minimised. This responsibility is delegated to the radiographic staff performing examinations which do not involve the clinical radiologist directly. Responsibility after the exposure There will be occasions when a radiologist becomes aware that protocols/guidelines have been breached after the event. In this case, they would be expected to take steps to ensure that the appropriate procedures are adhered to in the future. There are also occasions where a female patient is inadvertently exposed to radiation during early pregnancy. In this situation where there has been no significant exposure of the fetus, the clinical radiologist should offer prompt reassurance and appropriate advice. However, when there is doubt, there should be a clearly defined process for involvement of the radiation protection adviser, an estimation of the dose involved, an accurate assessment of risk and the appropriate advice offered. Responsibility for safety of non-ionising radiation Clinical radiologists should maintain up-to-date knowledge of the risks associated with imaging modalities involving non-ionising radiation; for example, ultrasound30 and magnetic resonance imaging. Although these procedures are currently identified as low- or no-risk procedures, it remains prudent to apply the ALARP principle to all diagnostic exposures. Responsibility for installation of up-to-date equipment Advances in equipment development within clinical radiology continue. They occur in response to clinical need, research and development by manufacturers, and changing management patterns primarily in order to: Provide more accurate and clinically useful diagnostic information prior to medical or surgical intervention Increase the speed of transmission of information within and between hospitals and the wider community n Replace invasive investigative procedures with non-invasive tests n Substitute non-ionising imaging procedures for those using ionising radiation n Further develop image-guided techniques to replace and enhance existing medical and surgical treatments. All departments should develop: n Clearly defined quality assurance systems with established delegated responsibility and clear lines of communication n Robust programmes for timely equipment replacement and development n Plans for commissioning and upgrading of information technology systems, picture archiving and teleradiology.31,32 n n Equipment replacement programmes need to reflect the fact that electronic equipment has a finite lifetime. The expected useful lifetime depends upon: n n n n n n Age and intensity of use Availability of spare parts Image quality Equipment maintenance Equipment upgrades Radiation dose. The replacement ages for imaging equipment have been defined by the RCR with the above factors in mind: Ultrasound 5 years Accident and emergency X-ray equipment 7 years Radionuclide equipment 7 years Interventional procedural equipment 7 years Mobile X-ray equipment 10 years Computed tomographic equipment 7 years MRI equipment 7 years Standard X-ray equipment 10 years 10 Good practice guide for clinical radiologists Picture archiving and communication systems (PACS) and teleradiology systems require particular attention within the radiology equipment replacement programme due to their cost, size, importance and frequent rapid advances within their field. The RCR has actively supported the expansion of the provision of PET-CT equipment within the UK.33 This service is currently mainly procured as a national contract with a private contractor. There will be a requirement for additional capital and revenue funding if this important imaging modality is to be more fully integrated into practice within NHS trust and foundation trust radiology departments.34 The availability of finite capital resources for radiology equipment replacement programmes as part of overall organisation budgeting may necessitate consideration of other methods of equipment financing and procurement such as leasing. Public responsibility There are limited resources available for healthcare. It is, therefore, important that clinical radiologists exercise care and responsibility in managing the resources available to them effectively and economically. Nonetheless, if factors within the working environment threaten the safety of patients, the security of diagnosis or the radiation safety of co-workers, clinical radiologists have a duty and responsibility to take appropriate action. This might mean withdrawal of a particular service or condemning a particular aging piece of equipment. Organisation, leadership, management and administration If you lead the team, you must take responsibility for ensuring that the team provides care which is safe, effective and efficient. General principles A clinical radiology department should provide an imaging and interventional service of high quality within a defined budget. Where appropriate there should be training facilities to the standards required by the RCR.35 Effective and efficient administration is facilitated by good leadership. This should be provided by a designated service leader who should be a clinical radiologist and who will be responsible for managing the activities of the department. Clinical radiology departments vary in size and service provision but frequently are large departments in terms of staff numbers, physical size and budget. No single person can achieve all of the leadership functions and be involved personally in every group within the department. The service leader should have a robust set of groupings or committees dealing with the different areas, functions or activities of the department. The service leader will have clearly defined line management responsibility to the trust board. They should be appointed for a defined and agreed period sufficient to allow for the proper development and continuity of management processes. To manage effectively, they should have the support of other clinical radiologists within the department, other professional groups and the medical school when appropriate. Responsibilities of the service leader Business planning Areas of key management and leadership activity include: n n n n Development of the department’s business plan and in-service planning Input into the trust’s contracting process and service planning, including the prioritisation of demands and workload agreements The development and maintenance of adopted policies, guidelines and protocols including the risk management strategy The training of radiologists and other staff groups within the department. The establishment of service level agreements linked to cost and volume contracts of activity is recommended to facilitate the management of workload in an orderly, efficient and clinically responsible manner. Preplanning of work volume should enable departments to manage the flow of patients and to respond to changes in clinical practice. The practice of medicine is inseparable from risk.4 Clinical radiologists are responsible for balancing the risk of any investigation or interventional procedure against the risk of leaving the condition undiagnosed or untreated. Risk management requires the recognition that risk exists, identification of factors which increase risk and implementation of policies which reduce such these factors, such as the World Health Organization (WHO) Surgical checklist adapted for radiological practice.36 The reduction of risk to patients and staff to the lowest level achievable within existing resources should be the focus of managerial activity. Training of all staff groups within clinical radiology departments requires an appropriate structure and resource to promote safe and effective delivery of this essential part of any radiological service. Good practice guide for clinical radiologists 11 Budgets The operational control of the finances of a department of clinical radiology will be the joint responsibility of the business manager and the service leader. It is the responsibility of the service leader to prepare and present a well-argued and evidence-based case for adequate resources, and to keep within agreed budgets. Staff management The service leader must ensure that there is an equitable distribution of work within the department with efficient rostering to meet the required activities.37 This includes the proper management of annual, study and professional leave. All consultants are required to have a job plan specifying their contractual obligations. These should be reviewed and agreed annually, providing an opportunity for consultants to assess their own programmes and workloads and to plan their personal professional development. Appraisal based upon the job plan is a valuable method of assessing the performance and effectiveness of individual radiologists. Satisfactory annual appraisal will be required for GMC revalidation requirements over a five-year cycle for clinical radiologists. The service leader has a responsibility for other staff within the department, through the support of the radiology business manager and other senior radiographic, nursing and other allied professional managers. Regular and effective staff appraisal/evaluation forms an important part of staff management and underpins the professional development of all members of the department, serving to enhance service delivery to patients. PACS and teleradiology The continued development and expansion of electronic data transmission and storage requires robust planning for existing PACS and future upgrading. The principle of sharing imaging data across networks for safe and effective patient management requires service leaders to review and update routinely their own internal and externally networked teleradiology arrangements. The RCR has published guidance on this important subject which provides further detail.32 Managerial responsibilities The contribution of clinical radiology to the work of the trust requires recognition as a core clinical service. The department must be represented at senior level in trust management structures and at a similar level to other clinical specialties. The importance and hence influence of the service leader for radiology within the trust management structure should not be undervalued. Critical decisions relating to the organisation and delivery of clinical radiology services should reflect the service leader’s knowledge of service provision, training and maintenance of standards. Plans for clinical service reconfiguration within or between trusts may be directed towards improving the quality of and/or reducing the cost of the clinical service provision. Clinical radiologists must be involved from the outset in any such discussions with representation by the service leader. Support Service leaders need protected time and appropriate support to perform their managerial tasks adequately. A separate contract for this part of their work should be drawn up and an agreed job description formulated. Service leaders should be supported by, and work closely with, business and radiography managers. Ready access to financial, personnel and management expertise, secretarial and information technology support are all required to facilitate effective clinical management of a radiology department. Requests for an investigation A request to a clinical radiology department for an imaging investigation represents a request for an opinion from a clinical radiologist. These requests are usually but not exclusively received from other medical practitioners within the hospital, in the community or in general practice. Direct access to a wide range of imaging and advice on optimum imaging strategies is essential to the proper practice of all clinicians including general practitioners.38 The clinical radiologist is responsible for the medical care of the patient while in the department of clinical radiology. They are responsible for the appropriate imaging investigation, the conduct of the examination, the management of complications and the provision of the report.4,8 12 Good practice guide for clinical radiologists Requests for clinical radiological examinations will usually be made on a standard radiology request form. This enables effective and efficient communication of the relevant clinical information. It is the responsibility of the referring clinician to complete the form properly, but it is the responsibility of the clinical radiologist (and through delegation, the radiographer) to ensure that the clinical information received is adequate and appropriate for the performance of a particular investigation. The form also affords the collection of data such as the number of films, contrast details where appropriate, exposure and dose. Electronic referral and reporting of imaging examinations are increasingly supplanting the paper request form. The same principles for the justification of investigations clearly apply in this circumstance. Electronic order communications systems facilitate accurate patient demographic details and structured questioning of the clinical details relevant to a particular imaging investigation from the referrer.39 Departmental protocols should be in place to deal with requests from healthcare practitioners who are not medically qualified.40 Communication of information and the radiologist’s report In providing care, radiologists must keep clear, accurate and contemporaneous patient records which report relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed. Radiologists and all clinicians must keep colleagues well informed when sharing the care of patients. An accurate healthcare record will enable the patient to receive effective continuing care, enables the healthcare team to communicate successfully, and allow another doctor or professional member of the team to assume care of the patient at any time. It enables the patient to be identified without risk or error, facilitates the collection of data for research, education and audit and can be used in legal proceedings. The written radiology report constitutes the legal record of the imaging investigation. It is, therefore, vital that the information contained within the record is accurate, explicit, understandable and informative. It should be unambiguous with a level of confidence either clearly implied or explicitly stated. Where uncertainty exists, this should be made clear within the text of the report. The report should include clear patient identification, the name of the clinical radiologist and the secretarial support where appropriate and record advice or information given to the patient at the end of the examination. It should include documentary evidence of drugs/contrast used during the procedure and advice on post-procedural care. (Note: Many departments will record details of drug administration separately in the patient’s clinical case notes. Similarly, certain procedures which are the subject of departmental written protocols requiring the routine use of drugs for the procedure such as a muscle relaxant for barium enema examinations would not require separate documentation within the report.) Information with respect to patient dose exposure and the number of films will usually be recorded separately, most commonly on the request form. Robust methods of prompt and accurate transcription and secure transmission of the written report whether by post, courier or electronic methods is vital. The written radiology report is essential for the communication of information between the clinical radiologist and other groups involved in the care of the patient. It represents the centrepiece of communication and is a legally important document. Rapid means of communication should be used as an adjunct to the written report in situations of clinical urgency. These should include brief entries in the patient’s medical notes, direct or telephone conversations with other medical staff or, where appropriate senior nursing staff. Occasionally it will be necessary to communicate important information directly to a general practice surgery via a senior administrative/clerical assistant. While it is not the responsibility of the clinical radiologist to ensure the competence of staff within other departments/practices, it is their responsibility to ensure that the information has been received precisely, unambiguously and if communicated to non-medical staff, is fully understood. NPSA recommendations and specific guidance on significant unexpected radiological findings provide valuable information and/or guidance on individual, departmental and trust responsibilities in this area.9,13 Electronic order communication systems have the potential to record when, where and by whom written reports have been read. Ideally clinically urgent written reports should be highlighted as requiring immediate attention and action by the referrer. Referrers should be encouraged to record that they have received, read and understood the content of the report and acted appropriately in response to the urgent report. These actions have the potential to improve significantly the clinical care of patients and efforts to advance electronic communication form an effective method of reducing clinical risk to patients.15 Good practice guide for clinical radiologists 13 4 Individual responsibilities In providing care, the radiologist must recognise and work within the limits of individual professional competence; be competent when making diagnoses; and be willing to consult with others. The duty of care to the patient requires detailed up-to-date knowledge in specialist and subspecialist areas. A major aspect of the work of clinical radiologists relates to the optimisation of clinical imaging strategies for different clinical conditions. Radiologists need to ensure that their skills are appropriate for the areas of clinical radiology in which they practise and that they remain up to date in their knowledge of relevant medical conditions. The RCR has published guidance in a number of areas, of which the following are examples: n n n Guidance on the use of cross-sectional imaging in the initial investigation and staging of common malignancies41 Guidance on the provision of interventional radiology19 Guidance on the provision of newer techniques such as image-guided ablation and radiofrequency ablation.42,43 The skills of the individual clinical radiologist must be appropriate to the task. A consequence of increasing subspecialisation within clinical radiology is that all radiologists will have particular skills but that these will not cover all areas of radiological practice. Recommendations from the RCR and other bodies concerning specialist knowledge and expertise for the performance of various diagnostic and therapeutic procedures give guidance on clinical areas such as oncological, paediatric and obstetric imaging. In recognition of the need for specific subspecialty training, the RCR has established subspecialty curricula in breast imaging, radionuclide radiology, neuroradiology and interventional radiology. Interventional radiology was recognised as a subspecialty of radiology in 2010. Standards for training in interventional radiology are set out in the interventional radiology training curriculum which was available from 2010.44 Trainees starting from 2010 onwards will follow the new curriculum. Trainees who started before 2010 will be able to follow either the special interest curriculum or the new curriculum. It is recommended that those about to start subspecialty training in Year 4 should follow the new curriculum while recognising that this may affect their date of eligibility for a certificate of completion of training (CCT). Many clinical radiologists will develop skills in interventional procedures. Some of these are within the core curriculum and expected of all radiologists. Other competences are acquired at Levels 1 and 2 and only expected of those who will practise interventional radiology. Specific training rotations are provided for the development of practical skills within the curriculum. Adverse reactions Clinical radiologists have a responsibility for the care of the patient which requires that reasonable precautions are taken to ensure that possible adverse reactions can be identified and managed to an appropriately high standard. For example, all clinical radiologists should be able to recognise and respond quickly to adverse reactions to intravenous and other contrast media. A departmental protocol based on RCR advice should be displayed prominently within the department. There should be a regular review of the management strategies employed and regular updating of staff with the management protocols.45 Clinical radiologists need to be aware of drug reactions that are relevant to their practice. The RCR issues advice in response to reports of drug interactions and co-ordinates this information with data from other professional bodies. Clinical radiologists who perform interventional procedures requiring sedation and/or analgesia should maintain an awareness of the pharmacological actions of these agents, of any drug interactions and potential complications and be prepared to manage the initial care of such complications. Although serious adverse reactions are rare in clinical radiology departments, nonetheless clinical radiologists have a responsibility to maintain their skills in basic life support and resuscitation. Out-of-hours work The need to work within the limits of professional competence is particularly relevant to out-of-hours work.39 Extension of the normal working day to routine evening and routine weekend session working and emergency on-call situations need to be considered in this context. Consequent upon progressive subspecialisation of individual clinical radiologists, the breadth of skill and experience that would be available during the normal working day is not available out of hours. Consequently, the RCR recommends: 14 Good practice guide for clinical radiologists n n n n n n Emergency on-call consultant staff must be readily identifiable on a rota and must be readily and easily contactable A radiologist should only carry out those procedures out of hours that they have previous experience of and are competent to perform within normal working hours Only those examinations which affect immediate patient management should be performed as emergency on-call imaging studies Each department should agree a portfolio of examinations that can be safely and reliably offered out of hours by the clinical radiologists on the on-call rota Interventional radiology procedures performed out of hours require careful planning with assessment of the risk–benefit in each case. The RCR has published advice on potential models of service which discuss these issues19 Supervision of junior on-call staff must be real and not just titular.37 Professional relationships with patients Successful relationships between doctors and patients depend upon trust. The clinical radiologist usually works as part of a team within a department. Several members of the team may interact with the patient. In many cases, the first, or the only, contact with the patient may be with a radiographer. Communication with patients should therefore address a number of issues. Qualifications and expertise An essential part of communication between the department of clinical radiology and the patient is to ensure that patients know which procedures are carried out by which staff. Such information should be communicated individually to the patient and augmented by written information – either given to the patient or displayed prominently within the department. Social skills and the patient-friendly environment The process of welcoming the patient and making them feel at their ease is vital in the doctor–patient relationship. This depends not only on the personal manner of the individual practitioner, but also on the appropriateness of the environment for waiting, examination and communication of information. Information provided by clinical radiologists Most examinations are not performed by clinical radiologists and the information of the report is communicated to the responsible medical practitioner rather than directly to the patient. Where a procedure is performed by a radiologist, it is not unreasonable for the patient to expect that the provisional or preliminary results of the examination be given to them at the time of the examination. Clinical radiologists should exercise careful judgement, using their skills as medical practitioners, to select the best method of communicating information to patients. Factors contributing to this decision will be the patient’s prior knowledge of their condition, the availability of follow-up support and information as well as the expectations of the individual patient and referring clinician. There should be time within the programme of a clinical radiologist to ensure that information is presented in a sympathetic and understandable form and in an environment that is sensitive to patient anxieties. The content of such discussions held with the patient should also be reported to the responsible medical practitioner. Clinical radiologists should receive training in communication skills, including the process and timing of ‘breaking bad news’. Information about risks and risk–benefit Many procedures within departments of clinical radiology carry a risk. These include radiation risks as well as specific risks associated with interventional procedures. Patients require not only details of the process of the examination, any expected discomfort and its duration but also the risks of morbidity and of mortality. This data must be provided to the patient in a clear and understandable form. Although most departments have leaflets about procedures, these are not a replacement for verbal communication. Clinical radiologists need to be prepared to provide this information, often using comparison with examples of risk from everyday life. It is important that the clinical radiologist can present this information in a manner which reflects the balance of risk and the potential benefit to the patient of the investigation or therapeutic procedure as well as the potential risk of avoidance of the procedure. Information about diagnosis and treatment options This is particularly appropriate to interventional procedures. Alternative procedures and/or treatments should be clearly and precisely presented to the patient and they should be given the opportunity to discuss them. Good practice guide for clinical radiologists 15 Consent Successful relationships between doctors and patients depend upon trust.4 Patients must be given information, in a way they can understand, to enable them to exercise their right to make informed decisions about their care. Effective communication is the key to enabling patients to make informed decisions. The entity of ‘patient-initiated non-informed consent’ needs to be considered and, wherever possible, this outcome should be avoided by careful and considerate discussion with the patient. This may require the use of third parties such as relatives or friends of the patient or other clinical staff to improve the communication of information. The GMC has issued guidance on consent by patients to examinations or treatment which is based on certain critical principles. The RCR has adapted the advice of the GMC in relation to imaging procedures.46 Information about risk and risk–benefit is particularly important for interventional procedures with a high risk of morbidity and mortality and for techniques involving high radiation doses. Confidentiality and access to patient records Patient confidentiality forms a central part of all aspects of medical care. Patients need to be confident that the maintenance of confidentiality is a priority within a department of clinical radiology, but need to be aware also that certain staff will require access to their records.31 Intimate examinations Departments should have written protocols for intimate examinations. The RCR has published guidance to ensure that procedures are carried out in the most appropriate settings, acknowledging the need for privacy, dignity and respect for individual beliefs. This advice stresses the need for proper information prior to and during the examination.47 Professional relationships with colleagues Healthcare is increasingly delivered in multidisciplinary teams and you are expected to work constructively within teams and to respect the skills and contributions of colleagues. Clinical radiologists work closely with many other professionals. The ability to work harmoniously within a department is essential for optimum patient care. While clinical radiologists may lead the clinical team, an environment must be created where opinions are sought and valued and the contribution of all groups to the working of a department is respected. Working in teams does not change your personal accountability for your professional conduct and the care you provide. You must ensure the safety of patients from risk of harm at all times. You must participate in regular reviews and audits of the standards and performance of the team, taking steps to remedy any deficiencies. You must support colleagues who have problems with performance, health or conduct. Using the skills of all healthcare professionals appropriately is a priority for the delivery of healthcare in a timely fashion while maintaining standards of care. Role extension has been used to improve accessibility of diagnostic procedures to patients and the RCR supports this where it provides significant advantage for the patient and recommends that this is delivered in a structured way to ensure that the standard of care delivered is not compromised.7 Delegation and referral You may delegate medical care to other medical colleagues or to other healthcare professionals. Although you will not be accountable for the decisions and actions of those to whom you delegate, you will still be responsible for the overall management of the patient and accountable for your decision to delegate. Referral involves transferring some or all of the responsibility of patient care, such as when requesting a specialist opinion on an imaging examination or requesting a procedure that is outside your competence. During referral and delegation you are expected to communicate effectively with colleagues, both within and external to your team. The RCR has produced advice on delegation to ensure the competence of the person to whom the task is delegated and has defined the roles and responsibilities within this process. The RCR advises that issuing a description of findings as a descriptive process can also be delegated. However, the RCR also advises that issuing a medical interpretation and/or opinion – that is, the medical report – can only be provided by an appropriately trained registered medical practitioner – the clinical radiologist.9,12,48 16 Good practice guide for clinical radiologists Probity You must not defraud patients or the service or organisation you work for. The contract with the trust and the personal job plan clearly set out the duties of each clinical radiologist. It is a disciplinary offence to fail to meet these obligations. There are clear guidelines provided by the GMC publication Good Medical Practice4 relating to financial and commercial dealings, conflicts of interest and hospitality. Clinical radiologists have a duty to be aware of these strictures and the potential for compromise of their independence as a source of professional advice. Research You have an absolute duty if engaging in research to conduct research with honesty and integrity. Clinical radiologists who are involved in biomedical research involving human beings have the same responsibilities as all scientists. This responsibility demands that the conduct of research is subject to certain inviolable principles: n n n n n n n n Adherence to the principles defined in the Helsinki Declaration and its subsequent revisions49 Approval of the research by an appropriate research ethics committee Assurance that recruitment is based on free will and that there are no inducements or pressure brought to bear on participants That proper informed consent is obtained Where necessary, ARSAC approval is obtained Communication with patients is maintained throughout the study to ensure that the patients remain fully informed Patient confidentially is respected Arrangements to remove patients from the study or to terminate the study if this is in their best interest. Good practice guide for clinical radiologists 17 5 Maintaining good practice Clinical audit You must work with colleagues to monitor and maintain your awareness of the quality of the care you provide. In particular you must: n n Take part in regular and systematic medical and clinical audit, recording data honestly. Where necessary, you must respond to the results of audit to improve your practice; for example, by undertaking further training Respond constructively to assessments and appraisals of your professional competence and performance. Audit is the systematic critical analysis of the quality of medical or clinical care including the procedures for diagnosis and treatment, the use of resources and the resulting outcomes and quality of life for the patient. It is an essential part of clinical practice, strongly supported by the GMC and a contractual obligation for doctors. Audit is fundamental to the process of clinical governance. Good data management with appropriate information technology must be in place for clinical audit to be effective. Clinical audit within departments Within a clinical radiology department, it is necessary to audit the structure, process and outcome of healthcare interventions. The audit programme This should be a regular activity both as an essential part of clinical care and as part of the training provided within a department of clinical radiology for all staff members. Local organisation n n n n n n A named clinical radiologist should be responsible for the implementation of audit. The name of the audit lead should be made known to the RCR to facilitate national audit. Clear lines of communication and responsibility should exist between clinical radiology audit and organisation-wide audit. All radiologists are required to participate in audit activity. There should be regular meetings held throughout the year with a programme published in advance. Errors/discrepancies and complications sessions are of specific value within the overall programme to allow the department to address significant educational issues and/or clinical problems.52 Choice of audit topics Audit topics should reflect high-volume and high-risk procedures but should also reflect the concerns, difficulties and potential problems experienced by patients and staff within the department and the wider hospital environment. Complaints and clinical incident reporting may be useful in determining particular topics to be addressed. n n n Structure; for example, the suitability, quality and adequacy of departmental equipment and staffing levels. These factors influence outcome and audit can be used to support investment in new resources. Process; for example, waiting time monitoring for examinations may allow assessment of the process. Outcome; this is clearly important in all aspects of medicine. This can be most difficult to assess in many areas of clinical radiology. Outcome audit is well established in two areas of clinical radiology. Breast screening The NHS Breast Screening Programme as part of its quality assurance methodology has specific standards of clinical audit practice. The principles of such audit are applicable to other areas of clinical radiological practice including symptomatic breast imaging. Interventional radiology This is frequently associated with significant risk of morbidity and mortality. Audit should assess: n n n 18 Appropriateness or indications Safety or complication rate Minimum efficacy rates. Good practice guide for clinical radiologists Regular review of relatively common procedures such as vascular intervention18 and percutaneous nephrostomy24 can be achieved by systematic data entry into established interventional registries. Review of such data will allow identification of significant deviation from accepted standards and allow a plan for remedial action. Referral patterns, equipment and other facilities as well as individual performance may all require consideration in such planning. Audit with other groups Audit should involve other departments and specialties and extend outside the hospital, where appropriate. Optimising care pathways for particular pathologies and clinical presentations can be facilitated by inter-specialty audit. Collaborative audit with GPs should be undertaken. Resources required for effective clinical audit n n n Time – doctors should be spending the equivalent of 0.5 supporting programmed activity (SPA) per week on audit activities. This should include time spent collecting the data, time completing the audit and the formal meeting structure. Support – clerical staff must be available to help with audit activities such as the collection and collation of information. RCR audit committee – the restructuring of the RCR committee has further advanced the role and importance of audit within the RCR. National audits initiated by the committee help to establish bench-marking for individual departments and highlight both good practice and deficiencies within clinical radiology. AuditLive (www.rcr.ac.uk/crauditlive) is a valuable interactive resource for all departments and individual radiologists to access via the RCR website. Confidentiality The maintenance of confidentiality of outcome incidents, complications, errors and omissions is essential if local audit is to be beneficial and if national comparisons are to be achieved. Confidentiality is also necessary if clinical radiologists are to perceive audit and review as a process by which their practice is informed and enhanced, rather than threatened. Nevertheless, the responsibility to monitor structure, process and outcome of the work of the department clearly rests with all clinical radiologists. Clinical radiologists have an individual and joint responsibility to identify patterns of poor care, to establish clear-cut mechanisms for remedial action and to involve other clinicians, health workers, managers and external bodies when and where appropriate. Continuing professional development (CPD) You must keep your knowledge and skills up to date throughout your working life. If you have special responsibilities for teaching, you must develop the skills, attitudes and practices of a competent teacher. CPD is a process of lifelong learning for all doctors. It represents a continuum of learning from medical school to retirement.51 CPD focuses on the maintenance and improvement of specific medical knowledge and skills. Each of the medical Royal Colleges has developed CPD schemes which are based on the acquisition of credits granted for undertaking externally accredited activities such as attendance at external courses and scientific meetings (Category 1) and for local and individual activities (Category 2). CPD is an integral part of the revalidation process for all doctors. The development of personal CPD plans for individual doctors should take into account the needs of the doctor, the imaging department and the employing trust. Part of this overall planning process for the imaging department should include the resources required to undertake CPD for each clinical radiologist. Funding of CPD Employers, namely the healthcare trust, are responsible for clinical governance and should assume responsibility for funding CPD. Time for CPD As CPD is a requirement for all individual clinical radiologists, sufficient time during the working week needs to be set aside to allow CPD to take place. The RCR position is that 1.5 SPAs per week are a minimum for CPD within the clinical radiologist’s consultant job plan. Monitoring CPD The individual clinical radiologist needs to record their CPD activity. During a five-year cycle this documentation will include retaining evidence of external accreditation (for example, certificates of course attendance) for Category 1-type activities and retaining evidence of learning for Category 2-type activities. This will form part of the revalidation process for each clinical radiologist. The annual review of job Good practice guide for clinical radiologists 19 plan provides an opportunity to discuss the ability to fulfil CPD activities. Professional development plans can then be developed for future individual requirements. Evolution of CPD The RCR believes that attendance at formal meetings and courses is a valuable learning experience allowing exchange of ideas, views and knowledge. This type of activity will continue to form an important part of CPD. However, self-directed learning including electronically communicated distance learning and reflective practice are also playing an increasingly important part of contemporary CPD. The types of activities which are also valuable in CPD include: n n n n n Visiting other hospitals or centres of excellence within the UK or abroad Learning or improving management skills Improving teaching skills and interview techniques Improving patient communication skills Improving skills in research and writing. It is clear that CPD is a core requirement of clinical governance. All doctors should participate in lifelong learning. Individual failure to participate in CPD will become unacceptable to trusts, the GMC, the medical insurers and the public. Revalidation Revalidation is the process by which licensed doctors will be required to demonstrate to the GMC, on a regular basis, that they remain up to date and fit to practise. Revalidation will be based on a local evaluation of doctors’ performance through appraisal. Doctors will be expected to participate in annual appraisal in the workplace and will need to maintain a folder or portfolio of supporting information to bring to their appraisals as a basis for discussion. Information from the appraisal will be provided to their local Responsible Officer (usually the medical director) who will make a recommendation to the GMC, normally every five years, on whether to revalidate a doctor. Supporting information requirements for revalidation The GMC published their document Supporting information for appraisal and revalidation52 in April 2011. This outlined the six types of supporting information that all doctors will be expected to provide and discuss at appraisal at least once in each five-year revalidation cycle. The categories are: a) b) c) d) e) f) Continuing professional development Quality improvement activity Significant events Feedback from colleagues Feedback from patients (where applicable) Review of complaints and compliments. In addition, the following general information will also have to be provided: i. ii. iii. iv. v. vi. Personal details Scope of work Record of annual appraisals Personal development plans and their review Probity Health. The RCR is working with the Academy of Medical Royal Colleges to produce a specialty-specific supporting information framework by populating each of these categories with the requirements for clinical radiologists. This is published on the RCR website – www.rcr.ac.uk/ revalidation To help radiologists provide the supporting information for revalidation, the RCR has developed a series of tools and templates which could be used as a practical means of collecting and documenting supporting information. These tools are entirely optional, but designed to be helpful and save time. They can be downloaded from the RCR website www.rcr.ac.uk/CRtools 20 Good practice guide for clinical radiologists Timescales Following a test of readiness in 2012, the GMC intend to implement revalidation by the end of 2012, although the details of how it will be rolled out are still unclear. Doctors in difficulty, remediation and retraining In the case of those in whom revalidation cannot be recommended, there will have to be a process of further assessment, and in the case of potential removal from the medical register it is likely that the full fitness to practise procedure would apply before this occurred. There are existing mechanisms available to deal with conduct that falls short of acceptable practice and radiologists should note advice from the GMC that doctors should ‘act without delay if you have good reason to believe that you or a colleague may be putting patients at risk’.4 NHS disciplinary procedures are available to deal with problems relating to: n n n n General employment law and contractual obligations Personal conduct Professional conduct Professional competence. In the case of concern about an individual’s practice, referral can also be made to the National Clinical Assessment Service where evaluation of individual personal and professional performance can be carried out. Various remedial procedures, for example, specific retraining may be suggested as part of an action plan. At present, the arrangement for remediation for those doctors whose revalidation is called into question is unclear and the RCR is currently looking at how it might assist those who need specific help and guidance. The RCR Service Review Committee has now over ten years’ experience in the systematic review of clinical departments of radiology which provides a valuable resource for the RCR, its Fellows and members.6 The RCR, through its service review mechanism, can be requested to look in detail at imaging departments where problems have been identified. The service review is carried out by a team of experienced clinical radiologists at the request of senior trust management. The team can evaluate all aspects of service delivery including departmental workloads, job planning, support staff, management and organisational arrangements, equipment, quality of reporting, CPD, skills mix, information technology, communication, on call and continuity of care. The final report delivered to the trust identifies and defines any areas where practice falls short of expected standards and gives advice on how to achieve improvements. Good practice guide for clinical radiologists 21 6 Conclusion Clinical radiologists, like all doctors, practise in a contemporary environment that makes great demands upon their knowledge, ability to respond to change, social skills, ability to work in teams and their stamina. This good practice guide outlines what should be expected of a clinical radiologist and the framework that should be provided within departments of clinical radiology to support their activities. Within a modern healthcare environment, sustaining continued lifelong education and appropriate changes in clinical practice to continue to provide safe and effective clinical outcomes requires proactive, rather than reactive, clinical management. To achieve adequate resourcing for departments of clinical radiology within a period of current financial stringency for the NHS requires the participation of all clinical radiologists to assist in the effective management of their departments and in support for their clinical leaders. Approved by the Board of the Faculty of Clinical Radiology: 25 February 2011 22 Good practice guide for clinical radiologists References 1. Department of Health. The White Paper Trust, assurance and safety: The regulation of health professionals. London: DH, 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH_065946 (last accessed 6/7/2011) 2. Department of Health. High quality care for all: NHS Next Stage Review final report. London: The Stationery Office, 2008. http://www.dh.gov.uk/en?Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH_085825 (last accessed 6/7/2011) 3. Department of Health. 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Standards for providing a 24-hour Interventional Radiology Service. London: The Royal College of Radiologists, 2008. 20. http://www.cirse.org/index.php?pid=412 (last accessed 6/7/2011) 21. http://www.sirweb.org/clinical/all.shtml (last accessed 6/7/2011) Good practice guide for clinical radiologists 23 22. The Royal College of Radiologists and the British Society of Interventional Radiology. Standards in vascular radiology, 2nd edition. London: RCR, 2011. 23. http://www.bsir.org/ (last accessed 6/7/2011) 24. Chalmers N, Jones K, Drinkwater K et al. The UK nephrostomy audit. Can a voluntary registry produce robust performance data? Clin Radiol 2008; 63: 888–894. 25. The Royal College of Radiologists. Standards for the Introduction of New Procedures and New Devices. London: The Royal College of Radiologists, 2009. 26. British Nuclear Medicine Society. Clinical procedure guidelines. http://www.bnms.org.uk/guidelines.htm (last accessed 6/7/2011) 27. 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London: The Royal College of Radiologists, 2009. 24 Good practice guide for clinical radiologists 46. The Royal College of Radiologists. Standards for Patient Consent Particular to Radiology. London: The Royal College of Radiologists, 2005. 47. The Royal College of Radiologists. Intimate Examinations. London: The Royal College of Radiologists, 1998. 48. The Royal College of Radiologists. Standards and recommendations for the reporting and interpretation of imaging investigations by non-radiologist medically qualified practitioners and teleradiologists. London: The Royal College of Radiologists, 2011. 49. WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2008, 18th World Medical Association General Assembly. http://www.wma.net/en/20activities/10ethics/10helsinki/index.html (last accessed 6/7/2011) 50. The Royal College of Radiologists. Standards for Radiology Discrepancy Meetings. London: The Royal College of Radiologists, 2007. 51. The Royal College of Radiologists. Continuing Professional Development (CPD) Scheme, 2nd Edition. London: The Royal College of Radiologists, 2010. 52. http://www.gmc-uk.org/Supporting_information__2_.pdf_39974163.pdf Acknowledgements Dr H M Dobson Dr P A S Spencer Dr C R Thind Dr R Fitzgerald Professor F J Gilbert Professor C L Kay Dr R A Manns Dr D L Richardson Dr E J Adam (Chair of the Revalidation Committee) Dr M P Callaway Dr R J Warwick Good practice guide for clinical radiologists 25 Appendix 1. Recommended upper limits for complications arising from diagnostic and interventional vascular procedures Procedure Recommended upper limit of complications Diagnostic vascular procedures – angiography Puncture site: Haematoma (requiring transfusion, surgery or delayed discharge) 3.0% Occlusion 0.5% Pseudoaneurysm 0.5% Arteriovenous fistula 0.1% Non-puncture site: Distal embolisation causing tissue damage 0.5% Unintended occlusion of selected vessel 2.0% Interventional vascular procedures Percutaneous transluminal angioplasty ± stenting Puncture site: Haematoma (requiring transfusion, surgery or delayed discharge) 4.0% Occlusion 0.5% Non-puncture site: Distal embolisation causing tissue damage 0.5% Unintended occlusion of selected vessel 3.0% Vessel rupture/perforation requiring surgery 0.5% Emergency surgery 3.0% 26 Good practice guide for clinical radiologists The Royal College of Radiologists 38 Portland Place London W1B 1JQ Tel +44 (0)20 7636 4432 | Fax +44 (0)20 7323 3100 | Email [email protected] | URL www.rcr.ac.uk | A Charity registered with the Charity Commission No. 211540 Citation details: The Royal College of Radiologists. 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