ASF Standards · Ambulatory Clinic · Standard 16

Standard 16 — Diagnostic Imaging

3 criteria · 2 non-negotiable · 1 core · Version 3.0

Criteria in this standard

16.1 — CT Radiation Dose Is Tracked and Benchmarked, Not Just Delivered
16.2 — MRI Safety Screening Happens Before Every Scan, Not Assumed From Intake
16.3 — Contrast Media Protocols Match the Same Standard Used Elsewhere in This Facility

16.1

CT Radiation Dose Is Tracked and Benchmarked, Not Just Delivered

Non-Negotiable

CT radiation dose is tracked per examination and periodically benchmarked against recognised national or international diagnostic reference levels, with protocols reviewed and adjusted when dose consistently runs high — not delivered and filed with no comparison to any external standard.

In plain terms: CT radiation dose is recorded for every scan and regularly compared with national reference levels; protocols giving more dose than necessary are adjusted.

Facility category	Crisis	Transition	Small	Standard
Applicability	N/A	Full	Full	Full

Why this matters

A CT abdomen delivers the equivalent of two years of background radiation. Dose varies four-fold between facilities for the same scan, mostly through protocol settings that nobody has reviewed since installation. Children are especially sensitive, and a single unnecessary high-dose CT measurably increases lifetime cancer risk. Diagnostic reference levels — published nationally or internationally — give a benchmark; a facility whose median dose exceeds the DRL for a given examination is delivering more radiation than most of its peers. Tracking, benchmarking, and adjusting is how a facility knows it is not among the worst.

What good looks like

Dose is tracked consistently for every CT examination.
Facility data is periodically compared against a recognised external benchmark.
A real example exists of benchmarking leading to protocol review and adjustment.

Common failure modes

Dose tracking is occasional or incomplete.
No external benchmark comparison happens, only internal review if any.
Benchmarking data, if collected, has never led to a protocol change.

Worked example

In practice

An imaging centre with one 64-slice CT scanner performing 4,000 scans a year.

BeforeDose was recorded by the scanner but never extracted or reviewed. Protocols were the manufacturer's defaults from installation six years earlier. No paediatric protocols existed; children were scanned with adult settings. Nobody knew whether the centre's doses were high or low.

ActionA dose management process was set up: monthly extraction of CTDIvol and DLP for the ten most common examinations, median compared to national DRLs; protocols exceeding DRLs were reviewed with the manufacturer's applications specialist and adjusted (iterative reconstruction, automatic exposure control, reduced kV for small patients); paediatric protocols were created by weight band. Results are reviewed quarterly by the radiologist and radiographer lead.

AfterThe Monitor reviewed three quarterly dose reports showing median doses below DRLs for all ten examinations after adjustment, and the new paediatric protocol set. Verified.

If you are starting from zero — do this first

Extract last month's CTDIvol and DLP for your ten most common scans.
Find your national DRLs (or use EU/ACR references).
Compare. Any scan above the DRL needs protocol review.
Create paediatric protocols by weight if you have none.

The most common mistake: Scanning children on adult protocols — a child receives several times the necessary dose.

Self-assessment questions

1. Is radiation dose tracked for every CT examination, not only sampled occasionally? — Consistent tracking for every examination, not periodic spot-checking alone.
Evidence: Dose tracking record

2. Is facility dose data periodically compared against a recognised external benchmark, not only reviewed internally? — A real external reference point, not only comparison against the facility's own historical data.
Evidence: Benchmarking comparison record

3. When dose consistently runs high against the benchmark, is the protocol actually reviewed and adjusted? — Genuine review leading to action, not benchmarking data collected without consequence.
Evidence: Protocol review and adjustment record

Common reasons for a PARTIAL answer

Dose is tracked for common examination types but not less frequent ones. — Every examination type carries the same real benchmarking value, not only high-volume ones.
Benchmarking happens but the comparison reference used is outdated. — Reference levels are periodically updated, and comparison against an outdated benchmark may not reflect current best practice.
High-dose findings are noted but protocol review doesn't consistently follow.

Implementation plan

When	What
Week 1	Review current dose tracking coverage across all CT examination types.
Week 2	Establish or verify periodic comparison against a recognised, current external benchmark.
Week 3	Establish a defined process for protocol review when dose consistently runs high.
Ongoing	Repeat benchmarking comparison periodically and track resulting protocol changes.

How the Monitor verifies this

Method	What	Detail
DOCUMENT	Dose tracking review	Reviews dose tracking records for consistency across CT examinations.
DOCUMENT	Benchmarking record review	Reviews evidence of periodic comparison against a recognised external dose benchmark.
ASK	Protocol adjustment interview	Asks staff for a real example where benchmarking led to a protocol review or adjustment.

Supervisor tips

Ask for actual benchmarking comparison data, not a general assurance that dose is monitored. — Specific, dated comparison records are the only real evidence of genuine benchmarking.
Ask for a real example where a protocol was changed because of a benchmarking finding. — A real example reveals whether benchmarking leads to genuine action, not just data collection.

Evidence base

[76] Established radiology practice guidance for performing and interpreting diagnostic computed tomography requires facility dose data to be compared against recognised benchmarks, with protocol review when dose consistently exceeds expected levels.

Train your team: AMB-16 · Diagnostic Imaging on GMJ Academy →

This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.

16.2

MRI Safety Screening Happens Before Every Scan, Not Assumed From Intake

Non-Negotiable

Every patient undergoes a genuine, verbal MRI safety screening immediately before entering the scan room, reviewing a completed written questionnaire in full — not relying on an intake form completed earlier and never actively reviewed at the point of the actual scan.

In plain terms: Every patient is verbally checked for metal, implants, and devices immediately before entering the MRI room, by going through their completed form question by question — not relying on a form filled in at reception.

Facility category	Crisis	Transition	Small	Standard
Applicability	N/A	Full	Full	Full

Why this matters

An MRI magnet is always on. A ferromagnetic aneurysm clip twists and tears the vessel. A cochlear implant is destroyed. An unrecognised pacemaker stops. A steel oxygen cylinder brought into the room becomes a projectile that has killed patients. The written screening form is necessary but not sufficient: patients forget, misunderstand, or tick 'no' by default. The verbal check — the radiographer going through the form with the patient at the door of the scan room, asking each question again — catches what the form missed. It takes two minutes and is the last chance.

What good looks like

Every patient undergoes genuine verbal screening immediately before entering the scan room.
The full questionnaire is reviewed in its entirety at that point.
Patients are specifically asked to remove relevant items immediately before the scan.

Common failure modes

Screening relies on an intake form completed earlier, without review at the point of scanning.
Verbal review is abbreviated rather than covering the full questionnaire.
Item removal is assumed rather than specifically checked.

Worked example

In practice

An imaging centre with a 1.5T MRI scanner.

BeforePatients completed a screening form at reception. The radiographer glanced at it and proceeded. A patient with a programmable shunt valve, who had ticked 'no implants' because she did not think of it as an implant, was scanned; the valve setting was altered. A cleaner had once brought a steel bucket into the room.

ActionA two-stage screening process was implemented: the written form at reception; then, at the scan room door, the radiographer reads every question aloud, asks the patient to confirm, and probes for anything implanted, ever, anywhere. A ferromagnetic detector was installed at the door. Zone signage and access control were established per ACR guidance. All non-radiography staff who enter Zone III were trained. A checklist is signed by the radiographer before every scan.

AfterThe Monitor observed three patients screened verbally at the door and the checklist signed. Reviewed zone signage and the detector. Interviewed a cleaner who described the access rules. Verified.

If you are starting from zero — do this first

Watch a patient enter the scan room. Does the radiographer verbally re-screen at the door?
Make the verbal re-screen mandatory with a signed checklist.
Install zone signage and, if possible, a ferromagnetic detector.
Train every staff member who might enter the room.

The most common mistake: Trusting the reception form — patients do not know that a shunt valve, a stent, or a tattoo can matter.

Self-assessment questions

1. Does every patient undergo a genuine verbal screening review immediately before entering the scan room, not only earlier intake screening? — A real, verbal review at the actual point of entry, not reliance on an earlier form alone.
Evidence: Pre-scan verbal screening record

2. Is the full written questionnaire reviewed in its entirety, not just a quick verbal confirmation? — Complete review of every question, not an abbreviated check.
Evidence: N/A — tested directly

3. Are patients specifically asked to remove jewellery, metallic clothing items, and similar objects immediately before the scan? — A specific, direct check, not an assumption the patient already did this.
Evidence: N/A — tested directly

Common reasons for a PARTIAL answer

Verbal screening happens but is rushed during busy scheduling periods. — A rushed screening risks missing exactly the detail this process exists to catch.
Screening is thorough for new patients but abbreviated for returning ones. — A returning patient's circumstances — a new implant, a recent procedure — can genuinely have changed since their last scan.
The questionnaire is reviewed but item removal isn't specifically, separately confirmed.

Implementation plan

When	What
Week 1	Observe current pre-scan screening practice for genuine, complete verbal review.
Week 2	Reinforce full questionnaire review immediately before scan room entry for every patient.
Week 3	Establish a specific, separate item-removal confirmation step.
Ongoing	Observe screening practice periodically, particularly during busy periods.

How the Monitor verifies this

Method	What	Detail
OBSERVE	Pre-scan screening observation	Observes an actual pre-scan screening for genuine, complete verbal review immediately before entry.
DOCUMENT	Questionnaire completeness review	Reviews completed questionnaires for full coverage, not abbreviated screening.
ASK	Technologist practice interview	Asks a technologist to describe their specific pre-scan screening routine.

Supervisor tips

Observe an actual pre-scan screening if timing allows. — Direct observation reveals whether this is a genuine, complete review or an abbreviated formality.
Ask about screening for a returning patient specifically. — This is where screening rigor most commonly, and riskily, relaxes in practice.

Evidence base

[77] Established MRI safety guidance requires a written safety screening questionnaire reviewed orally with the patient in its entirety immediately prior to entry into the MRI scan area.

Train your team: AMB-16 · Diagnostic Imaging on GMJ Academy →

This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.

16.3

Contrast Media Protocols Match the Same Standard Used Elsewhere in This Facility

Core

Where imaging uses contrast media, the reaction recognition and management protocol is identical to the one used elsewhere in this facility for the same purpose — not a separate, independently developed protocol that may have quietly diverged from current guidance.

In plain terms: If the imaging department gives contrast, its reaction protocol is the same as the one used everywhere else in the facility — one protocol, not several.

Facility category	Crisis	Transition	Small	Standard
Applicability	N/A	Full	Full	Full

Why this matters

When a facility has a cath lab, an imaging department, and an oncology unit, each may have written its own contrast reaction protocol — with different drug doses, different escalation steps, different kit contents. A nurse who floats between departments faces three algorithms for one emergency. A facility-wide protocol, identical in every location, means that anyone trained anywhere can respond correctly everywhere. This criterion is about consistency: one document, one kit list, one training programme.

What good looks like

The imaging protocol is genuinely identical to the version used elsewhere in the facility.
Protocol updates happen synchronously across departments.
Staff training content is consistent across departments.

Common failure modes

Imaging maintains its own separate protocol, independently developed.
Imaging's protocol has visibly lagged behind updates made elsewhere.
Staff in different departments describe meaningfully different protocols.

Worked example

In practice

A multi-specialty ambulatory centre with imaging, cardiology, and oncology all using contrast.

BeforeThree departments had three protocols, written at different times by different people. Adrenaline doses differed. One department's kit included items the others' did not. Nursing staff rotated between departments and were unsure which protocol applied.

ActionA facility-wide contrast reaction protocol was written by a working group from all three departments, based on current national guidance. One kit list. One laminated algorithm. One training module with an annual competency check. The three departmental protocols were withdrawn. The document is controlled with a review date and owner.

AfterThe Monitor found the identical protocol and kit in all three departments, reviewed the single training record, and asked a rotating nurse which protocol applied; she pointed to the one. Verified.

If you are starting from zero — do this first

Collect every contrast reaction protocol in the facility. Count them.
Compare the adrenaline doses. If they differ, that is the finding.
Write one protocol with a working group from all departments.
Withdraw the others and train everyone to the one.

The most common mistake: Each department writing its own version of a facility-wide emergency — the emergency does not know which department it is in.

Self-assessment questions

1. Is the contrast reaction protocol used in imaging identical to the one used elsewhere in this facility, not independently maintained? — A genuinely shared, single protocol, not two versions that happen to be similar.
Evidence: Cross-department protocol comparison

2. When the shared protocol is updated, does imaging's version update at the same time, not lag behind? — Synchronised updates, not a separate update cycle for each department.
Evidence: Protocol update record and timing

3. Are staff in imaging trained on the same protocol version as staff elsewhere in the facility? — Consistent training content, not department-specific variations.
Evidence: Training record comparison

Common reasons for a PARTIAL answer

Protocols were identical when first established but have since quietly diverged. — Without an active synchronisation process, separately maintained copies of the same protocol drift apart over time.
The core protocol matches but emergency medication stock differs between departments. — A protocol match without matching resources doesn't provide the same real readiness.
Staff in imaging know the protocol exists but haven't been trained on the most recent update.

Implementation plan

When	What
Week 1	Directly compare imaging's contrast protocol against the version used elsewhere in the facility.
Week 2	Resolve any divergence found, establishing one genuinely shared protocol.
Week 3	Establish a synchronised update process across departments.
Ongoing	Periodically reconfirm protocol consistency across departments.

How the Monitor verifies this

Method	What	Detail
DOCUMENT	Cross-department protocol comparison	Compares the imaging department's contrast protocol directly against the version used elsewhere in the facility.
DOCUMENT	Update synchronisation review	Reviews update records to confirm imaging's protocol updates in sync with the shared version.
ASK	Staff training consistency interview	Asks imaging staff to describe the protocol and compares against what other departments describe.

Supervisor tips

Ask for the actual protocol documents from both departments and compare them directly. — Direct comparison is the only real evidence of genuine consistency, not assumed alignment.
Ask staff in each department the same specific question and compare answers. — Consistent answers reveal genuine shared training; differing answers reveal quiet divergence.

Evidence base

[78] Consistency of contrast media reaction protocols across all departments within a single facility, rather than independently maintained departmental versions, is established practice for preventing protocol drift as clinical guidance evolves.

Train your team: AMB-16 · Diagnostic Imaging on GMJ Academy →

This course teaches practical implementation of this standard. Free to enroll. ASF certificate on completion.

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