Diagnostic Imaging

Requires Standards 1–7 verified first

3 criteria

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [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.

A dose that seems reasonable in isolation can still be meaningfully higher than what similar facilities achieve for the same examination, and without benchmarking against a real external reference, a facility has no way to know whether its own protocols are actually well-optimised or just familiar.

1 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.

2 Benchmarking happens but the comparison reference used is outdated.

Reference levels are periodically updated, and comparison against an outdated benchmark may not reflect current best practice.

3 High-dose findings are noted but protocol review doesn't consistently follow.

Noticing a high-dose pattern without acting on it doesn't provide the real protection benchmarking is meant to offer.

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.

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.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [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.

A ferromagnetic object entering the MRI's magnetic field can cause serious injury or death, and screening completed once at intake, days or hours before the actual scan, can miss a change — a new implant, a piece of information the patient didn't think to mention earlier, an item they're still wearing.

1 Verbal screening happens but is rushed during busy scheduling periods.

A rushed screening risks missing exactly the detail this process exists to catch.

2 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.

3 The questionnaire is reviewed but item removal isn't specifically, separately confirmed.

Reviewing the questionnaire and physically confirming items are removed are two distinct, both necessary checks.

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.

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.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.

REFERENCES

1. [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.

When different departments in the same facility each maintain their own contrast reaction protocol, they can quietly drift apart over time as guidance updates reach one but not the other — a genuine risk this facility has already specifically addressed for cardiology, and shouldn't allow to reappear here as a separate, unsynchronised version.

1 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.

2 The core protocol matches but emergency medication stock differs between departments.

A protocol match without matching resources doesn't provide the same real readiness.

3 Staff in imaging know the protocol exists but haven't been trained on the most recent update.

Training needs to be genuinely synchronised, not just protocol documentation.

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.

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.