Accréditation Sans Frontières · ASF Health Standards 9.0
Standard 11 · Radiology
6 criteria · base standard
Base standard. 6 criteria, of which 3 non-negotiable. Each criterion is numbered 11.Y, with its classification and verification questions.
Criteria
- 11.1 Radiation Dose Optimisation and Justification (NON-NEGOTIABLE)
- 11.2 Equipment Quality Assurance and Calibration (NON-NEGOTIABLE)
- 11.3 Timely, Accurate Reporting With Critical Finding Escalation (NON-NEGOTIABLE)
- 11.4 Contrast Media Safety Protocol (CORE)
- 11.5 MRI Safety Screening and Zone Control (CORE)
- 11.6 Image and Report Retention, Accessible for Comparison (STANDARD)
11.1 Radiation Dose Optimisation and Justification
NON-NEGOTIABLE
Every imaging study involving ionising radiation is clinically justified before ordering, with dose optimised to the lowest level consistent with diagnostic quality, not a default protocol applied regardless of patient size, age, or clinical indication.
VERIFICATION QUESTIONS
- Is clinical justification documented before the study is performed, not assumed from the order alone?
An order placed is not the same as a documented clinical justification for that specific radiation exposure. - Are dose protocols adjusted for patient size and age, particularly for paediatric patients, not a single adult default applied to everyone?
A paediatric patient given an adult-dose protocol receives a meaningfully higher radiation exposure. - Is actual delivered dose tracked and reviewable, not just the protocol setting assumed to reflect what was delivered?
Verified against actual dose records, not only the intended protocol.
11.2 Equipment Quality Assurance and Calibration
NON-NEGOTIABLE
All imaging equipment undergoes documented quality assurance testing and calibration on a defined schedule by qualified personnel, with any equipment failing to meet standards immediately removed from clinical use until corrected.
VERIFICATION QUESTIONS
- Is quality assurance testing performed on schedule, verified against completion records, not just a schedule that exists on paper?
A testing schedule that is routinely missed is not functioning. - Is equipment failing quality standards immediately removed from clinical use, not kept in service while awaiting repair?
Continued use of equipment known to be out of calibration is a specific, direct patient safety risk. - Is testing performed by qualified personnel, verifiable through credentials, not informally by whoever is available?
Quality assurance testing requires specific technical qualification, not general staff availability.
11.3 Timely, Accurate Reporting With Critical Finding Escalation
NON-NEGOTIABLE
Imaging studies are reported within a defined time frame appropriate to clinical urgency, with a documented, functioning critical finding communication protocol ensuring an urgent result reaches the ordering clinician directly, not left in a queue for routine review.
VERIFICATION QUESTIONS
- Is reporting turnaround time tracked and meeting defined targets, not assumed to be adequate?
Verified against turnaround data, not a general sense that reports "go out quickly enough." - Does a critical finding trigger direct, documented communication to the ordering clinician, not just entered into the standard reporting queue?
A critical finding left in a routine queue can go unnoticed for a dangerously long period. - Can the facility show a recorded example of the critical finding protocol being used?
Evidence the protocol functions, not just exists on paper.
11.4 Contrast Media Safety Protocol
CORE
A written protocol governs contrast media use, including pre-screening for allergy and renal function, informed consent, and a documented, immediately accessible emergency response plan for a contrast reaction — not a generic allergy question treated as sufficient screening.
VERIFICATION QUESTIONS
- Does pre-screening cover both allergy history and renal function, not a generic "any allergies?" question alone?
Renal function specifically matters for contrast safety and is easy to overlook without a specific check. - Is emergency response equipment and medication for a contrast reaction immediately accessible at the point of care, not stored elsewhere requiring retrieval time?
A contrast reaction can develop rapidly; retrieval delay for emergency response equipment is a specific, direct risk. - Are staff drilled on the emergency response protocol, not only given it as a reference document?
A drilled response functions differently under stress than one only read about.
11.5 MRI Safety Screening and Zone Control
CORE
Every patient and accompanying individual is screened for MRI contraindications before entering the magnetic field, with physical zone control preventing unscreened access — not a screening form completed but not verified before entry.
VERIFICATION QUESTIONS
- Is screening verified before entry into the magnet room, not just a form completed somewhere earlier in the process?
A completed form that is not checked at the point of entry provides no protection. - Does physical zone control prevent unscreened individuals from entering, not relying solely on a sign or verbal instruction?
A physical barrier or access control, not just a posted warning, is the safeguard. - Are accompanying individuals
not just the patient — also screened? — A family member or support person entering unscreened carries the same risk as an unscreened patient.
11.6 Image and Report Retention, Accessible for Comparison
STANDARD
Imaging studies and reports are retained for the required period and retrievable for comparison with prior studies, not archived in a way that makes practical retrieval difficult or unreliable.
VERIFICATION QUESTIONS
- Are prior studies quickly retrievable for comparison, not a retrieval process that is cumbersome enough to discourage checking?
A comparison that is technically possible but practically avoided due to friction defeats the purpose. - Is the retention period met and verifiable, not assumed from a general archiving practice?
Verified against actual retrieval of an older study, not just a stated retention policy. - Is there a documented backup or redundancy process protecting against data loss?
A single point of failure in image storage is a specific, serious risk. ————————————————————