SErIES IAEA HumAn HEAltH SErIES IAEA Hum

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3.1.2. Quality management system . . . . . . . . . . . . . . . . . . . . . 16 3.1.3. Structure of the diagnostic radiology facility . . . . . . . . . 17 3.1.4. Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3.1.5. Documentation control . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3.1.6. Patient confidentiality, feedback and complaints . . . . . . 21 3.1.7. Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.2. The audit programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.2.1. Mission and vision of the diagnostic radiology facility . . . 22 3.2.2. Quality management system . . . . . . . . . . . . . . . . . . . . . 23 3.2.3. Structure of the diagnostic radiology facility . . . . . . . . . 24 3.2.4. Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.2.5. Documentation control . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3.2.6. Patient confidentiality, feedback and complaints . . . . . 27 3.2.7. Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 4. PATIENT RELATED PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . 27 4.1. Principles and criteria for good practice . . . . . . . . . . . . . . . . . . 27 4.1.1. Referral of the patient for examination . . . . . . . . . . . . . 28 4.1.2. Identification of the patient . . . . . . . . . . . . . . . . . . . . . . 31 4.1.3. Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 4.1.4. The imaging report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 4.1.5. Report communication . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4.1.6. Continuity of clinical care . . . . . . . . . . . . . . . . . . . . . . . 36 4.1.7. Accident and incident reporting . . . . . . . . . . . . . . . . . . . 36 4.1.8. Retention of records and images . . . . . . . . . . . . . . . . . . 37 4.2. The audit programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.2.1. Referral of the patient for examination . . . . . . . . . . . . . 37 4.2.2. Identification of the patient . . . . . . . . . . . . . . . . . . . . . . 39 4.2.3. Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 4.2.4. The imaging report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.2.5. Report communication . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4.2.6. Continuity of clinical care . . . . . . . . . . . . . . . . . . . . . . . 43 4.2.7. Accident and incident reporting . . . . . . . . . . . . . . . . . . . 43 4.2.8. Record and image retention . . . . . . . . . . . . . . . . . . . . . . 44 5. TECHNICAL PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 5.1. Principles and criteria for good practice . . . . . . . . . . . . . . . . . . 44 5.1.1. Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 5.1.2. Radiation protection and safety . . . . . . . . . . . . . . . . . . . 48
5.1.3. Quality assurance processes for imaging equipment . . . 49 5.1.4. Optimization in clinical practice . . . . . . . . . . . . . . . . . . 51 5.1.5. Dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 5.1.6. Instrumentation and calibration . . . . . . . . . . . . . . . . . . . 53 5.2. The audit programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 5.2.1. Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 5.2.2. Radiation protection and safety . . . . . . . . . . . . . . . . . . . 55 5.2.3. Imaging equipment QA processes . . . . . . . . . . . . . . . . . 56 5.2.4. Optimization in clinical practice . . . . . . . . . . . . . . . . . . 58 5.2.5. Dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5.2.6. Instrumentation and calibration . . . . . . . . . . . . . . . . . . 59 6. EDUCATION, TRAINING AND RESEARCH PROGRAMMES . . . 60 6.1. Principles and criteria for good practice . . . . . . . . . . . . . . . . . . 60 6.1.1. Education and training programmes . . . . . . . . . . . . . . . 60 6.1.2. Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 6.2. The audit programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 6.2.1. Education and training programmes . . . . . . . . . . . . . . . 63 6.2.2. Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 APPENDIX I: AUDIT FLOW CHARTS . . . . . . . . . . . . . . . . . . . . . . . . 67 APPENDIX II: SUGGESTED SCHEDULE FOR AN AUDIT VISIT . . 69 APPENDIX III: AUDIT REPORT FORMAT: SUMMARY . . . . . . . . . . . 72 APPENDIX IV: AUDIT REPORT FORMS . . . . . . . . . . . . . . . . . . . . . . . 74 APPENDIX V: NOTES ON PHYSICIST MEASUREMENTS . . . . . . . . 132 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 ANNEX I : APPLICATION FORM . . . . . . . . . . . . . . . . . . . . . . . . . . 139 ANNEX II: ANNEX III: LIST OF ITEMS REQUESTED TO BE AVAILABLE ON-SITE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 EQUIPMENT-SPECIFIC CHECKLIST FORMS FOR SECTIONS 3–5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Page 1 and 2: IAEA HumAn HEAltH SErIES no. 4 Comp
Page 3 and 4: COMPREHENSIVE CLINICAL AUDITS OF DI
Page 5 and 6: IAEA HUMAN HEALTH SERIES No. 4 COMP
Page 7 and 8: FOREWORD The application of radiati
Page 9: CONTENTS 1. INTRODUCTION . . . . .
Page 13 and 14: 1. INTRODUCTION 1.1. CLINICAL AUDIT
Page 15 and 16: 1.1.3. Confidentiality of audits Co
Page 17 and 18: evidence based medical research is
Page 19 and 20: As a result of the comprehensive cl
Page 21 and 22: The facility/institution is respons
Page 23 and 24: 2.4.2. Review The review process wi
Page 25 and 26: 2.5.1. Title page and contents page
Page 27 and 28: 2.6. DISSEMINATION OF THE REPORT Th
Page 29 and 30: A QA committee should be establishe
Page 31 and 32: Lines of authority should be reflec
Page 33 and 34: —Medical support equipment such a
Page 35 and 36: (g) (h) (i) Make an assessment of t
Page 37 and 38: (c) (d) (e) (f) Examine the facilit
Page 39 and 40: (c) (d) Consider policy in regard t
Page 41 and 42: equire a written policy and procedu
Page 43 and 44: Once examination scheduling has bee
Page 45 and 46: Documentation of the details of the
Page 47 and 48: There should be a radiographer resp
Page 49 and 50: —Recorded; —Systematically eval
Page 51 and 52: 4.2.1.5. Pre-procedure screening an
Page 53 and 54: (f) (g) (h) (i) (j) (k) (l) (m) (n)
Page 55 and 56: 4.2.5. Report communication The aud
Page 57 and 58: —Digital image receptors (compute
Page 59 and 60: (b) (c) (d) Ensuring that appropria
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5.1.2.2. Occupational and public ex
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(f) (g) Performance criteria for al
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Dosimetry for those subjected to ra
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5.2.1.3. Management support The aud
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(b) (c) Discuss the facility’s po
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(g) (h) (i) Discuss with the medica
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Professionals engaging in such prog
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6.2. THE AUDIT PROGRAMME 6.2.1. Edu
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(d) (v) Regularity of research meet
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Six months before audit Audited ins
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Day 1: Morning: All audit team memb
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Appendix III AUDIT REPORT FORMAT: S
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Appendix IV AUDIT REPORT FORMS The
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Audit criteria Adequacy Comments Su
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5.3. AUDIT REPORT FORMS FOR TECHNIC
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6.3. AUDIT REPORT FORMS FOR EDUCATI
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Appendix V NOTES ON PHYSICIST MEASU
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V.2.3. Other measurements The other
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[16] COMMISSION OF THE EUROPEAN COM
Page 151 and 152:
Annex I APPLICATION FORM IAEA Clini
Page 153 and 154:
Department Vision Statement and imm
Page 155 and 156:
List of equipment Equipment type Id
Page 157 and 158:
Annex II LIST OF ITEMS REQUESTED TO
Page 159 and 160:
Annex III EQUIPMENT-SPECIFIC CHECKL
Page 161 and 162:
Form RXR — Items to be reviewed b
Page 163 and 164:
Form RXR — Items to be reviewed b
Page 165 and 166:
Form FIF — Items to be reviewed b
Page 167 and 168:
FORM FOR A MAMMOGRAPHY QA PROGRAMME
Page 169 and 170:
Form MAM — Items to be reviewed b
Page 171 and 172:
Form CTQ — Items to be reviewed b
Page 173 and 174:
FORM FOR A SCREEN-FILM AND PROCESSO
Page 175 and 176:
FORM FOR A COMPUTED OR DIGITAL RADI
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FORM FOR A VIEWING CONDITIONS (ANAL
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FORM FOR A QA PROGRAMME FOR HARD CO
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Form DPQ — Items to be reviewed b
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FORM FOR A QA PROGRAMME FOR ULTRASO
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FORM FOR A QA PROGRAMME FOR MRI For
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Form MRI — Items to be reviewed b
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TECHNIQUE OBSERVATION SHEET Radiogr
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Tube focus to tabletop distance d F
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K i Patient: Radiographic Calculati
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Manufacturer of phantom: __________
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P KA Patient: Fluoro 1 DETERMINATIO
Page 199 and 200:
Phantom: MGD 1 CALCULATION OF INCID
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Phantom: CT1 MEASUREMENT OF C a,100
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REFERENCE TO ANNEX IV [IV-1] INTERN
Page 205:
CONTRIBUTORS TO DRAFTING AND REVIEW
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Korea, Republic of KINS Inc., Infor
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SErIES IAEA HumAn HEAltH SErIES IAEA Hum

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