SErIES IAEA HumAn HEAltH SErIES IAEA Hum

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publication can also be used for clinical audits with a limited scope, where only selected aspects of radiological practice are evaluated. The guidelines given here outline the principles and criteria for good practice of the various components of the clinical service, followed by advice for the conduct of the audit programme, and provide corresponding audit checklists for items undergoing evaluation. More exactly, Sections 3.1, 4.1, 5.1 and 6.1 define the principles of good practice, while Sections 3.2, 4.2, 5.2 and 6.2 introduce the corresponding audit programmes, i.e. the practical methods of assessment. Appendices IV and V introduce the corresponding forms for recording of observations. Further information on the basis of setting the criteria for good practice can be found in Refs [9–24]. The guidelines also include guides to audit applications, preparations, site visits and audit reports. It is the ultimate objective of the IAEA that Member States will establish their own appropriate sustainable systems for clinical auditing of diagnostic radiology practices, covering their own local or national needs. The principles, methods and procedures presented in these guidelines can serve as a model for developing such Member State systems. 2. AUDIT STRUCTURE FOR QUAADRIL MISSIONS 2.1. REQUEST FOR AN AUDIT IAEA comprehensive clinical audits in diagnostic radiology are voluntary. The request for an audit normally originates from the diagnostic radiology facility to be audited. In some cases, the administration of the institution or another body may request an audit. In cases where radiological procedures are performed outside of the diagnostic radiology facility, in the cardiology department, for example, the request for the audit should include authorizations from all relevant facilities for participation in the audit. The head of the radiology facility is responsible for coordination of the audit process, in order to ensure optimum cooperation and adherence to time-frames, and to maximize the benefits of the audit. It is expected that the responsible staff at any facility/institution participating in an audit should have read these audit guidelines before the request is made. It is assumed that the requesting facility/institution will have at least the basic infrastructure and quality processes in place to deliver good quality diagnostic imaging or interventional procedures. 6
As a result of the comprehensive clinical audit, the facility/institution may expect: —Assistance in improving clinical practice; —Strengthening of their QA programme; —Assistance towards ensuring that the requirements for patient protection are met; —Assistance in the development of local clinical audit programmes; —Guidance for further development of the facility/institution. The vision and immediate objectives of the facility/institution should be clearly stated in the request. The audit process may assist in the achievement of goals such as: —Becoming a training centre for a region; —Soliciting funding from national authorities or other funding bodies including the IAEA. The request should be prepared in accordance with given application instructions (the application form is given in Annex I). The auditing body, the IAEA, will communicate the result of the audit request to the requesting facility/institution. If the request is approved, a proposed time-line for the audit process will be agreed upon between the facility/institution and the audit body, subject to the availability of the audit team. 2.2. COMPOSITION OF THE AUDIT TEAM The audit team will consist of a multidisciplinary peer review panel with expertise in diagnostic radiology and familiarity with clinical audit methodology. At least one member of the audit team must be able to interview members of the audited department in a language they understand. One member of the audit team will act as the team leader. The composition of the audit team will depend on the nature of the audit visit, but will usually include as a minimum: —A radiologist 2 ; —A diagnostic radiology medical physicist; —A radiographer or diagnostic radiology facility manager. 2 Also referred to as a radiological medical practitioner in the text. 7
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 and 10: CONTENTS 1. INTRODUCTION . . . . .
Page 11 and 12: 5.1.3. Quality assurance processes
Page 13 and 14: 1. INTRODUCTION 1.1. CLINICAL AUDIT
Page 15 and 16: 1.1.3. Confidentiality of audits Co
Page 17: evidence based medical research is
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
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Page 41 and 42: equire a written policy and procedu
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Page 45 and 46: Documentation of the details of the
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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
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Annex I APPLICATION FORM IAEA Clini
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Department Vision Statement and imm
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List of equipment Equipment type Id
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Annex II LIST OF ITEMS REQUESTED TO
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Annex III EQUIPMENT-SPECIFIC CHECKL
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Form RXR — Items to be reviewed b
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Form RXR — Items to be reviewed b
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Form FIF — Items to be reviewed b
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FORM FOR A MAMMOGRAPHY QA PROGRAMME
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Form MAM — Items to be reviewed b
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Form CTQ — Items to be reviewed b
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FORM FOR A SCREEN-FILM AND PROCESSO
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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
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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
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CONTRIBUTORS TO DRAFTING AND REVIEW
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Korea, Republic of KINS Inc., Infor
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