SErIES IAEA HumAn HEAltH SErIES IAEA Hum

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Six months before audit Audited institution Request for audit submitted including completed application form Audit team No action Audit body Agreement Five months before audit Audited institution No action Audit team Agreement Audit body Form audit team and designate leader Four months before audit Audited institution Set audit date; Inform other departments of schedule Audit team Set audit date Audit body Set audit date; Initiate travel and accommodation arrangements for team; Initiate equipment calibration Three months before audit Audited institution Respond with requested information sent to audit team Audit team Send request for information to institution Audit body Introduce audit team to institution Send copy of application form to team Two months before audit Audited institution Respond with requested information sent to audit team members Audit team Members request additional information from institution if needed Audit body Confirm travel and accommodation arrangements for team Two weeks before audit Audited institution Confirm address details for sending of test equipment Audit team Members request additional information from institution if needed Audit body Confirm address details and send test equipment Audit visit Audit team + institution Draft report completed and reviewed with institution Two weeks after audit Audited institution Audit team Responds to audit body Audit body Reviews report and communicates with audit team and institution if necessary Six weeks after audit Audited institution Audit team Notified of report authorization Audit body Authorized report sent to institution After receiving the audit report Audit team Prepare response plan Audit body Monitor response FIG. 2. Time-line of clinical audit process. 68
Appendix II SUGGESTED SCHEDULE FOR AN AUDIT VISIT II.1. SUGGESTED SCHEDULE A suggested schedule for an audit visit is given below (see also Fig. 3). Day 1 Entrance briefing: Introductions Orientation presentations Commence review: Tour of facilities Interviews Days 2-3 Radiologist: Review of policy and procedures Review of procedures Audit of practice and images Physicist: Review of policy and procedures Review of QC and acceptance testing protocols Practical measurements Radiographer: Review of policy and procedures Review of radiographic procedures Review of radiographic QC Day 4 Meet with staff to complete information collection (including measurements if required) and clarify any issues: Audit team complete drafting of audit report as a group Day 5 Exit briefing: Audit team finalize draft report, and hand report and copies of relevant worksheets to institution FIG. 3. Programme for a typical clinical audit visit. 69
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IAEA HumAn HEAltH SErIES no. 4 Comp
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COMPREHENSIVE CLINICAL AUDITS OF DI
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IAEA HUMAN HEALTH SERIES No. 4 COMP
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FOREWORD The application of radiati
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CONTENTS 1. INTRODUCTION . . . . .
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5.1.3. Quality assurance processes
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1. INTRODUCTION 1.1. CLINICAL AUDIT
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1.1.3. Confidentiality of audits Co
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evidence based medical research is
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As a result of the comprehensive cl
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The facility/institution is respons
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2.4.2. Review The review process wi
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2.5.1. Title page and contents page
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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
Page 61 and 62: 5.1.2.2. Occupational and public ex
Page 63 and 64: (f) (g) Performance criteria for al
Page 65 and 66: Dosimetry for those subjected to ra
Page 67 and 68: 5.2.1.3. Management support The aud
Page 69 and 70: (b) (c) Discuss the facility’s po
Page 71 and 72: (g) (h) (i) Discuss with the medica
Page 73 and 74: Professionals engaging in such prog
Page 75 and 76: 6.2. THE AUDIT PROGRAMME 6.2.1. Edu
Page 77: (d) (v) Regularity of research meet
Page 82 and 83: Day 1: Morning: All audit team memb
Page 84 and 85: Appendix III AUDIT REPORT FORMAT: S
Page 86 and 87: Appendix IV AUDIT REPORT FORMS The
Page 88 and 89: Audit criteria Adequacy Comments Su
Page 120 and 121: 5.3. AUDIT REPORT FORMS FOR TECHNIC
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Audit criteria Adequacy Comments Su
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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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SErIES IAEA HumAn HEAltH SErIES IAEA Hum

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