National Diagnostic Imaging Framework - NHS Wales Diagnostic Imaging... · 1 Executive Summary The...

National Diagnostic Imaging Framework

December 2009

Edition 1

Contents Page

Executive Summary 1 1. Introduction 3 1.1 The Future Delivery of Diagnostic Imaging Services in Wales 3 1.2 Diagnostic Imaging Services covered by this Framework 4 2. Guidance and Standards which impact on Diagnostic Imaging 4 2.1 Waiting Times 4 2.2 Healthcare Standards for Wales 4 2.3 National Service Frameworks (NSFs) 15 2.3.1 NSF for Children, Young People and Maternity Services

in Wales 15 2.3.2 The Cardiac Disease National Service Framework 16 2.3.3 Diabetes NSF 25 2.3.4 Adult Mental Health NSF 25 2.3.5 National Service Framework for Older People 26 2.3.6 Renal NSF 27 2.4 Other Relevant Standards and Guidance 29 2.4.1 Delivering Emergency Care Services (DECS) 29 2.4.2 Designed to Improve Health and the Management of

Chronic Conditions in Wales 29 2.4.3 Quality Requirements for Adult Critical Care in Wales 30 2.4.4 Stroke Guidelines 31 2.4.5 The Cancer Standards 33 2.4.6 National Institute for Health and Clinical Excellence

(NICE) Guidance 36 3. Quality and Standards in Diagnostic Imaging 36 3.1 Accreditation 36 3.2 Interventional Radiology 37 3.3 Information Management and Technology (IM&T) 39 3.4 Benchmarking 39

3.5 Radiation Protection Legislation 40 3.5.1 IR(ME)R 2000 40 3.5.2 Healthcare Inspectorate Wales Self Assessment Tool 40 3.5.3 IRR99 40 3.6 National Patient Safety Agency (NPSA) Advice 41 3.7 Recommended Standards for the Routine Performance Testing of

Diagnostic X-Ray Imaging Systems 41 3.8 Standard Protocols and Methods 42 3.9 Other Quality Related Documents 42 4. Appropriate Use of Imaging 43 4.1 Royal College of Radiologist Guidelines (RCR) 43 4.2 Non Medical Referral for Diagnostic Imaging 43 4.3 Reporting of Imaging Investigations 44 Appendix 1 45 References 49

1

Executive Summary The National Diagnostic Imaging Framework (NDIF) for Wales provides an overview of the standards applicable to the planning and delivery of diagnostic imaging services in Wales at local, regional or national levels as appropriate. It should be read in relation to the recommendations set out in ‘The Future Delivery of Diagnostic Imaging Services in Wales’. Evidence of compliance with the standards herein will help organisations meet the requirements of the Healthcare Standards for Wales, and the requirements of the Welsh Assembly Government (WAG) for key patient groups as specified in the National Service Frameworks (NSFs) and other strategic documents. The National Diagnostic Imaging Framework:

• provides assurance to patients that the services they receive are of the highest quality;

• identifies the Healthcare Standards that impact on diagnostic imaging and clarifies the quality standards to which diagnostic imaging services are expected to perform; and

• provides the context to enable planners to identify areas where resources may be required to meet standards.

Section 1 puts the NDIF into context and contains details of the diagnostic imaging services covered by this Framework. Section 2 sets out quality standards which diagnostic services should meet to fulfil the requirements of the Healthcare Standards for Wales and the NSFs. Section 3 sets out additional requirements specific to the provision of high quality services within imaging departments. Section 4 describes standards for the appropriate use of imaging.

3

1. Introduction The National Diagnostic Imaging Framework (NDIF) references a wide range of standards and guidance that diagnostic imaging service providers will be expected to demonstrate compliance with. The NDIF provides a mechanism for assessing current and future services including those that require investment of either capital or revenue. Service developments that are in line with this framework should be encouraged. Priorities for service delivery in different healthcare environments are described, but it does not define the organisational structures within which services will be delivered. The Framework specifically identifies the contribution of diagnostic imaging to broader policies and guidelines such as the Healthcare and Cancer Standards and National Service Frameworks (NSFs). The contents of this document have been agreed with service providers and planners, and endorsed by the Medical Imaging Sub Committee of the Welsh Scientific Advisory Committee. The standards are evidence based, measurable and aligned with broader service development. The purpose of this document is to:

• provide assurance to patients that the services they receive are of the highest quality;

• identify the Healthcare Standards that impact on diagnostic imaging and clarify the quality standards to which diagnostic imaging services are expected to perform; and

• provide the context to enable planners to identify areas where resources may be required to meet standards.

Individuals working within imaging services must adhere to their registration body and employer Codes of Conduct and professional standards where appropriate. The Royal College of Radiologists (RCR), the Society and College of Radiographers (SCoR), the Royal College of Nursing (RCN), the Institute of Physics and Engineering in Medicine (IPEM) and the Health Professions Council (HPC) provide professional advice and guidance which is updated on a regular basis. These bodies have produced a range of standards which are available on their websites.

Imaging related quality requirement Evidence

Registration with appropriate regulatory body where applicable.

Registration checked on an annual basis.

1.1 The Future Delivery of Diagnostic Imaging Services in Wales(1) The Future Delivery of Diagnostic Imaging Services proposes a way forward for the planning and delivery of diagnostic imaging services in Wales, and builds on the collaborations that are already underway in order to deliver the range and quality of service required by a changing health service.

4

1.2 Diagnostic Imaging Services covered by this Framework The consensus from stakeholders in the imaging community is that the same standard of service provision should apply to all imaging services regardless of location. Therefore, the Framework will apply to radiology departments; Breast Test Wales; nuclear medicine departments; medical physics departments; point of care settings such as ultrasound undertaken in Outpatient or GP clinics; and other departments where a range of imaging modalities are undertaken. Specific quality requirements for these services will be available in updated versions of the document as they become available. The modalities covered by this Framework are shown in Appendix 1. 2. Guidance and Standards which impact on Diagnostic Imaging 2.1 Waiting Times Access 2009 Targets(2) require that the patient care pathway from initial contact with primary care to diagnosis and treatment must be completed within 26 weeks with a maximum 8 weeks waiting time for access to specified diagnostic services.


Maximum 8 weeks waiting time for access to specified diagnostic services.

Audit of waiting times.

2.2 Healthcare Standards for Wales The Healthcare Standards for Wales(3) came into effect from June 2005 and constitute a common framework of healthcare standards to support the NHS and partner organisations in providing safe, high quality care for all patients in Wales. Along with the development of National Service Frameworks and National Institute for Clinical Excellence (NICE) guidance, this forms part of a sustained drive to remove inequalities in health across the breadth of Wales. The standards are grouped into four domains:

• The Patient Experience – The standards support the provision of healthcare in partnership with patients, service users, their carers and relatives and the public;

• Clinical Outcomes – Healthcare decisions and services should be based on appropriately assessed research evidence of an effective outcome for patients and service users;

• Healthcare Governance – Providers and commissioners of healthcare will have in place systems that support both managerial and clinical leadership and accountability centred on patient and service user needs and preferences; and

5

• Public Health – Healthcare organisations will collaborate with relevant organisations and local communities to ensure that programmes and services are designed and delivered to promote, protect and improve health, tackle health inequalities and help people to live healthy and independent lives.

Good practice in diagnostic imaging and adherence to guidelines will enable NHS organisations to demonstrate compliance with these Standards. In addition, The Royal College of Radiologists and the Society and College of Radiographers have jointly developed The Imaging Services Accreditation Scheme (ISAS). The standards for this programme are also based on 4 domains:

• Facilities, resources and workforce (FRW);

• Patient experience (PE);

• Clinical outcomes (C); and

• Safety (S). In many instances the requirements of The Imaging Services Accreditation Scheme map to the Healthcare Standards as illustrated below: Diagnostic Imaging Related Quality Requirement Evidence

Healthcare Standard Description Corresponding Imaging Services Accreditation Scheme (ISAS) Standards

First Domain: The Patient Experience

Standards to support the provision of healthcare in partnership with patients, service users, their carers and relatives and the public will be based on plans and decisions that respect diverse needs and preferences. Services will be user friendly and patient centred. Healthcare will be provided in environments that promote patient and staff wellbeing and respect for individual patient’s needs and preferences in that they will be designed for the effective and safe delivery of treatment and care and are well maintained and cleaned to optimise health outcomes for patients.

Standard 1 The views of patients, service users, their carers and relatives and the public are sought and taken into account in the design, planning, delivery, review and improvement of health care services and their integration with social care services.

PE3; C8; FRW5

6

Diagnostic Imaging Related Quality Requirement Evidence


Standard 2 The planning and delivery of healthcare: a) reflects the experiences, views and preferences

of patients and service users; b) reflects the health needs of the population

served; c) is based on nationally agreed evidence and best

practice; and d) ensures equity of access to services.

PE5; C8; 7; FRW5

Standard 3 Patients with emergency health needs access appropriate care promptly and within national time-scales set annually by the Welsh Assembly Government.

C1

Standard 4 Healthcare premises are well-designed and appropriate in order to: a) promote patient and staff well-being; b) respect different patients needs, privacy and

confidentiality; c) have regard for the safety of patients, users and

staff; and d) provide a safe and secure environment which

protects patients, staff, visitors and their property, and the physical assets of the organisation.

FRW1 S4 PE2; S4, 5

Standard 5 Healthcare services are provided in environments, which: a) are well maintained and kept at acceptable

national levels of cleanliness; b) minimise the risk of healthcare associated

infections to patients, staff and visitors, achieving year on year reductions in incidence; and

c) emphasise high standards of hygiene and reflect best practice initiatives.

S5; FRW1

7



Standard 6 Healthcare organisations, in recognising different language, communication, physical and cultural needs: a) make information available and accessible to

patients, service users, their carers and relatives and the public on their services;

b) provide patients and service users with timely information on their condition; the care and treatment they will receive as well as after-care and support arrangements; and

c) provide patients and service users with opportunities to discuss and agree options relating to their care.

PE1, 4 PE1 PE1, 3

Standard 7 Patients and service users, including those with long-term conditions, are encouraged to contribute to their care plan and are provided with opportunities and resources to develop competence in self-care.

Not detailed within Imaging Services Accreditation Scheme standards.

Standard 8 Healthcare organisations ensure that: a) staff treat patients, service users, their relatives

and carers with dignity and respect; b) staff themselves are treated with dignity and

respect for their differences; c) informed consent is obtained appropriately for all

contacts with patients and service users and for the use of confidential patient information; and

d) patient information is treated confidentially, except where authorised by legislation to the contrary.

PE2, 4 PE3 C7

Standard 9 Where food is provided there are systems in place that: a) patients and service users are provided with a

choice of food which is prepared safely and provides a balanced diet; and


8



b) patients and service users’ individual nutritional, personal, cultural and clinical dietary requirements are met, including any necessary help with feeding and having access to food 24 hours a day.

Standard 10 Healthcare organisations ensure that people accessing healthcare are not unfairly discriminated against on the grounds of age, gender, disability, ethnicity, race, religion, or sexual orientation.

PE2, 3, 4 FRW1 – 2

Second Domain: Clinical Outcomes

Healthcare decisions and services will be based on what appropriately assessed research evidence has shown will provide an effective outcome for patients and service users taking account of their individual needs and preferences. Patients and service users will receive services as promptly as possible, and will not experience unreasonable delay at any stage of service delivery or of their care pathway.

Standard 11 Healthcare organisations ensure that: a) clinical care and treatments are delivered by

healthcare professionals who make clinical decisions based on evidence based practice;

b) clinical care and treatments are carried out under appropriate clinical supervision and leadership;

c) clinicians continuously update skills and techniques relevant to their clinical work including peer reviews; and

d) clinicians participate in regular audit and review of clinical services.

PE4; S1, 3, 5, 6; C1 -4; FRW3 S1; C3 – 4; FRW3, 4 PE1-5; S1-9; C1-5; FRW1-8 PE1-5; S1-6; C1-9; FRW1

Standard 12 Healthcare organisations ensure that patients and service users are provided with effective treatment and care that: a) conforms to the National Institute for Clinical

Excellence (NICE) technology appraisals and interventional procedures, and the

PE1-5; S1-9; C1-9; FRW1 -8

9



recommendations of the All Wales Medicines Strategy Group (AWMSG);

b) is based on nationally agreed best practice and guidelines, as defined in National Service Frameworks, NICE clinical guidelines, national plans and agreed national guidance on service delivery;

c) takes account of patients physical, social, cultural and psychological needs and preferences; and

d) is integrated to provide a seamless service across all organisations that need to be involved, including social care organisations.

Standard 13 Healthcare organisations, which either lead or participate in research, have systems in place to ensure that the principles and requirements of the research governance framework are consistently applied.

C9

Third Domain: Healthcare Governance

Providers and commissioners of healthcare will have in place systems that support both managerial and clinical leadership and accountability centred around patient and service user needs and preferences. Working practices will be in place to enable probity, quality assurance, quality improvement and patient safety to be the central components of all routines, processes and activities.

Standard 14 Healthcare organisations continuously and systematically review and improve all aspects of their activities that directly affect the safety and health of patients, service users, staff and the public. They will not only comply with legislation, but apply best practice in assessing and managing risk.

PE4 S1 – 9 C6 FRW2

Standard 15 Healthcare organisations, recognising different language and communication needs, ensure that patients, service users, relatives and carers: a) can provide feedback on their experiences and

the quality of services;

FRW 7 PE5; C8

10



b) have their complaints looked at promptly and thoroughly in accordance with complaints procedures;

c) are given information about complaints advocacy support provided by Community Health Councils in Wales; and

d) receive assurance that organisations act on any concerns and make appropriate changes to ensure improvements in service delivery.

Standard 16 Healthcare organisations have systems in place: a) to identify and learn from all patient safety

incidents and other reportable incidents; b) to report incidents to the National Patient Safety

Agency’s (NPSA) National Reporting and Learning System and other bodies in line with existing guidance;

c) to demonstrate improvements in practice based on shared local and national experience and information derived from the analysis of incidents; and

d) to ensure that patient safety notices, alerts and other communications concerning safety are acted upon within required time-scales.

S1 – 9; C5, 6; FRW2

Standard 17 Healthcare organisations comply with national child protection and vulnerable adult guidance within their own activities and in their dealings with other organisations.

PE4

Standard 18 Healthcare organisations have planned and prepared, and where required practiced, an organised response to incidents and emergency situations, which could affect the provision of normal services.

FRW8

11



Standard 19 Healthcare organisations ensure that: a) all risks associated with the acquisition and use

of medical devices are minimised; b) all reusable medical devices are properly

decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed;

c) quality, safety and security issues of medicines are managed; and

d) the prevention, segregation, handling, transport and disposal of waste are managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment.

S1 – 3, 4, 6, 8; FRW2 S1-3, 5, 6; FRW2 C5 S6

Standard 20 Healthcare organisations work to enhance patient care and to continuously improve staff satisfaction by providing best practice in human resources management.

FRW3

Standard 21 Healthcare organisations: a) undertake all necessary employment checks and

ensure that all employed or contracted professionally qualified staff are registered with the relevant bodies;

b) require that all employed professionals abide by their published codes of professional practice and conduct; and

c) address where appropriate under-representation of minority groups.

FRW3, 4 C2 – 4

Standard 22 Healthcare organisations ensure that staff: a) are appropriately recruited, trained and qualified

for the work they undertake;

PE1-5; S1-9; C1-5, 7, 8, 9; FRW1-8

12



b) participate in induction and mandatory training programmes; and

c) participate in continuing professional and occupational development.

Standard 23 Healthcare organisations ensure that staff are supported by: a) processes which permit them to raise, in

confidence and without prejudicing their position, concerns over any aspect of service delivery treatment or management; and

b) organisational and personal development programmes which recognise the contribution and value of staff.

FRW3 FRW4

Standard 24 Healthcare organisations work together with social care and other partners to meet the health needs of their population by: a) having an appropriately constituted workforce

with appropriate skill mix across the community; and

b) ensuring the continuous improvement of services through better ways of working.

FRW6 FRW3 C1; FRW5

Standard 25 Healthcare organisations use effective information systems and integrated information technology to support and enhance patient care, and in commissioning and planning services.

FRW2

Standard 26 Healthcare organisations have effective records management processes in place to ensure that: a) from the moment a record is created until its

ultimate disposal, the organisation maintains information so that it services the purpose it was

C3, 7; FRW2

13



collected from and disposes of the information appropriately when no longer required; and

b) patient confidentiality is maintained.

Standard 27 Governance arrangements representing best practice are in place which: a) apply the principles of sound clinical and

corporate governance; b) ensure sound financial managements and

accountability in the use of resources; c) actively support all employees to promote

openness, honesty, probity, accountability, and the economic, efficient and effective use of resources;

d) include systematic risk assessment and risk management; and

e) are integrated across all health communities and clinical networks.

PE1-5; S1 – 9; CO1-9; FRW6 FRW6 PE1-5; S1 – 9; C1- 9; FRW1 -8

Standard 28 Healthcare organisations: a) ensure that the principles of clinical governance

underpin the work of every team and every clinical service;

b) have a cycle of continuous quality improvement, including clinical audit; and

c) ensure effective clinical and managerial leadership and accountability.

PE1-5; S1-9; C1– 9; FRW1-8 PE1-5; S1-9; C1– 9; FRW1 -8 PE2; FRW4

Fourth Domain: Public Health

Healthcare organisations will collaborate with relevant organisations and local communities to ensure the design and delivery of programmes and services to promote, protect and improve health, and which will tackle health inequalities and help people to live healthy and independent lives.

Standard 29 Healthcare organisations promote, protect and demonstrably improve the health of the community served and reduce health inequalities by:


14



a) collaborating and working in partnership with local authorities and other agencies in the development, implementation and evaluation of health, social care and well being strategies; and

b) ensuring that needs assessment and sound public health advice informs their policies and practices.

Standard 30 Healthcare organisations: a) have systematic and managed disease

prevention and health promotion programmes, which include staff, which meet the requirements of the National Service Frameworks, national plans and health promotion and prevention priorities; and

b) take fully into account current and emerging policies and knowledge on public health issues in the development of their public health programmes, health promotion and prevention services and the commissioning and provision of services.


Standard 31 Healthcare organisations: a) have plans in place to mobilise resources to

protect the public in the event of significant infectious disease outbreaks and other health emergencies;

b) identify and act upon significant public health problems and health inequality issues, with Local Health Boards taking the leading role;

c) implement effective programmes to improve health and reduce health inequalities; and protect their populations from identified current and new hazards to health; and

d) encourage and support individuals to recognise their own responsibilities in maintaining their health and well being.

FRW8

15



Standard 32 Healthcare organisations achieve the Corporate Health Standard, the national quality mark for workplace health, moving to a higher level on reassessment.

S9 FRW3

2.3 National Service Frameworks (NSFs) There are six National Service Frameworks in Wales that provide a systematic approach by which to tackle the agenda of improving standards and quality across health care sectors. They set national standards and define service models for a service or care group, put in place programmes to support implementation and establish performance measures against which progress within agreed timescales can be measured. 2.3.1 NSF for Children, Young People and Maternity Services in Wales(4)

The scope of the NSF includes all children and young people from pre-conception to their 18th birthday. As the health of the mother and her maternity care can affect the health of the baby, these standards also cover maternity services. Special consideration is also given for transition management into adult services beyond the 18th birthday, for those requiring ongoing services. Children and Young People – Diagnostic Imaging Related Quality Requirement The overarching aim is that children, young people and their families receive services that meet their particular needs. They should be treated with respect by service providers and be given information and support (appropriate to their needs and ability) that assist them in making decisions about the care that they receive. Service users should be confident that staff dealing with children and young people have the appropriate skills and competencies for the role they are undertaking. When planning imaging departments, planners should be aware of the specific needs of children and young people and develop areas accordingly. Booking systems within imaging departments should meet NSF standards: Imaging related quality requirement Evidence

A booking system that is flexible and takes account of the needs of children and families.

Departmental booking protocols that clearly identify children and young persons and appoint them appropriately.

16


For children who require multiple appointments, these are synchronised on one setting and on one day whenever possible and appropriate.

Have maximum waiting times of 30 minutes.

Documented in departmental policies.

Do not move children from one waiting area to another unless unavoidable.


Within the District General Hospital (non specialist hospital) environment children and young people should be batch booked on a specific list in a designated area whenever possible.


Imaging departments should ensure that staff dealing with children and young people have had appropriate core training including basic paediatric life support appropriate to the levels of risk and child-specific aspects of equipment use.

Documented evidence of training.

Maternity Services – Diagnostic Imaging Related Quality Requirement The challenge for health care providers is to minimise risks for mother and baby, ensure that the experience of pregnancy and childbirth is a satisfying one, and support the family in adapting to the changes needed to love and nurture a new member of the family. Imaging related quality requirement Evidence

Where early pregnancy ultrasound dating scans and foetal anomaly scans are performed under the auspices of imaging departments, then staffing numbers, training, equipment and records meet the standards determined by Antenatal Screening Wales.

All departments should ensure the incorporation of specific standards from “Policy and Standards to support the provision of Antenatal Screening in Wales, December 2005” and subsequent updates, into departmental protocols and working practice.

2.3.2 The Cardiac Disease National Service Framework

The original National Service Framework (NSF) for Coronary Heart Disease(5) was published by the National Assembly for Wales in July 2001. It has been superseded by an updated NSF for Cardiac Disease(6) issued by the Welsh Assembly Government (WAG) in July 2009. This contains a separate standard for cardiac rehabilitation, an expanded standard on arrhythmias, and a new standard on

17

managing the care of adults with congenital heart disease. The Cardiac NSF must be implemented in full by 2015 and has implications for diagnostic imaging. The Standards in the NSF are as follows: Standard 1 Promoting healthy hearts; Standard 2 Managing risk factors and prevent further heart damage in those

with high risk factors or established disease; Standard 3 Managing the care of patients with Coronary Heart Disease; Standard 4 Managing the care of patients with Chronic Heart Failure; Standard 5 Managing the care of patients with Arrhythmias and families of

young victims of cardiac arrest; Standard 6 Providing Cardiac Rehabilitation; and Standard 7 Managing the care of adults with congenital heart disease. Cross Cutting Interventions cover areas common to the Standards in the NSF. The Cardiac Disease NSF has accompanying Quality Requirements (QRs) which reflect the content of the NSF and are mapped to the Healthcare Standards. They have been developed to support NSF implementation, have clearly stated demonstrations of compliance and can be monitored by self assessment. The Welsh Assembly Government has also issued a Cardiac disease Strategic Framework for 2008-2011(7) underpinned by the NSF Standards and the Quality Requirements. The Framework sets out the two strategic aims that WAG wants to achieve in terms of cardiac disease: firstly, to prevent cardiovascular disease and secondly, to improve survival rates and maximise quality of life for those with cardiac disease. The Framework sets out Key Actions and broad time scales for implementation. Diagnostic imaging contributes to the imaging of cardiac disease not only with the use of CT and MRI but also isotope imaging and general imaging support. A large proportion of cardiac imaging and angiography is undertaken by cardiology departments. The number of cardiac CT examinations is expanding rapidly and is predicted to replace some invasive coronary angiography due to its accuracy, patient tolerance, safety and economical benefit. MRI is used for the assessment of myocardial viability, cardiomyopathy and congenital heart disease. The Cardiac Disease NSF sets out the main characteristics of hospital cardiac services which should be available when fully developed and these appear below. Documented evidence of service provision should be available. District General Hospital (DGH)

• Emergency department, cardiac care unit and ‘step down’ beds • Consultant cardiologist available in normal working hours • Cardiac physiology service available in normal working hours

18

Enhanced District General Hospital (EDGH)

• Emergency department, cardiac care unit and ‘step down’ beds • Consultant cardiologist available 24/7 • Cardiac physiology service available 24/7 • Cardiac catheterisation available in normal working hours • Pacemaker implantation available in normal working hours

Tertiary cardiac service (TCS)

• Emergency department, cardiac care unit and ‘step down’ beds • Consultant cardiologist available 24/7 • Cardiac physiology service available 24/7 • Cardiac catheterisation available 24/7 • Cardiac surgery available 24/7 • Pacemaker implantation available 24/7 • Other specialised cardiac services

The Quality Requirements (QRs) below are taken from the full set of Cardiac QRs; they contain the elements relevant to diagnostic imaging and are numbered as in the Cardiac QRs. Imaging related quality requirement Evidence

QR 30f (Staffing and support) A member of staff with competence in echocardiography of adults with congenital heart disease should be available in an Enhanced District General Hospital (EDGH).

Details of staff available 1. Staff performing echocardiography should be trained to British Society of Echocardiology (BSE) Adult Accreditation, or equivalent, standard and have additional competence in echocardiographic assessment of congenital heart disease.

QR 43 (Staffing and support) Basic radiological imaging and CT scanning should be available at all times in a District General Hospital (DGH).

Details of services available

QR 44 (Staffing and support) Echocardiography assessment should be available during normal working hours in a DGH.

Details of services available 24 hour diagnostic services are also available during normal working hours.

19


QR 45 (Staffing and support) Basic radiological imaging, CT scanning, echocardiography assessment and trans-oesophageal echocardiography should be available at all times in an Enhanced DGH.


QR 46 (Staffing and support) Stress echocardiography, nuclear imaging and coronary angiography should be available during normal working hours in an Enhanced DGH.


QR 47 (Staffing and support) Basic radiological imaging, CT scanning, echocardiography assessment, trans-oesophageal echocardiography, and coronary angiography should be available at all times in a Tertiary Cardiac Service.


QR 48 (Staffing and support) Stress echocardiography and nuclear imaging should be available during normal working hours in a Tertiary Cardiac Service.


QR 49 (Staffing and support) PET scanning should be available to a Tertiary Cardiac Service.


QR 50 (Staffing and support) Access to echocardiography assessment, nuclear imaging and angiography services should be available for patients with suspected heart failure in the care of a Local Heart Failure Team (LHFT).

Details of services available, including contact details for referrals. Referral guidelines for each service.

QR 51 (Training) All echocardiograms should be performed and reported by an appropriately trained and experienced member of staff.

Details of staff performing echocardiography, with training and CPD details 1. Staff newly performing echocardiography should be trained to BSE Adult Accreditation, or equivalent, standard.

20


2. This QR applies to echocardiographs performed in whatever settings (i.e. in community or hospital).

QR 52 (Service organisation) A daily rapid access chest pain assessment service should be available. The operational policy for the service should cover, at least, handling test results, referral for investigations and advice to be given to the patient. (This QR is applicable to DGH, EDGH and Tertiary Cardiac Services.)

Details of service available and operational policy 1. Arrangements may vary at weekends and Bank Holidays but the service should still be available.2. The service should comprise, at least, someone to supervise and assess an exercise test and counsel the patient appropriately.

QR 53 (Service organisation) A diagnostic heart failure clinic at which a consultant cardiologist/physician with a special interest in heart failure and heart failure specialist nurse are both present should be held at least weekly. Echocardiography, 12-lead ECG and chest radiology should be available during the clinic time. The arrangements for accessing this clinic should have been communicated to local practices and local acute hospitals admitting patients as emergency.

Details of clinic times, staff usually available and operational policy for clinic 1. The diagnostic heart failure clinic may not require a whole clinic session. 2. For community-based or DGH LHFTs, the consultant role in the clinic may be taken by an associate specialist, or GP with a special interest, working under the direction of a consultant. 3. This QR applies to tertiary cardiac services acting as the LHFT for the local population.

QR 54 (Staffing and support) Echocardiography should be available according to agreed referral guidelines, with routine reports available within four weeks.

Arrangements for access to echocardiography Referral guidelines Details of waiting times for echocardiography and for reports “Four weeks” refers to the time from Echocardiography to the report being received by the receiving clinician.

21


QR 56 (Service organisation) The Tertiary Heart Failure Team (THFT) should hold a clinic at least monthly to which local teams can refer patients for specialist investigations and advice.

Details of clinic arrangements. Communication of arrangements to referring local Heart Failure Team

QR 58 (Service organisation) A rapid access arrhythmia service should be available. The operational policy for the service should cover, at least, handling test results, referral for investigations and advice to be given to the patient. (This QR is applicable to DGH, EDGH and Tertiary Cardiac Services.)

Details of service available and operational policy 1. The service should be available at least weekly. 2. The service should comprise, at least, ECG recording, 24 hour ECG testing, echocardiography and patient activated monitoring, and advice from a heart rhythm specialist.

QR 65 (Staffing and support) All angiography and Percutaneous Coronary Intervention (PCI) services should conform to the standards laid down by the British Cardiovascular Intervention Society and participate in the British Cardiovascular Intervention Society (BCIS) inspection process.

BCIS inspection reports showing compliance with relevant standards

QR 66 (Staffing and support) Cardiovascular imaging including echocardiography and cardiovascular radiology where staff have appropriate training and expertise in the care of adults with all types of congenital heart disease, should be available in Tertiary Cardiac Services providing care for adults with congenital heart disease.

Details of arrangements 1. Anaesthetic advice should be easily available as well as anaesthetic care during procedures.

QR 67 (Service organisation) A member of staff with competence in echocardiography of adults with congenital heart disease should be available at a clinic for the review of adults with congenital heart disease which should be held regularly. (This QR is applicable to EDGHs and Tertiary Cardiac Services.)

Details of arrangements 1. Appointment times should exclude time for echocardiography. 2. Additional clinic time should be allowed when a doctor in training is present.

22


QR 72 (Clinical & Referral Guidelines) Clinical guidelines should be agreed and in use covering the assessment and initial management of patients with a suspected diagnosis of acute coronary syndromes, including diagnostic work-up. (This QR is applicable to DGH, EDGH and Tertiary Cardiac Services.)

Clinical guidelines easily available in all areas where patients with suspected acute coronary syndromes may arrive at the hospital, the cardiac care unit and cardiac ward. 1. Guidelines should be based on network-agreed guidance. 2. Ambulance ACS management is covered in QRs 16 and 17.

QR 74 (Service organisation) An operational policy should be in use in Tertiary Cardiac Services covering the arrangements to ensure that primary PCI takes place within 90 minutes of arrival at hospital.

Operational policy 1. Audit of time from arrival to PCI is a desirable demonstration of compliance. 2. This QR also applies to EDGHs if they form part of a network-wide PCI service.

QR 75 (Clinical & Referral Guidelines) Clinical guidelines should be agreed and in use in EDGHs and Tertiary Cardiac Services covering assessment of cardiac structure and function, including: a) indications for use of different

assessment techniques; and b) frequency of assessment.

Clinical guidelines 1. These guidelines should cover transthoracic and transoesophageal echo Doppler, MRI, radionuclide perfusion analysis, cardiovascular CT angiography, cardiopulmonary exercise testing and invasive haemodynamic assessment. 2. Guidelines should be based on network-agreed guidance.

QR 78 (Service organisation) An operational policy should be in use covering the arrangements to ensure that in patients at high risk of a further cardiac event: a) an angiogram is undertaken within

48 hours of completion of risk stratification; and

b) PCI or cardiac surgery is undertaken within 48 hours of angiography, if required.

(This QR is applicable to DGH, EDGH and Tertiary Cardiac Services.)

Operational policy, based on network-agreed guidance 1. Audit of times to angiogram and PCI/cardiac surgery is a desirable demonstration of compliance.

23


QR 87 (Clinical & Referral Guidelines) Clinical guidelines should be agreed and in use including the diagnosis, management and monitoring of patients with heart failure. (This QR is applicable to DGH, EDGH and Tertiary Cardiac Services (see note 2.)]

Clinical guidelines easily available in all areas of the hospital where patients with heart failure may be assessed and treated. 1. These guidelines should be based on network-agreed guidance and the guidelines of the LHFT. (QRs 53, 88 to 94, 96, 99 and 100). 2. In tertiary cardiac services, the THFT may act as the LHFT for the local population.

QR 88 (Clinical & Referral Guidelines) The Local Heart Failure Team should have agreed guidelines for the diagnosis of heart failure. These guidelines should include: Diagnostic tests; indications for echocardiography; alternative methods of imaging if a poor image is produced on echocardiography; indications for referral to the Tertiary Heart Failure Team for assessment or specialist investigations.

Diagnosis guidelines Evidence of agreement with local practices and local acute hospitals. 1. These guidelines should be based on network guidance, NICE chronic heart failure guidance and should be consistent with the locally agreed heart failure pathway.

QR 89 (Clinical & Referral Guidelines) The Tertiary Heart Failure Team should have agreed guidelines for the diagnosis of heart failure. These guidelines should include: Diagnostic tests; indications for echocardiography; alternative methods of imaging if a poor image is produced on echocardiography.

Diagnosis guidelines 1. These guidelines should be based on network guidance, NICE chronic heart failure guidance and should be consistent with the locally agreed heart failure pathway.

QR 98 (Service organisation) The Local/Tertiary Heart Failure Team should have an agreed operational policy including the arrangements for sending a copy of the patient’s echocardiogram report to their GP.

Operational policy of the heart failure team 1. The arrangements for giving advice and support to patients, primary care acute hospitals and Local Heart Failure Teams should include clear timescales within which a response will be guaranteed. 2. The arrangements for notifying the patient’s general practitioner whenever a patient is given a diagnosis of heart failure should

24


reach the GP by the end of the next working day and should specify the contact point for advice and support that has been given to the patient. 3. The operational policy should be clear about responsibility for recording information in patients’ notes. 4. The LHFT aspects of this QR also apply to tertiary cardiac services acting as the LHFT for their local population.

QR 101 (Clinical & Referral Guidelines) Clinical guidelines should be agreed and in use covering the investigation and management of patients with transient loss of consciousness. (This QR is applicable to DGH, EDGH and Tertiary Cardiac Services.)

Clinical guidelines available in all areas where patients with transient loss of consciousness may be seen 1. This QR is linked to QR104 and 105 relating to referral to a heart rhythm specialist. 2. Guidelines should be based on network-agreed guidance.

QR 103 (Clinical & Referral Guidelines) Clinical guidelines should be agreed and in use covering the assessment and initial management of patients with arrhythmias, including patients already fitted with a pacemaker or ICD. (This QR is applicable to DGH, EDGH and Tertiary Cardiac Services.)

Clinical guidelines easily available in all areas of the hospital where patients with suspected arrhythmias may be assessed and treated. 1. Guidelines should be based on network-agreed guidance.

QR 124 (Service organisation) Regular multi-disciplinary meetings should be held to discuss the care of adults with congenital heart disease in tertiary cardiac services providing care for adults with congenital heart disease. The meetings should include a member of staff with competence in echocardiography of adults with congenital heart disease and cardiac imaging specialist. (This QR is applicable to DGH, EDGH and Tertiary Cardiac Services.)

Operational policy covering meeting arrangements 1. Cardiologists with an interest in the care of adults with congenital heart disease should have the option to attend this meeting, especially when the care of their patients is discussed.

25

2.3.3 Diabetes NSF(8)

The Diabetes NSF aims to “empower people with diabetes through skills, knowledge and access to services to manage their own diabetes with support and fulfil their potential to live long lives free of the complications that can accompany diabetes”. People with diabetes are at risk of developing microvascular complications; diabetic retinopathy, diabetic nephropathy and diabetic neuropathy. They are also at increased risk of developing cardiovascular disease, including coronary heart disease, stroke and peripheral vascular disease. The impact on diagnostic imaging will arise from the investigation and image guided interventions, of the complications of diabetes. This will further increase the workload for CT, MRI and US especially as the prevalence of diabetes is predicted to increase. Renal failure is another common complication of diabetes and imaging resources will be needed to investigate these patients, some of whom will need specialist investigations such as MR angiography and renal angioplasty. Imaging related quality requirement Evidence

To identify, monitor and treat any long term complications using timely and appropriate imaging.

Protocols developed taking account of imaging requirements to influence timely referral to appropriate specialty, investigation and or treatment.

2.3.4 Adult Mental Health NSF(9)

This NSF establishes the practical guidelines to ensure the consistent and comprehensive implementation of the vision set out in the Adult Mental Health Strategy published in 2001. Imaging does not have a major role in the delivery of a mental health service. However, there are patients in whom the clinical diagnosis may be in doubt and occasionally imaging may be necessary to exclude an underlying structural cause for their problems. If this is the case, then the appropriate imaging, usually a CT scan of the brain is indicated. Imaging related quality requirement Evidence

Investigations should be available in a timely fashion, to enable early recognition, prompt diagnosis and where necessary, appropriate treatment.

Services delivered should be patient centred, in a patient and relative friendly environment, which is accessible to them.

Protocols developed taking account of imaging requirements to influence timely referral to appropriate speciality, investigation and or treatment. Documented policies which take into account fully the needs of people with mental health problems.

26

2.3.5 National Service Framework for Older People(10)

Designed to ensure that as we grow older we are enabled to maintain our health, well being and independence for as long as possible, this NSF sets national standards to ensure prompt, seamless, quality treatment and support when required. It is based on several broad principles:

• removal of explicit age barriers;

• removal of indirect age discrimination;

• prompt access to diagnostic and specialist services when required;

• care planned appropriately for each individual;

• partnership between health and social care; and

• identification of and provision for any specific communication needs. Rapid access to diagnostic procedures and informed interpretation of the results is essential for timely assessment and direction of patients to the most appropriate care pathway. However, it is necessary to allow increased time for imaging of frail, immobile or confused patients and where possible to offer alternative investigations, appropriate to the patient’s physical state, e.g. CT colonography rather than barium enema. Fractures are a major cause of pain, disability and death in older people. The vast majority of fractures and injuries in older people are the result of falls. Diagnostic imaging will have a key role to play in the diagnosis of such injuries within the agreed timescale. There are a number of specific references to imaging in relation to accident and emergency and acute admissions, stroke, osteoporosis, fractures and dementia. The above principles, however, also imply certain standards in the way services are provided. Imaging related quality requirement Evidence

Rapid access to and informed interpretation of results of diagnostic procedures for both accident and emergency and admission units.

Local policies to confirm the principle of “patient centred care” should require that each individual is prioritised according to clinical need and not according to age.

Stroke This is covered in section 2.4.4.

Falls and fractures Open access to radiography to confirm suspicion of vertebral fracture, when assessing risk of osteoporosis.

Local documented pathways in accordance with clinical and other good practice guidelines for the timely imaging of older people who have fallen and those with a resultant fracture.

27


Availability of imaging to enable surgery, should it be necessary, to be carried out within 24 hours of admission. DXA scan for diagnosis of osteoporosis when drug therapy is being considered (in accordance with NICE guidelines).

Audit data to show targets are being met. DXA facilities available and documented in pathway.

Undertaking of investigations such as neuroimaging for the initial diagnosis of dementia.

Provision of neuroimaging services for diagnosis of dementia where this will influence management.

Provision of care appropriate to the individual.

Local imaging department policies to reflect the requirements of frail, immobile, confused patients.

2.3.6 Renal NSF(11)

The renal NSF focuses on:

• primary prevention – to reduce the incidence of renal disease in Wales;

• early detection – to delay the progression of the disease;

• improved access to services – to provide diagnosis, appropriate treatment and palliative care services for people with renal disease; and

• better services – to provide the best diagnosis, treatment and palliative care services for people with renal disease.

It aims to improve detection of renal disease, ensuring that where renal disease does occur that it is identified at an early stage, and reduce the progression of renal disease by proactive action taken to delay its progression. The first aim should be achieved locally by adoption of the Chronic Kidney Disease (CKD) early detection and management pathway developed by the Renal Advisory Group. Reduced progression would be achieved by early management and appropriate interventions of patients with renal impairment in line with patient pathways and protocols set by the Renal Advisory Group and Renal Networks(12). The NSF will impact on Diagnostic Imaging Services in a number of ways:

• increased imaging demand, particularly for Ultrasound, from primary care screening for CKD in high risk patient groups;

• CKD is staged according to the degree of renal failure associated with it, CKD 1 being mild and CKD 5 indicating severe disease requiring dialysis or transplant. All patients with CKD 3 and above require investigation;

• increased nephrology referral with consequent increases in renal biopsies, MRI and CT Angiography and interventional procedures; and

• provision of 24/7 services for interventional radiology.

28


Children: 1. Measurement of renal size in age related centiles (by ultrasound) in children at risk of chronic kidney disease (CKD). 2. Monitor Children with CKD 2 or greater. Aid postnatal management of antenatal uropathy. 3. Develop guidelines for a standardised approach to imaging and reporting of images for children requiring investigation of kidneys or urinary tract. Adults: 24 hr access to imaging in acute renal failure (ARF).

Investigation of CKD 3 and above Screening of first degree relatives of patients with congenital renal disease of known inheritance pattern. Assessment of the urinary tract in patients with lower urinary tract symptoms, outflow obstruction and neurogenic bladder.

Specialist Requirements For Dialysis and Transplantation. Involvement in vascular access team prior to haemodialysis. Prompt investigation of decreased renal graft function. Appropriate investigative and intervention imaging for:

1. assessment of patients for vascular access;

2. vein mapping in patients with poor calibre vessels;

3. monitoring of arteriovenous fistulae; and

4. to carry out surgical and radiological intervention within

Multidisciplinary teams with imaging input set up in each renal unit to lead and monitor the implementation of the NSF standards for delivering an integrated and high quality renal service across Wales. Documented evidence that healthcare professionals in imaging departments are educated and trained to the level specified in the competency framework. Documented integrated care pathways for key interventions within each standard to include imaging requirements so that quality of access and quality of care can be achieved and monitored. Audit data to show targets are being met.

29


a maximum of 72 hrs in case of thrombosis of vascular access.

Evaluation of live donors as per British Transplant Society guidelines. Post operative monitoring of renal transplant recipients including renal biopsy and relief of obstruction. Long term follow up investigations for a variety of problems in transplant patients, e.g. Lymphoma.

2.4 Other Relevant Standards and Guidance 2.4.1 Delivering Emergency Care Services (DECS)(13)

The DECS strategy is aimed at those people who need access to health and social care that is not planned. This ranges from those requiring emergency care to patients needing help to care for themselves at home. It is delivered within the context of a range of Health and Social Care strategies with the aim of maximising benefits and producing joined up solutions. Imaging related quality requirement Evidence

Services will be managed to ensure that the capacity exists to treat people in the right place, at the right time and by the right people.

Local care pathways documenting appropriate access to diagnostic imaging investigations.

Staff will work in innovative ways across traditional boundaries, fully utilising their skills in order to maximise their contribution.

All imaging staff to have detailed personal training and development plans enabling them to meet the DECS modernisation agenda.

Care will be delivered to clear and measurable standards, which will cover each element of the service and the whole of the patient’s journey.

Audit data to show standards are being met.

2.4.2 Designed to Improve Health and the Management of Chronic Conditions in Wales(14) Chronic conditions are those which in most cases cannot be cured, only controlled; they are often life-long and limiting in terms of quality of life. They can have far

30

reaching implications on all areas of life and can have a particularly profound effect on the social life and independence of individuals, their families and other carers. Wales has the highest rates of long-term limiting illness in the UK accounting for a large proportion of unnecessary emergency admissions to hospital. Early identification, assessment, diagnosis and monitoring of chronic conditions are important in order to provide appropriate treatment and support to individuals to maintain healthy active lives. It is also important to monitor these conditions over long periods of time. This is likely to require a more standardised approach to primary care access to imaging investigations.


Early identification, assessment, diagnosis and monitoring of chronic conditions closer to peoples’ homes.

Evidence of imaging requirements addressing the need at each of the 4 levels across the generic care pathway.

2.4.3 Quality Requirements for Adult Critical Care in Wales (15)

This document describes five levels of adult general critical care relating to a patient’s condition:

• At level 0 patients can be appropriately cared for in general hospital wards in acute hospitals and general departments of surgery and medicine.

• Level 1 is suitable for patients at risk of their condition deteriorating, whose needs can be met on an acute ward with additional advice and support from the multidisciplinary critical care team.

• At level 2 patients require single organ support, but invasive ventilatory support would not be appropriate.

• At level 3, patients at all levels of severity might be appropriately treated at this level. Organ support and monitoring must be available for most body systems. All hospitals with an A&E department must be supported by full services and hospitals accepting major trauma or emergency surgical patients must be able to treat level 3 patients.

• At Level 3T (Tertiary) organ support and monitoring must be available for most body systems for patients with multiple organ failure. Level 3T units should act as tertiary referral units for patients with multiple organ failure and must have a significant teaching and training role.


Access to radiography, ultrasonography and CT for Levels 0 and 1 patients.

Rapid access to radiography, ultrasonography and CT for Levels 1, 2 and 3 patients and at Level 3T units.

Documented evidence of service provision.

31

A further developmental quality requirement included in this document is for the provision of on site 24 hour emergency access to MRI for Level 3 patients and at Level 3T units. 2.4.4 Stroke Guidelines Stroke is caused by a disturbance of blood supply to the brain and can have a major impact on people’s lives. It starts as an acute medical emergency, presents complex care needs, may result in long-term disability and can lead to admission to long-term care. The stroke guidelines form part of the NSF for Older People. Transient ischaemic attacks (TIAs) are often described as “mini strokes”. The term TIA is used where the symptoms and signs resolve within 24 hours. A TIA increases the subsequent chance of a stroke. Various documents have been produced giving guidance on the diagnosis, treatment and management of strokes and TIAs.

• The National Collaborating Centre for Chronic Conditions (NC-CCC) has produced the National Clinical Guidelines for the Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA)(16).

• The National Clinical Guidelines for Stroke were produced in July 2008(17).

• The Department of Health has produced a document entitled “Implementing the National Stroke Strategy – an Imaging Guide”(18) which has been endorsed by the Royal College of Radiologists.


Where a diagnosis of a TIA with low risk of stroke requires confirmation, specialist assessment and investigation, which may include diffusion weighted MRI, should be undertaken within one week of onset of symptoms. Where a diagnosis of a TIA with high risk of stroke requires confirmation specialist assessment and investigation, which may include diffusion weighted MRI, should be undertaken within 24 hours of onset of symptoms.

Imaging requirements are documented in care pathway. Response times and availability demonstrated by audit data.

Carotid duplex Ultrasound should be performed on all patients being considered for carotid endarterectomy and confirmed with Magnetic Resonance Angiography (MRA) or with a second Ultrasound.

Imaging requirements are documented in care pathway.

32


CT or MRI (if available) should be performed immediately (defined as “ideally the next slot and definitely within one hour of a request”) for acute stroke if any of the following apply:

• indications for thrombolysis or early anticoagulation treatment;

• on anticoagulation treatment; • a known bleeding tendency; • depressed level of

consciousness; • unexplained progressive or

fluctuating symptoms; • papilloedema, neck stiffness or

fever; or • severe headache at onset.

CT or MRI (if available) should be performed as soon as possible (defined as “within a maximum of 24hours after onset of symptoms”) for acute stroke without indications for immediate brain imaging.

Imaging requirements are documented in care pathway. Response times and availability demonstrated by audit data.

Further imaging should be considered:

• in the event of an unexpected deterioration in patient’s condition, to identify intracranial complications;

• to investigate atypical presentation; and

• to provide a differential diagnosis.


MRI should be performed when presentation has been delayed for more than 7 days after stroke, or if stroke is of atypical presentation.


In cases of suspected subarachnoid haemorrhage a CT brain scan should be undertaken immediately if there is an impaired level of consciousness and within 12 hours for all patients.


33

2.4.5 The Cancer Standards(19)

“Designed to Tackle Cancer in Wales, 2006”(20) sets out the Welsh Assembly Government’s clear and specific policy aims and strategic direction to tackling cancer at a national and local level across Wales for delivery by 2015.


Early detection through appropriate public education, information and screening. Provide improved access to and quality of diagnosis, treatment and palliative care services for people with cancer.

Maintenance and development of screening programmes. Imaging requirements are documented in care pathway.

The Cancer standards published in 2005 are a series of Topics that address the key organisational requirements for effective delivery of care and follow the main stages in the patient journey. These standards define the core aspects of the service that should be provided for cancer patients throughout Wales. They describe the context to the specific standards and the appropriate monitoring criteria. Cancer is staged according to the TNM staging system, T being the extent of the tumour, N any spread to lymph nodes and M the presence of metastases. Knowing the stage of the disease is a prognostic indicator and helps with treatment decisions. Diagnostic imaging provides a means of staging the disease for many types of cancer. The standards recommend that cancer care is provided by a specialist multidisciplinary team (MDT), which should include a radiologist. These MDTs should have access to high quality imaging services as imaging is important in the diagnosis and staging of many patients with cancer. There is evidence that higher survival rates are associated with detection and treatment of early stage, less advanced disease. Patients should be diagnosed, staged and treated promptly and in line with best practice guidelines. With the introduction of many new drugs for the treatment of cancer, sometimes within the clinical trial setting, there will be an impact on the demand for diagnostic imaging for baseline and follow up scans. General Requirements for all Cancers Imaging related quality requirement Evidence

Imaging departments should provide clear, written information to MDTs on the range of investigations provided, and their availability.

Copy of documentation to be provided by the appropriate clinical head of imaging services.

34


All Departments of Clinical Radiology should have written policies on the referral and imaging investigations of patients with cancer or suspected cancer by cancer site. These should reflect the latest advice from the Royal College of Radiologists (RCR).

Detail of written policies to be provided by the appropriate clinical head of imaging services.

Standardised imaging protocols for staging should be agreed within each Cancer Network.

Network Manager to have copies of standardised protocols. Local copies of documentation to be provided by the appropriate clinical lead of imaging services.

Staging should be reported in a standardised format agreed within each Cancer Network.

Copies of documentation to be held by Network Manager. MDT to provide. Evidence of adherence to the standardised format.

All reports should, as a minimum, allow assessment of that component of TNM status, which relies on diagnostic radiology.

Clinical audit of assessment and recording of stage.

Each MDT should have access to specialist opinion for radiological diagnosis and staging where appropriate.

Documentation detailing names of Radiology specialists.

Specialist radiologists should have regular sessions in their area of expertise identified in their job plan.

Detailed in Job Plan.

Results of diagnostic tests should be communicated to patients within one week of the last diagnostic procedure.

Organisational monitoring.

Site Specific Cancer Requirements - these should be read in conjunction with the general requirements. Colorectal Cancer Imaging related quality requirement Evidence

New patients diagnosed with colorectal cancer should have their liver imaged by either CT or MRI unless this information would have no influence on management.

Clinical audit of the number of newly diagnosed patients with colorectal cancer who undergo CT or MRI imaging of the liver.

35

Urological Cancers


Specialist teams performing complex urological operations at Network and supra Network level should be backed up by emergency radiological support.

Named Radiologist with interest in interventional uroradiology.

Gynaecological Cancers The Cancer Services Co-ordinating Group issued the “All Wales Guidelines for the Management of Gynaecological Cancers”(21) in 2001, to establish standard approaches to the management of gynaecological cancers in Wales.


All investigations and staging should be completed within 15 working days from the initial hospital visit.

Clinical Audit.

Radiography, Ultrasound, CT and MRI should be readily available.

Detail access.

Head and Neck Cancers Imaging related quality requirement Evidence

CT, MRI, Ultrasound, Ultrasound guided fine needle aspirations (FNAs), video fluoroscopy and Nuclear Medicine facilities should be readily available.

Detail access.

Sarcoma The National Standards for Sarcoma Services(22) was issued in June 2009 by The Cancer Services Co-ordinating Group. They recommend that Diagnostic Clinics should be designated by the Sarcoma Treatment Centre and run by a Radiologist with a special interest in soft tissue sarcoma. The NHS in Wales are required to submit plans to the Assembly Government by the end of September 2009, identifying how the new standards will be achieved by June 2012. Imaging related quality requirement Evidence

Diagnostic clinics should provide ultrasound imaging and biopsy facilities.

Sarcoma treatment centre to provide details of services provided.

Staff working in designated diagnostic clinics must be trained appropriately and work undertaken audited.

Documented evidence of training and results of audit of the diagnostic work undertaken.

36


Standardised imaging protocols for staging and tumour imaging for soft tissue sarcoma should be agreed between the supra network sarcoma MDT and the designated diagnostic clinics.

Cancer Network Directors to have copies of standardised protocols.

All images should be available for electronic transfer and review by specialist sarcoma radiologists and discussion at the sarcoma MDT meeting.

Local copies of protocols to be provided by the appropriate clinical lead in imaging services.

2.4.6. National Institute for Health & Clinical Excellence (NICE) Guidance(23) The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. NICE produces guidance in three areas of health:

• Public Health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector;

• Health Technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS; and

• Clinical Practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

NICE guidance is developed using the expertise of the NHS and the wider healthcare community including NHS staff, healthcare professionals, patients and carers, industry and academia. Currently there are 32 NICE guidelines relating to diagnostic imaging, which can be accessed via their website - www.nice.org.uk. 3. Quality and Standards in Diagnostic Imaging 3.1 Accreditation The Welsh Assembly Government requires diagnostic services to enrol in accreditation schemes where they exist or as they are developed(24). The Royal College of Radiologists (RCR) and the Society and College of Radiographers (SCoR) have jointly developed the Imaging Services Accreditation Scheme (ISAS)(25) in collaboration with other health professionals and patient representatives. The purpose of the ISAS is to ensure high quality care for patients and a safe working environment for staff within radiology departments. It will be

37

operated by the United Kingdom Accreditation Service (UKAS), the sole national accreditation body recognised by government to assess against agreed standards. Evidence of meeting the standards will be undertaken using a web-based self assessment tool. The expected benefits of accreditation are identified from three perspectives:

• The patient perspective:

- Provision of safer services. - Review of services by independent experts and areas of best practice

and weaknesses identified.

• The healthcare professional perspective:

- They and their colleagues are competent to perform the tasks they undertake, ensuring safer services.

- Commitment by employers to provide services with a focus on constant quality improvement.

• The Providers perspective:

- Competent staff providing safer services which reflect current

legislation and best practice. - Development of action plans to ensure continued quality improvement.

More information, including how to apply for accreditation can be found on the UKAS website - www.ukas.com. Imaging related quality requirement Evidence

Radiology Departments enrolled in the Imaging Services Accreditation Scheme.

Documentation confirming enrolment with the Imaging Services Accreditation Scheme.

3.2 Interventional Radiology Interventional Radiology (IR) is a subspecialty within radiology where, using image guidance, diagnostic and therapeutic procedures are performed through small percutaneous punctures. The procedures are minimally invasive and therefore designed to reduce the morbidity and mortality of patients who would traditionally have had such procedures performed by open surgery. Examples vary from image guided targeted biopsies throughout the body, to abscess drainage, recanulisation of blocked arteries, treatment of life threatening haemorrhage, aortic aneurysm repair and fibroid embolisation. This is a rapidly developing field with new techniques and procedures being devised continually. Growth is particularly significant in oncological intervention.

38

The British Society of Interventional Radiologists (BSIR)(26) as a specialist subgroup of the RCR produces guidelines and standards for practitioners. They also run several registries of procedures such as iliac angioplasty, biliary interventions, oesophageal stenting and vena cava filter insertion. These registries have been established in collaboration with other societies and colleges. All Radiologists who perform these interventions should comply with BSIR standards where available, audit their outcomes regularly and enter the procedures in the relevant BSIR registries. This is important from a clinical governance, patient safety viewpoint. Many of these procedures have significant complications and therefore informed consent is vital. Outcome figures for individual centres and radiologists should be available for patients to give informed consent. Data from these audits will be useful for informing appraisals and re-certification. Consultant job plans must reflect the time needed to participate in those audits. The practice of interventional radiology is evolving rapidly and the provision of 24 hour cover will require the development of networks and or centralisation of IR services at larger centres. The RCR have published the following standards which relate to Interventional Radiology:

• Standards for providing 24 hour interventional radiology service;

• Standards for Patient Consent Particular to Radiology;

• Achieving Standards in Vascular Radiology;

• Guidelines for Nursing Care and Interventional Radiology;

• Safe Sedation Analgesia and Anaesthesia within the Radiology Department; and

• Shaping the future of Interventional Radiology These standards can be accessed via the RCR’s website - www.rcr.ac.uk. Imaging related quality requirement Evidence

Provision of 24 hour emergency interventional radiology service where required. Procedures entered into relevant BSIR registry. Compliance with BSIR standards for each procedure. Audit of outcomes and complications.

Arrangements for 24 hour cover for interventional radiology. Record of entries. Individual Radiologist documentation. Clinical audit.

39

3.3 Information Management and Technology (IM&T) Informatics is at the heart of modern diagnostic imaging and diagnostic imaging data is a major component of the patient record. The standardisation and integration of clinical radiology systems is essential to underpin imaging modernisation. The NHS Wales Radiology Information System, RadIS2, is being implemented in imaging departments across Wales. The system will help to provide the foundation for further integration of service provision between the separate departments (and instances of RadIS). Historically NHS Trusts in Wales have modified imaging procedure codes to suit local needs and developments to such an extent that meaningful comparison of imaging data across Wales has proved impossible and has, in some circumstances, created artificial barriers to patient care. To improve this situation, standardised national imaging procedure codes have been agreed and approved for use across Wales and are expected to be in use by December 2009(27). Imaging related quality requirement Evidence

Implementation of the national codes by imaging departments by December 2009.

Use of the national codes by imaging departments.

The digital images produced during a diagnostic imaging investigation are stored on Picture Archiving and Communications Systems (PACS). Integration of these systems across Wales is necessary in order for increased capability for off-site viewing and reporting of images. Information within these systems is subject to the same confidentiality constraints as any other patient data held electronically. The Royal College of Radiologists (RCR) have published “Standards for Patient Confidentiality and PACS”(28) which gives clarity around the contractual and legal obligations of patient confidentiality.


Adherence to RCR document. An audit template is in preparation and will be available on AuditLive on www.rcr.ac.uk.

3.4 Benchmarking Benchmarking provides a baseline assessment of workload, facilities and equipment status against which organisational change can be evaluated. The Acute Hospitals Portfolio – Diagnostic Imaging Module(29) provides an evidence base for decisions, by assessing performance across a range of performance indicators, backed up by interpretation by independent local auditors.

40

Historically, there is difficulty in benchmarking between organisations due to variations in the use of codes and definitions. The introduction of common codes and data definitions, as part of the IM&T project, should alleviate this problem. Breast Test Wales (BTW) audits breast screening annually using United Kingdom (UK) standard annual returns, contributes to annual UK reports on breast screening, and to the annual UK British Association of Surgical Oncology (BASO)(30) audit of breast screening. BTW also takes part in annual standard and occasional topic-specific radiological audits carried out by the UK breast screening Radiology Quality Assurance (QA) group(31).


Participation in relevant schemes. Completion of relevant data collection. 3.5 Radiation Protection Legislation These regulations are intended to protect patients and staff from hazards arising from the use of Ionising radiation. MRI and Ultrasound images are not acquired using ionising radiation and therefore are not covered by this legislation. Detailed advice on requirements must be obtained from the relevant organisation’s Radiation Protection Adviser. 3.5.1 IR(ME)R 2000(32)

The Ionising Radiation (Medical Exposure) Regulations 2000, (IR(ME)R2000) and The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006(33) impose duties on those responsible for administering ionising radiation to protect persons undergoing medical exposure as part of their medical diagnosis or treatment. 3.5.2 Healthcare Inspectorate Wales Self Assessment Tool Healthcare Inspectorate Wales (HIW)(34) are responsible for undertaking routine on site inspections of the compliance of imaging departments in Wales with the IR(ME)R regulations on behalf of the Welsh Assembly Government. HIW has developed self assessment tools for Nuclear Medicine and General Radiology to enable departments to establish the level to which they comply both with IR(ME)R and the Healthcare standards for Wales. Both the Standards and the self assessment tool are available on the HIW website - www.hiw.org.uk. 3.5.3 Ionising Radiation Regulations 1999 (IRR99)(35)

The Ionising Radiation regulations 1999 lay down requirements intended to protect staff and members of the public against the dangers of ionising radiation. These regulations are enforced by the Health and Safety Executive.


Meet requirements of Radiation Protections Legislation.

Appropriate documentation and practices in place.

41

3.6 National Patient Safety Agency (NPSA) Advice The NPSA aims to lead and contribute to improved, safe patient care by informing and influencing healthcare organisations and individuals working in the health sector. A Safer Practice Notice was issued in February 2007 entitled “Early identification of failure to act on radiological imaging reports”(36). This safer practice notice advises healthcare organisations to make changes to ensure that imaging results are communicated and acted on appropriately. “Standards for the communication of critical, urgent and unexpected significant radiological findings” (37) have been published by the RCR which include an audit template for the communication of urgent reports. The standards and audit template can both be accessed via the RCR website, www.rcr.ac.uk. Imaging related quality requirement Evidence

Radiological imaging reports of all patients are communicated to, and received by, the appropriate registered health professional and, where necessary, action is taken in a manner appropriate to their clinical urgency.

Documented departmental procedures. Record of action taken when necessary in line with Policy. Audit of communication tracking systems to ensure compliance.

3.7 Recommended Standards for the Routine Performance Testing of Diagnostic X-Ray Imaging Systems The Institute of Physics in Engineering and Medicine (IPEM) Report 91(38) provides essential guidance for anyone responsible for diagnostic x-ray equipment. This document gives clear advice on which routine performance tests are essential and which are desirable, where to get information on how to do them, who should be doing them and how often they should be done. For many tests it also gives guidance when the results indicate that further action should be taken. The second edition of this report takes into account the introduction of new technologies in medical imaging including computed radiography (CR), digital radiography (DR) and image display devices. The Welsh Scientific Advisory Committee (WSAC) has provided guidance for the procurement of equipment used for medical exposure to ionising radiation, detailing good practice guidelines for the tender, supply, installation and handover of equipment. The aim of these guidelines, entitled “Procurement of Equipment used for Medical Exposure to Ionising Radiation”(39) is to ensure that new radiation equipment is safe (radiologically, electrically and mechanically), meets its specification (performance and calibration) and that the vendor and purchaser meet their statutory obligations. The general principles contained in the document may also be applied to the procurement of imaging equipment using non ionising radiation e.g. MRI and Ultrasound.

42


Systems in place to assure the appropriate procurement, installation, operation, maintenance, quality assurance and replacement of all equipment.

Documented systems.

3.8 Standard Protocols and Methods In order to deliver consistent, high quality services across Wales and also to reduce duplication of effort, national professional advisory committees support a standardised approach to the development of local protocols and procedures. Relevant all-Wales guidance has been developed by the Welsh Scientific Advisory Committee (WSAC) in relation to procedures for:

• control of dose from CT;

• Left & Right Side Marking of Radiological Images - Best practice in the use of markers to mark images "L" and "R", and in labelling of digital and ultrasound images; and

• good practice guidance non medical/dental referral for diagnostic investigation – providing guidance regarding referral for diagnostic investigations by registered healthcare professionals other than registered medical and dental practitioners.

Current guidance is available via the following link: www.new.wales.gov.uk/topics/health/professionals/committees/wsac. Imaging related quality requirement Evidence

Local practice consistent with WSAC guidance.

Documented in local procedures.

3.9 Other Quality Related Documents Recommendations on the provision of Nuclear Medicine services have been produced by the Royal College of Physicians and the British Nuclear Medicine Society while the National Osteoporosis Society has published guidance on the provision of Bone Densitometry services. The Institute of Physics and Engineering in Medicine has published recommendations on the contribution of Medical Physics to various aspects of healthcare including imaging; the Society for Vascular Technology of Great Britain and Ireland has done similarly for Vascular Technologists in Ultrasound.

43

Further information can be accessed via the following websites: www.rcplondon.ac.uk; www.bnms.org.uk; www.nos.org.uk; www.ipem.org.uk; and www.svtgbi.org.uk. 4. Appropriate Use of Imaging A request for a radiological examination is a request from one clinician to another for an opinion, based on a radiological examination, to assist in management of a clinical problem. 4.1 Royal College of Radiologist Guidelines (RCR) The current edition of the Royal College of Radiologists’ Guidelines “Making the best use of a department of clinical radiology”(40) provides evidence based guidance on indications for imaging in specified clinical circumstances. The Guidelines should be used as a standard for audit studies of appropriate referral practices and it is a legal responsibility, under IR(ME)R2000, for organisations to ensure their clinicians have access to and base their referral practice on the guidelines. The planned introduction of an all-Wales electronic test requesting and results reporting system (TRRR) will contribute to a more consistent and streamlined imaging process. It is planned that the system will incorporate these Guidelines which will provide advice to referrers at the time of making the request. The guidelines can be accessed via the following link: http://howis.wales.nhs.uk/sites3/docmetadata.cfm?orgid=520&id=94142. Imaging related quality requirement Evidence

Availability of RCR Guidelines to referrers.

Referral guidelines provided.

Referral for diagnostic imaging investigations based on the Guidelines.

Audit of appropriate referral practice.

4.2 Non Medical Referral for Diagnostic Imaging It is a requirement of the Ionising Radiation (Medical Exposure) Regulations 2000 that those who refer patients for diagnostic imaging investigations utilising ionising radiation should provide sufficient clinical information to allow imaging specialists receiving the request to judge whether the procedure is justified.

44

The modernisation of health and social care in Wales has led to changes in clinical practice and the development of extended roles for many clinical professions. It is now recognised that there are benefits (in terms of reducing waiting times for diagnosis and treatment for example), for some referrals to be made by registered but non-medically qualified staff. “Good Practice Guidance for non medical/dental referral for diagnostic investigation”(41) has been produced jointly by the Wales Therapy Advisory Committee, Welsh Nursing and Midwifery Committee and WSAC and endorsed by the Joint Professional Forum and chairs of the Welsh Medical, Dental, Pharmaceutical and Optometric Advisory Committees. It is intended to facilitate the development of local policies and procedures for non-medical/dental referral for diagnostic investigation. Imaging related quality requirement Evidence

Local practice consistent with non medical referral guidance.

Appropriate documented procedures in place in line with guidance.

4.3 Reporting of Imaging Investigations In order to provide high quality and effective patient-centred imaging services it is essential that the provision of an accurate report for imaging investigations is made available to the referring clinician in a timely manner. This will reduce the risk of delay in diagnosing unexpected findings and aid in meeting the targets for treatment of patients. Regulation 7(8) of IR(ME)R 2000 states that “The employer shall take steps to ensure that a clinical evaluation of the outcome of each medical exposure, is recorded in accordance with the employer’s procedures or, where the employer is concurrently practitioner or operator, shall so record a clinical evaluation, including, where appropriate, factors relevant to patient dose. The Royal College of Radiologists (RCR) produce “Standards for the Reporting and Interpretation of Imaging Investigations”(42) which are applicable to all staff undertaking the reporting of imaging investigations. Imaging related quality requirement Evidence

Adherence to the RCR document.

Compliance with local clinical governance procedures.

45

Appendix 1 Plain film or conventional radiography, which provides the first line investigation for the majority of patients attending imaging departments. Images were recorded on radiographic film and early applications were restricted to imaging of the skeletal system. However, as a result of significant developments over many years, the technique can also be used for detecting disease processes in soft tissues such as the lungs. X-rays are a type of ionising radiation and so radiography involves radiation exposure to the patient. The further application of the principles behind conventional radiography has enabled the development of more specialised imaging including:

• Fluoroscopy - providing real time (‘live’) images of internal body structures and the position of inserted medical instruments, using a fluorescent detector plate which produces light when exposed to x-rays. Like radiography, it is a planar (or projection) method in which body structures are superimposed upon each other in the images; and

• Mammography - the technique for imaging breast tissue, which has been undertaken on dedicated equipment since 1969.

The application of computers has revolutionised diagnostic medical imaging equipment and techniques with the result that newer imaging modalities have been developed. The use of digital imaging techniques commenced in the 1970s with the introduction of CT scanning. These techniques have also impacted on conventional radiography with electronic image receptors replacing radiographic film, enabling the image to be displayed on a computer screen rather than viewed on a light-box. Such Digital or Computed Radiography systems have largely replaced film-based systems in Welsh hospitals. One of the biggest advantages of digital imaging is the ability of the operator to post-process images for optimal diagnostic quality. It also allows the electronic transmission of images so that many people can share the information and assist in the diagnosis. Digital imaging is environmentally friendly since it does not require chemical film processing. Radiation dose reduction is also a benefit derived from the use of digital systems. Computed Tomography (CT) provides cross-sectional (or ‘slice’) views of internal body structures, thus overcoming the problem of superimposed structures that is inherent in plain film radiography and fluoroscopy. During a CT scan, x-rays are passed through the body from multiple directions and high-speed computing is used to produce a series of transverse (along the head to toe axis of the patient) images. The computer can reformat these to show slices in the sagittal (side to side) or coronal (front to back) planes or to display the data as a three-dimensional image. Although CT was first developed over thirty years ago, significant advances continue to be made in this imaging modality with modern multi-detector scanners being fast enough to ‘freeze’ the motion of the beating heart. The constantly improving capability of CT provides opportunities to explore new imaging techniques and to

46

improve patient care; however, CT is regarded as a relatively high radiation dose technique. Dual Energy X-Ray Absorptiometry (DXA) is a specialised and low radiation dose form of planar digital radiography used for measuring bone mineral density. It is used primarily for the diagnosis of osteoporosis, estimating fracture risk and monitoring the effect of treatment. Modern DXA scanners incorporate the ability to acquire digital radiographic images of the spine in order to indicate the presence of vertebral fractures. Diagnostic imaging has developed to include the following imaging techniques that do not use ionising radiation. Ultrasound Imaging is the application of echoes from high frequency sound waves to visualise internal organs of the body. It produces cross-sectional ‘live’ images which can be used for diagnosis or to guide the positioning of inserted medical instruments e.g. for taking tissue biopsies. By utilising the Doppler effect (the change in frequency of sound waves when they are reflected by moving structures), it is possible to measure the flow rate of blood in arteries and veins. Ultrasound imaging is considered a relatively safe procedure compared with methods that use ionising radiation (such as x-rays). Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic method which uses a high magnetic field, radio waves and a computer to produce detailed images of internal body structures. MRI provides much greater soft tissue contrast than CT making it especially useful in neurological, musculoskeletal, cardiovascular and oncological diseases. Images are directly acquired in any plane and no ionising radiation is used. One of the most recent developments with MRI is the use of magnets of higher strength e.g. 3T machines, which can give markedly increased quality images of certain parts of the body. Another major development in diagnostic imaging has been the application of pharmaceutical contrast agents or contrast media to help visualise organs and blood vessels with more clarity and greater image contrast. They are often referred to as ‘dyes’ and are adminstered orally or via intra-venous injection. Pharmaceutical contrast agents are now very much part of many diagnostic imaging investigations, particularly fluoroscopic, CT and MRI procedures. Physical contrast agents have also been developed for ultrasound imaging. A further group of imaging techniques involves the administration of short-lived radioactive materials (called radiopharmaceuticals) in order to demonstrate the function of an organ or system. The radiopharmaceutical is chosen so as to be appropriate to the clinical condition of the patient and is usually administered by intra-venous injection. It accumulates in the organ or body system of interest and emits gamma rays (which are similar in nature to x-rays). Radiopharmaceuticals require specialised facilities for their production. In Radionuclide Imaging (RNI), the gamma radiation emitted by the target body organ or system is detected using a gamma camera which shows the distribution of the radiopharmaceutical within the body. Like radiography and fluoroscopy, it is a

47

planar technique and involves ionising radiation, although radiation doses are usually relatively modest. It is part of the speciality of Nuclear Medicine which also encompasses the use of radioactive substances for treatment. Single Photon Emission Computed Tomography (SPECT) is a slice imaging nuclear medicine technique whose relationship to radionuclide imaging is similar to that between CT and planar radiography. It is performed by rotating the gamma camera around the patient and using a computer to generate cross-sectional images. SPECT scanners may also be used for planar RNI although radiation doses in SPECT imaging tend to be higher than those associated with planar imaging (because the administered radioactivity is greater). Modern SPECT scanners are often combined with an x-ray CT scanner to give a SPECT/CT image. SPECT and CT images may be ‘fused’ (superimposed) for greater diagnostic accuracy by enabling the functional SPECT image to be matched against the detailed anatomical information in the CT scan. Positron Emission Tomography (PET) is a more sophisticated type of nuclear medicine slice imaging technique. It uses very short-lived radioactive materials attached to biological molecules to allow the visualisation of metabolic processes in the body by producing images of the distribution of the radiopharmaceutical. Like other nuclear medicine imaging techniques, PET gives functional information about the biological behaviour of tissues and the activity of disease processes. However, PET scanners utilise a ring of gamma radiation detectors and are dedicated for this purpose. As with SPECT, when combined with an x-ray CT scanner (PET/CT), as is now generally the case, functional and anatomical images can be acquired at the same time and fused to display the anatomical site of a functional abnormality. Interventional Radiology – is a clinical radiological sub-specialty that uses fluoroscopy, CT, MRI and ultrasound to guide treatment. Examples include performing biopsies, draining fluids, inserting catheters and dilating or stenting narrowed ducts or vessels. The development of interventional radiology has meant that some traditional surgical operations have been replaced. This can result in reduced complication rates and shorter stays in hospital.

49

References 1. Diagnostic Services Programme. The Future Delivery of Diagnostic Imaging Services in Wales, 2008 2. Welsh Assembly Government. WHC(2007)014 - ACCESS 2009 – Referral to Treatment Time Measurement 3. Welsh Assembly Government. Healthcare Standards for Wales – Making the Connections Designed For Life, 2005 4. NHS Wales website www.wales.nhs.uk, National Service Framework for Children, Young People and Maternity Services, 2005 5. NHS Wales website www.wales.nhs.uk, Coronary Heart Disease National Service Framework, 2001 6. Welsh Assembly Government. National Service Framework for Cardiac Disease, 2009 7. Welsh Assembly Government. Cardiac Disease Strategic Framework 2008-11 8. NHS Wales website www.wales.nhs.uk, Diabetes National Service Framework, 2002 9. NHS Wales website www.wales.nhs.uk, Revised National Service Framework for Adult Mental Health Services, 2005 10. NHS Wales website www.wales.nhs.uk, National Service Framework for Older People in Wales, 2006 11. NHS Wales website www.wales.nhs.uk, Designed to Tackle Renal Disease in Wales: A National Service Framework, 2007 12. Renal Advisory Group and Renal Networks. www.renal.org 13. Welsh Assembly Government. Delivering Emergency Care Services. An Integrated Approach for Delivering Unscheduled Care in Wales, 2008 14. Welsh Assembly Government. Designed to Improve Health and the Management of Chronic Conditions in Wales. An integrated model and framework, 2007 15. Welsh Assembly Government. Designed for Life: Quality Requirements for Adult Critical Care in Wales, 2006 16. National Collaborating Centre for Chronic Conditions. National Clinical Guidelines for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA), 2008

50

17. Royal College of Physicians Intercollegiate Stroke Working Party. The National Clinical Guidelines for Stroke, 2008 18. Department of Health. Implementing the National Stroke Strategy – an Imaging Guide, 2008 19. Welsh Assembly Government. National Standards for Cancer Services, 2005 20. Welsh Assembly Government. Designed to Tackle Cancer in Wales, 2006 21. Cancer Services Co-ordinating Group. All Wales Guidelines for the Management of Gynaecological Cancers, 2001 22. Cancer Services Co-ordinating Group. National Standards for Sarcoma Services, 2009 23, National Institute for Health and Clinical Excellence (NICE) Guidance: www.nice.org 24. Welsh Assembly Government. Welsh Health Circular: Diagnostic Services Strategy, WHC(2004)061 25. Radiology Accreditation Programme, www.accreditation.rcr.ac.uk 26. The British Society of Interventional Radiologists, www.bsir.org 27. Welsh Information Governance and Standards Board http://howis.wales.nhs.uk/sites3/page.cfm?orgid=299&pid=28441 28. Royal College of Radiologists, www.rcr.ac.uk 29. Healthcare Commission. Acute hospital portfolio review: An improving picture? Imaging service in acute and specialists, 2007 30. British Association of Surgical Oncology, www.baso.org.uk 31. Quality Assurance Guidelines for Radiologists, www.cancerscreening.nhs.uk/breastscreen/publications 32. The Ionising Radiation (Medical Exposure) Regulations 2000, www.dh.gov.uk/en/Publicationsandstatistics 33. The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006, www.dh.gov.uk/en/Publicationsandstatistics 34. Healthcare Inspectorate Wales, www.hiw.org.uk 35. Ionising Radiation Regulations 1999, www.hse.gov.uk/radiation/ionising/

51

36. National Patient Safety Agency, Safer Practice Notice 16, 2007, www.npsa.nhs.uk 37. Royal College of Radiologists, www.rcr.ac.uk 38. Institute of Physics in Engineering and Medicine Report 91, 2005, www.ipem.ac.uk 39. Welsh Scientific Advisory Committee, www.wales.gov.uk/topics/health/professionals/committees/wsac/ 40. Royal College of Radiologists, www.rcr.ac.uk 41. Welsh Scientific Advisory Committee, www.wales.gov.uk/topics/health/professionals/committees/scientific/?lang=en 42. Royal College of Radiologists, www.rcr.ac.uk

National Diagnostic Imaging Framework - NHS Wales Diagnostic Imaging... · 1 Executive Summary The...

Documents

Transcript of National Diagnostic Imaging Framework - NHS Wales Diagnostic Imaging... · 1 Executive Summary The...