Implementing a Non-Mandated Radiation Safety Initiative

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By Neil Singh

August 2013—In an article published in April 2013, we focused on a radiation dose safety initiative being implemented in California at Sutter Health. Since California healthcare providers have been mandated to implement specific quality measures around CT imaging practices, the interview provided a good insight into managing existing and upcoming radiation dose safety mandates. We learned that California healthcare providers are well vested in maximizing patient safety by developing robust internal radiation safety programs. This practice of radiation dose management, which many thought was just a California regulation, has gained momentum nationally.

Beginning May 1, 2013, Texas healthcare providers have been mandated to implement a radiation safety program and committee; collect, store, and manage CT and interventional radiology dose information; and educate staff on safe imaging practices. As the benefits of a radiation safety program become apparent and the general patient awareness grows, progressive healthcare providers in other states, who have not yet been mandated to implement radiation safety initiatives, are developing internal radiation safety programs to stay ahead of the curve.

You might wonder why a provider should invest time and money into a program when there is no mandate to follow. Adopting such a program will not only prove that these healthcare providers are leaders in their industry, but will also help their facilities to:

1. Minimize a litigation nightmare like Cedars-Sinai and Mad River Community Hospital.

2. Be ahead of upcoming radiation mandates.

3. Increase efficiency and reduce cost through streamlined workflow and modernization of legacy systems.

4. Leverage patient safety (it’s the right thing to do).

The current mandates follow a similar trend: the requirement of capturing specific radiation dose data, the importance of having an internal radiation safety committee and program, establishing radiation dose thresholds, defining and reporting radiation related incidents, and radiation safety training and communication. To better understand the driving factors behind a non-mandated healthcare provider’s radiation safety program, we (AHC) sat down with Continuum Health Partners (CHP) of New York about their enterprise radiation safety initiative.

Located in the heart of New York City, CHP is an integrated delivery network of healthcare providers and consists of 11 locations, all of which recently went live with their enterprise radiation safety management program. Below, CHP program leaders Marc Katz, Corporate Director of Radiology, Vince Monte, Radiology Administrator, and Dr. Michael Abiri, Chairman of Radiology CHP, discuss their experiences in leading the CHP enterprise radiation dose safety transformation.

AHC: New York has not been mandated on radiation dose safety practices. Describe your catalyst for initiating the dose reduction program.

CHP: CHP has always been ahead of the curve when it comes to patient safety, imaging protocols, technology, and overall radiation dose awareness. We always had a radiation dose management system in place. We started with diagnostic imaging; collecting and analyzing imaging repeat and reject rates. The catalyst to broaden our radiation safety initiative was to be ahead of the curve and be the industry leader in patient radiation dose management. We wanted to expand our existing radiation dose management program, and this was a good opportunity to do so.

AHC: Describe your vision, assessment, and development and delivery strategy for a dose reduction program across your organization’s people, processes, and technologic components.

CHP: CHP has a two-stage approach.

First Stage: Implement technology to monitor, collect, and analyze CTDi and DLP dose information across the enterprise. Assess and develop radiation safety committee approved, standardized imaging protocols, which meet CT scanner variations based on vendor and workflow throughout the enterprise.

Second Stage: Provide access to the dose management tool and program for physicians, and train them to use the tool as a decision making point when placing an imaging order. Integrate the radiation dose management system to other imaging application systems as part of a complete health information management system.

There is so much potential with this program.

AHC: What organizational changes and workflow transformations are being considered, required, or underway?

CHP: Automatically, the technologist workflow was affected. An analysis of the current state of the workflow was conducted at all institutions. All workflow variances were identified, and new workflow policies and procedures were developed to integrate technology and provide flexibility to accommodate different variances at an enterprise level. All workflows were restructured to incorporate the new processes in managing patient radiation dose. Today, over 130 staff members, including physicians, technologists, and administrative staff, have been trained on the radiation dose management software. We utilize a project management committee to assess the programs overall effectiveness and success.

AHC: What are your next steps or lessons learned as you move to a truly enterprise wide dose reduction program?

CHP: After successfully integrating all of our CT units in the automated dose management system, we are now beginning to integrate other modalities in our program. Our project management team will continue to assess the program’s effectiveness and success. This type of project requires significant resource, and we advise organizations beginning their radiation safety project to plan resources accordingly. Having a good radiation safety program in place will allow organizations to closely monitor radiation dose as one of the key patient safety measure. Managers should understand that managing a radiation safety program is long-term with plenty of potential; organizations leading their radiation safety transformation should develop a program that contains the most or heightened patient safety measures.

Radiation safety is continuing to gain significant attention nationally at patient, health system, and legislative levels.  Organizations like Sutter Health and Continuum Health Partners provide an excellent roadmap to addressing enterprise dose management across strategy, people, process, and technology components.

Neil Singh is a consultant at Ascendian Healthcare Consulting and a frequent speaker and thought leader on Enterprise Dose Management. If you have questions you can contact Neil via email

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