7 Requirements for an Enterprise Dose Program

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NMullens_eleakis201565-05By Neomi Mullens

October 2013—If your organization’s patient radiation dose management program is attempting to transform under the onslaught of articles, legislation, and litigation surrounding radiation safety, use these seven requirements! Patient-focused and proactive providers are assessing their existing radiation dose management programs and realizing, based on the backdrop of today’s healthcare environment, that they may need to update their legacy dose safety programs.

While reviewing these top requirements, determine where your organization stands against each item. Evaluate your current activities compared and contrasted to the ‘to be’ vision to identify the gaps to be filled in building a comprehensive patient radiation dose safety management solution:

Enteprise Radiation Safety Program

Requirement 1: A Productive Radiation Safety Committee

A successful radiation safety program will begin with your organization’s key stakeholders, who share a collective goal in patient care. When building the team, which will ultimately become your Radiation Safety Committee, it is important not only to select the appropriate resources, but include members of your organization to be advocates of the organization’s radiation safety objectives. Key team members will be: a C-suite sponsor, chief legal counsel, radiology directors, IT staff, your organization’s physicist, and the radiologist. The Radiation Safety Committee that you create will ultimately drive the successful development and implementation of your patient radiation safety program. Ensure you have your key resources on board!

Requirement 2: Clinical and Technical Workflows

It is imperative to clearly outline the current clinical and technical workflows within your organization. This will include a full assessment of the workflows of the departments and staff members who will be impacted as part of your program. Purchasing an automated radiation dose management software solution may further impact your future workflows and should be identified early on.  Adoption of new processes related to an automated system will rely heavily on a clear understanding of new clinical routines to be introduced into the radiology department. In addition to any IT changes, a workflow analysis allows for all procedural components to be evaluated for efficiency and best practice methodologies for all members supporting the radiation safety program.

Requirement 3: CT Protocol Review

It is essential that your organization addresses standardizing and password protecting the CT imaging protocols. With regular review of CT protocols and imaging techniques utilized by technologists, the radiation safety committee will ensure patients are being scanned using ALARA radiation standards, while maintaining high quality diagnostic images. Dose thresholds should be evaluated and maintained in alignment with recommended industry standards. The American College of Radiology (ACR) and American Association of Physicists in Medicine (AAPM) are two excellent resources.  Organizations should implement CT radiation dose thresholds based on the perfect balance of good image quality and delivering the lowest radiation dose to the patient.

Requirement 4: Software/Automation

Radiation monitoring and dose data collection software is a highly desirable and efficient method of standardizing radiation safety procedures within healthcare organizations. By capturing patient and imaging modality radiation dose data and providing a detailed report of your current imaging procedures, thresholds, and protocols, these radiation safety automated solutions empower your radiation safety committee to evaluate current imaging practices and determine where inefficiencies can be addressed or changes can be made to build a more robust radiation safety program. An automated radiation dose management system will allow your organization to receive consistent data, thus increasing efficiency in gaining a snapshot into your current environment, utilizing the information to educate physicians and employees, and consistently re-evaluating your radiation safety program on a regular basis.

Requirement 5: Policies, Procedures, and Risk Management

To gain organization-wide support and participation in your radiation safety program, it is imperative to develop organizationally-approved and clearly defined roles and responsibilities in your program’s policies and procedures. These should be a codified set of processes that address all components of a radiation safety program from imaging standards and dose thresholds, to dose incident management and patient communication. They must clearly define the rules and practices for all individuals supporting the radiation safety program. In particular, the policies and procedures should directly outline a process for tracking and reporting events where patient dose exposure exceeds the thresholds or guidelines developed and implemented by your organization. This risk management guide should to be followed to ensure all patient safety incidents are properly addressed and rectified in a timely manner with the proper resources involved.

Requirement 6: Communication, Education, and Training

As mentioned earlier, building a strong radiation safety committee that represents your organization is critical to ensuring the success of a radiation safety program. Consistent education and training among your organization’s executives, clinicians, technologists, patient care advocates, nursing staff, and everyone else involved in your radiology workflows are critical to the understanding and adoption of an effective radiation safety program and for providing your staff with a knowledge base to lead a successful transformation.

Requirement 7: Marketing Plan

Legislation and legal ramifications may have been the stimulus behind the initial dive into radiation safety awareness within the medical community. However, today’s urgency and demand for the adoption of a patient radiation safety program is coming directly from healthcare organizations themselves. A fully codified radiation awareness initiative and strong dose management program are invaluable additions to any healthcare organization striving to be competitive in the healthcare market. A radiation safety program is very attractive in today’s highly competitive world of healthcare, so make sure your organization is at the top of the list when it comes to providing the best possible radiology services and patient care and safety as it pertains to radiation dose measurement.

Neomi Mullens is a Project Manager at Ascendian Healthcare Consulting and a frequent and published contributor to the subject of Enterprise Dose Management and Tracking. You may contact her directly at nmullens@ascendian.com or visit the Ascendian website for more information at www.ascendian.com.


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