Revamping Your Dose Safety Policies and Procedures: Part 2

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NeomiNeil SinghBy Neomi Mullens and Neil Singh 

In part one of this article series, we discussed why your policies and procedures manual needs a makeover and how to develop your new manual. This final part of our series will discuss implementing your new radiation dose policies and procedures.


Implementing & Managing Your New Policies and Procedures

When implementing your imaging policies and procedures, you must remember it’s not just the policies and procedures being implemented, it’s an entire program. The implementation strategy will fail if there are holes in the imaging policies and procedures. Regardless, as a healthcare organization embarks on the radiation safety program initiative, it is imperative the organization is transparent. For a successful end user adoption, whether it is just an update to your policies and procedures or an entire patient radiation safety program, you must begin with clear and adequate communication to all members of the organization impacted by the change. As a program manager, be prepared with clear and concise workflows for all caregivers involved, as well as developing an ongoing staff and patient education/training process. Educating caregivers on the big picture regarding radiation safety and including them in organizational discussions and workflow enhancements will allow clinical end users to become involved in radiation dose management initiatives and thus more readily adopt new standards.

It is imperative that healthcare organizations are proactively seeking to enhance patient focused radiation safety efforts by going further than simply meeting compliance regulations. Key stakeholders within an organizationally defined radiation safety committee should be driving clinical teams to become educated on the many components of a robust radiation safety program. Following an assessment of workflows within your current clinical environment and identifying gaps or changes that need to be addressed, the implementation of new processes or IT enhancements can begin.

The revision of CT protocols and imaging techniques being utilized by technologists is another key step in ensuring the best patient care is being provided safely and appropriately within your radiology department. Dose thresholds should be regularly evaluated and maintained in alignment with recommended industry standards.

The rules and practices for all individuals supporting the radiation safety program should be clearly defined, including risk management guidelines to be followed in the event that a patient’s dose exposure exceeds the organization’s defined thresholds. The risk management guide should be adhered to in the event of any radiation safety incident to ensure incidents are addressed and rectified in a timely manner with the proper resources involved.

Now more than ever, radiation safety initiatives are at the forefront of the healthcare industry and on display both nationally and internationally. Empowering your organization with a fully codified radiation safety awareness initiative and strong dose management program exemplifies a genuine commitment to patient safety and solid foundation for offering best practices in radiology and imaging services.

If you have implemented any sort of automated dose management solution (Radimetrics, DoseMonitor, Sectra, GE, iMalogix, etc.) you will be able to trend and report your organization’s imaging practices and protocols almost immediately, dependent on the data available in the system (some systems are also able to process legacy data). As a program manager and the keeper of the policies and procedures, you must review and update the data reported by the automated solution and update your imaging policies and procedures as it relates to the information discovered at least for the first 6 to 12 months. It is after the automated dose data reports normalize that a program manager can begin the annual policies and procedure update cycle.

As a program manager, you must remember it’s not policies and procedures management, it’s program management. As you continue developing your organization’s internal patient radiation dose safety program, complete these three simple statements:

  • Today, my patient radiation dose safety program looks like ________.
  • I like my patient radiation safety to be _________.
  • I will measure the success of my patient radiation dose safety program by __________.

Having a third party organization review your policies and procedures can give you a fresh set of eyes not only on the documents, but also the processes and technology components that will drive true change across your enterprise.


The American College of Radiology. House of Representatives Passes 12-Month SGR Patch; Numerous ACR Supported Imaging Provisions Included in Legislation. 2014. Available at: Accessed May 13, 2014.

The Joint Commission. Prepublication – Diagnostic Imaging Services Requirements. 2013. Available at: Accessed May 13, 2014.

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 or visit the Ascendian website for more information at

Neil Singh is a Senior Consultant at Ascendian Healthcare Consulting and a frequent speaker and published contributor to the subject of Enterprise Dose Management and Tracking.

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