Preparations for the accreditation procedure had started since 2014.
Department head formed a group of motivated personnel from the radiology department staff (radiologists,
medical physicists,
radiographers and nurses) who undertook specific responsibilities in the different tasks of the project.
An advisory company was also selected by the administration,
to guide the procedures under the supervision of the “quality office” of the hospital.
A quality management system was introduced in order to anticipate integration of all procedures necessary for the fulfillment of the quality policy of the radiology department and its objectives,
and meet the needs and requirements of users,
including the provision of advice and diagnosis.
The main points and scopes that were included in different areas were as follows
1.
Organization and management: the radiology department management should ensure the proper functioning of it and the continuous improvement of services provided.
The scientifically responsible radiologist and the radiation consultant or radioprotection responsible person,
whose activities and duties are in accordance with the regulatory framework for ionizing and non-ionizing radiations were appointed.
2. Control of documents: all documents,
including those in electronic form,
issued as part of the quality management system,
were checked and approved by authorized personnel prior to their adoption. The use and maintenance of updated versions of existing regulations,
standards and other regulatory documents was ensured.
3.
Service agreements: authorized medical staff evaluates the referrals and adopt the appropriate imaging processes,
provided that the selected examination procedures are sufficient to meet the needs of the patients and those using ionizing and non-ionizing radiation take into consideration the radiation protection and safety of the patients,
and staff.
4.
External supplies and services: a documented procedure was established for the evaluation and selection of services,
equipment,
drugs,
contrast media and consumable materials that affect the quality of radiology department services.
5.
Consulting services: specific arrangements were made for communicating with the users of our services (e.g advice on the choice of examinations and use of services,
including the indicated examination,
clinical indications and limitations of an examination and frequency of a reexamination,
especially those using ionizing radiation).
6.
Resolution of complaints: a procedure was established to manage any complaint or other comments received from users of our services.
7.
Identification and control of non-conformities: a documented procedure was established for the identification and management of non-conformities,
in every aspect of the quality management system,
including quality control,
internal audits,
and examination procedures,
reporting results,
imaging equipment,
radiation protection,
security and administrative issues.
8.
Record keeping: records were kept in printed or electronic form as anticipated and required by accreditation standards and other regulations.
9. Quality control: internal quality control procedures were implemented including internal audits,
to ensure:
a) examinations are conducted in a way that meet the needs and requirements of the
patients and the referring physician;
b) compliance and continuous improvement of the quality management system.
10. Risk management: the operating methods were evaluated for eventual failures of the
examination results that affect the patients’ health and the relevant procedures were modified when needed (e.g possible pregnancy).
11.
Staff: a procedure for the management of staff was established (job descriptions,
qualifications of each person - certificates of education,
training,
experience and skills required,
continuing education,
etc.).
12.
Facilities and environmental conditions: adequate facilities,
sufficiently accommodated and controlled were provided to ensure the quality and effectiveness of services provided,
as well as hygiene,
safety and radiation protection of the patients,
the staff,
the public and the environment.
13.
Radiation protection: specific measures were taken to optimize the exposure of patients to ionizing and non-ionizing radiation in accordance with the regulatory framework and relevant records are kept to document radiation protection of personnel,
patients,
public and environment from the radiology department activities.
14. Equipment: a documented procedure was established for quality control of equipment
that directly or indirectly may affect the examination results and the protection of the patients.
15.
Examination procedures: working protocols were written for all exams.
Examinations with ionizing radiation are performed when alternative non-ionizing examinations are excluded or relevant data of the patient are taken into account.
16.
Reporting of results: structure reporting system was adopted and confidentiality was ensured.