Each year,
the Hospital attends 2,800,000 consultations,
manages 46,500 discharges and performs 52,000 surgical procedures in its 41 operating theaters.
It has a capacity of 785 beds,
of which 200 are for critical care,
and 800 beds of home medicine.
Its work team is made up of 9237 people: 3400 medical doctors,
3337 members of the health staff and 2,500 people from the administrative sectors.
As for the assistance it provides,
the Italian Hospital has more than 40 medical specialties,
a complete diagnostic and treatment equipment,
and a recognized professional staff.
In addition,
it has its own university that dictates careers in Nursing,
Medicine,
Biochemistry and Pharmacy,
and the Institute of Basic Sciences and Experimental Medicine.
The imaging department staffing is detailed in Table 1.
During 2018,
583,455 patients were attended (see distribution in Table 2).
Global political actions
1.- From the Head of the Imaging Department arose the idea for applying to become an EuroSafe Imaging Star institution.
2.- This idea was submitted as a major improvement in health care safety and quality to the main authorities of the Hospital (Medical Director,
Dean,
CEO,
etc).
3.- Approval of the hospital directory was obtained.
A task force was constituted (Head of the Imaging Department,
a radiologist specialized in quality and safety (Q&S)and two medical physicists) and started working on the first steps to proceed with the accreditation of the Hospital in the EuroSafe Imaging Stars program.
4.-A strategic decision of creating a Radioprotection Committee (RP) was decided institutionally,
which included the members of the aforementioned taskforce.
5.- The RPC integrated a multidisciplinary team of auditors (composed by medical experts in the use of ionizing radiation,
radiation physics,
radiation oncology,
nuclear medicine,
interventional radiologists,
etc.-) as well as experts in other safety and quality aspects of health care (clinical engineering,
occupational health ,
etc.) to perform an audit program.
A team leader was designated and responsible for organizing the tasks and preparing the final report making sure that no conflict of interest existed between the auditors and the areas to be audited.
Operative actions
1.- The quality manual was written.
One of the main tasks was education,
training in radiation protection,
information and use of written protocols.
2.- It was decided to give priority to the most sensitive areas: neonatology,
pediatrics and operating rooms.
3.- A basic knowledge survey was conducted in RPM among the staff of the institution through sampling of services and direct conversations with the staff to have a diagnosis about radioprotection knowledge.
4.- A training plan for referring physicians prescribing imaging studies was established.
5.- A training course with final evaluation on radiation and radioprotection for radiological technicians was conducted.
This course consisted of 5 classes of 1 hour and in three different shifts (morning,
afternoon,
night) so that all the personnel of Diagnostic Imaging could attend.
This is scheduled to be repeated and/or updated every year (Image 1).
6.- Quality control of the equipment of the Radiodiagnosis and Operating Rooms Service and determination of the reference doses for each practice and protocol with emphasis on pediatrics was performed.
7.- Monitoring through a radioprotection tracer checklist of radioprotection attitudes in the Operating Room.
This checklist is evaluated and once the main deviations have been determined,
re-training and educational actions with evaluation were carried out.
8.- Written and audiovisual material,
to communicate with patients and public about issues related to the RPM,
were uploaded to the Hospital's internal network and Hospital TV channel for consultation by staff and patients (Image 2).