Diagnostic Imaging Accreditation Scheme

Required Evidence

A documented safety and quality manual for the diagnostic imaging practice which addresses the practice’s:

• governance, policies and procedures regarding DIAS (Standard 1.1)
• registration and licensing of personnel (Standard 1.2)
• radiation safety and optimised radiation technique charts (Standards 1.3 and 3.2)
• diagnostic imaging equipment and servicing (Standards 1.4 and 1.5)
• healthcare associated infection policies and procedures (Standard 1.6)
• provision of diagnostic imaging services, reporting and recording image findings policies (Standards 2.1, 4.1 and 4.2)
• consumer consent and information policies (Standard 2.2)
• patient identification and procedure matching policies (Standard 2.3)
• medication management policies (Standard 2.4)
• diagnostic imaging protocols (Standard 3.1)
• consumer and stakeholder feedback and complaints policies (Standard 4.3).

Services are required to provide evidence to demonstrate that mechanisms are in place to evaluate, audit, review and monitor each one of the Standards and their specific actions.

Required Evidence

Copies of each registered health practitioner's Australian Health Practitioner Regulation Agency (AHPRA) registration documentation, or an AHPRA registration number which can be verified on the public register. These practitioners include:

• medical practitioners
• dentist
• medical radiation practitioners
• nurses and
• allied health practitioners (including podiatrists, osteopaths, chiropractors and physiotherapists).

Copies of the AHPRA registration documentation of each student who is registered on the AHPRA student register.

Where the practice provides imaging modalities that involve ionising radiation, copies of each registered health practitioner's Commonwealth, State or Territory radiation user licence (or similar), or a registration number which can be verified on the public register, if required in the relevant jurisdiction.

Copies of each non-registered health practitioner's Commonwealth, State or Territory radiation use licence, or a licence number which can be verified, if required in the relevant jurisdiction.

Where the practice provides ultrasound services, copies of each sonographer's statement of accreditation on the Australian Sonographer Accreditation Register (ASAR) or a registration number which can be verified on the ASAR register for the purpose of determining registration on the Services Australia Register of Sonographers.

Evidence that the registration status of practitioners is reviewed annually, in line with AHPRA's annual registration process.

Required Evidence

• Copies of relevant Commonwealth, State or Territory Radiation Safety Regulator equipment licences and registrations (or similar) or registration numbers which can be verified.
• Copies of radiation safety plans and all other relevant radiation safety documents required by Commonwealth, State or Territory radiation safety legislation, with evidence that they are reviewed a minimum of once per accreditation cycle.

Required Evidence

A current, documented equipment inventory which includes:

• the name of item;
• manufacturer; and
• serial number (or other identifier)

A copy of the most recent Services Australia Location Specific Practice Number (LSPN) register equipment record.

Required Evidence

Records and service reports, demonstrating the equipment used to provide images is serviced according to manufacturer’s guidelines by qualified persons and the requirements of applicable radiation safety legislation, including the:

• date of service, details and results of the service and the date of the next service; and
• actions taken at the practice in response to the results of the service.

A record of the service provider’s qualifications is to be provided to the approved accreditor, however they do not need to appear on every service report. The service provider shall:

• hold a radiation use licence (or similar) for service and repair (if servicing ionising radiation equipment) issued by the Commonwealth, State or Territory regulator relevant to where the service is performed; and
• provide evidence of successful completion of a recognised service training course appropriate to the equipment being serviced.

Required Evidence

A documented policy and procedure for preventing the transmission of infectious agents to patients and carers, healthcare workers, support staff and other visitors which includes the process for identifying, assessing and managing risks and reporting, investigating and responding to the transmission of infectious agents when they occur (Standard 1.1).

Where relevant, documented quality improvement activities, which describe the actions taken in response to the transmission of an infectious agent(s).

Where ultrasound services are being provided, a documented policy for reprocessing ultrasound transducers that is consistent with national standards and guidelines relating to disinfection.

Copies of consumer-specific information on the management and reduction of healthcare associated infections.

Required Evidence

For practitioners providing requested services:

• the practice must have a documented policy and procedure in response to inappropriate requests for diagnostic imaging procedures. (Standard 1.1)
• a sample of de-identified requests documenting the clinical need for the diagnostic imaging procedures rendered at the diagnostic imaging practice.

For practitioners providing self-determined services:

• a sample of de-identified records documenting clinical need.

Required Evidence

A documented policy and procedure for obtaining patient consent prior to a diagnostic imaging procedure being provided, ensuring that the consent requirements reflect the level of risk attached to each procedure. It is expected that practices obtain written patient consent prior to invasive or high risk procedures. (Standard 1.1)

A sample of de-identified records of consent obtained from the patient in respect of the diagnostic imaging procedure.

A sample of de-identified records documenting the patient’s health status, relevant to the diagnostic imaging procedure being undertaken, with regard to:

• asthma;
• previous exposure to intravenous contrast;
• allergies;
• medical conditions such as diabetes, kidney disease or heart disease;
• pregnancy status;
• medications such as metformin hydrochloride;
• breastfeeding; and
• medical devices and implanted devices such as intra- cranial aneurysm clips, cardiac pacemaker, coronary stents, intra ocular foreign bodies and cochlear implants.

Examples of service specific information for the diagnostic imaging services available at the practice.

A sample of de-identified records must be provided which demonstrate that risks have been advised to the patient.

Required Evidence

A documented policy and procedure for matching patients to their intended diagnostic imaging procedure including the report for that procedure, through all stages of the service and when transferring responsibility of care. (Standard 1.1)

A sample of appropriately de-identified records documenting the use of three patient identifiers.

A documented policy and procedure which sets out the process for reporting, investigating and responding to patient care mismatching events when they occur.

Where relevant, documented quality improvement activities, which describe the actions taken in response to patient care mismatching events.

1. using at least three (3) approved patient identifiers to match a patient to their request or medical record from the time the patient presents and through all stages of the diagnostic imaging service and when transferring responsibility of care;
2. correctly matching patients with their intended diagnostic imaging service and the anatomical site and side (if applicable) of the diagnostic imaging procedure;
3. utilising the 'time-out' technique for high risk procedures, including confirming the patient’s allergy status; and
4. reporting, investigating, and responding to patient care mismatching events when they occur and implementing changes, where relevant, to reduce the risk of future incidents.

Required Evidence

A documented policy and procedure describing the procedures for:

A documented management plan which identifies the procedures for managing adverse reactions at the time they occur;

Where a practice performs examinations using contrast, a documented protocol which ensures the appropriate use and administration of contrast.

A sample of de-identified records for relevant diagnostic imaging procedures documenting the information collected about the patient’s medication use and/or history regarding previous reactions to medications.

Example of records demonstrating managing adverse reactions at the time they occur.

Where relevant, documented quality improvement activities, which describe the actions taken in response to incidents related to medication management.

Required Evidence

Documented protocols for routine diagnostic imaging procedures or groups of diagnostic imaging procedures rendered at the diagnostic imaging practice, with evidence that they have been reviewed a minimum of once per accreditation cycle, which include all necessary information for the proper conduct of the examination taking into account any specifications for the required qualifications, experience and specialisation of the personnel. Where specific tasks are delegated to members of the imaging team, the protocols shall indicate any specific circumstances under which personnel shall seek further guidance and/or input from the supervising medical practitioner.

Required Evidence

A technique chart, consistent with the ALARA principle, for each unit of ionising radiation equipment located at the diagnostic imaging practice.

Ionising radiation equipment where settings are entered manually:

• evidence must be supplied that demonstrates the settings have been reviewed and authorised by a qualified person, annually for each episode.

Ionising radiation equipment where settings are embedded in the software and operators select a protocol:

• evidence must be supplied that demonstrates the underlying settings have been reviewed and authorised by a qualified person annually.

For each item of screening fluoroscopy equipment:

• a copy of a log of screening times, and evidence that the log has been reviewed by a qualified person annually.

For each item of interventional angiography equipment:

• evidence that system generated dose metrics have been logged and reviewed by a qualified person annually. If the interventional angiography equipment is not capable of generating dose metrics alternatively a copy of a log of screening times, and evidence that the log has been reviewed by a qualified person annually should be provided.

The practice must establish a program to ensure that radiation doses administered to a patient for diagnostic purposes are:

1. annually compared with diagnostic reference levels (DRLs) for diagnostic procedures for which DRLs have been established in Australia; and
2. if DRLs are consistently exceeded, reviewed to determine whether radiation protection has been optimised.

Required Evidence

A documented policy for the provision of reports to requesting practitioners and patients. (Standard 1.1)

A sample of de-identified imaging reports, consistent with the practice’s documented policy for reporting.

Where relevant, documented quality improvement activities, which describe the actions taken in response to feedback from requesting practitioners.

Required Evidence

A sample of de-identified records documenting the image findings and that show that it has been retained in the patient records.

Required Evidence

A documented policy for inviting, recording, managing and responding to feedback and complaints which is consistent with the principles of open disclosure and fairness, accessibility, responsiveness, efficiency and integration. (Standard 1.1)

Evidence of publicly accessible information for inviting, managing and responding to feedback and complaints which is consistent with the principles of open disclosure and fairness, accessibility, responsiveness, efficiency and integration.

Evidence of training practice staff in managing and responding to feedback and complaints.

A sample of de-identified feedback and complaints received and records of the actions taken.

Steps to becoming accredited

1. Obtain a Location Specific Practice Number (LSPN) or check that the LSPN you hold is valid by visiting the Services Australia website.
2. Determine if you are eligible for entry level accreditation or full suite accreditation.
   • Entry Level Accreditation: Practices seeking accreditation for the first time may apply for entry level accreditation, which requires compliance with Standards 1.2, 1.3 and 1.4 of the 15 diagnostic imaging standards. If these requirements are met, the practice is granted entry level accreditation for two years, after which it must transition to full suite accreditation. Entry level accreditation can only be held once.
   • Full Suite Accreditation: Practices must demonstrate compliance with all 15 diagnostic imaging standards. An accrediting agency reviews submitted documentation, and if all requirements are met, the practice is awarded full suite accreditation, valid for four years.
3. Select and engage an approved accrediting agency.
4. Apply to an approved accrediting agency in writing, specifying the diagnostic imaging practice and modalities to be accredited.
5. Complete the application process and provide the accrediting agency with the evidence required to undergo assessment.