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Problem Statement

CM Health Radiology Department attained accreditation against the New Zealand Code of Radiology Management Practice: Radiology Services – Particular Requirements for Quality and Competence, and numerous other guidelines and legislation, in 2007. This is an annual assessment whereby a team of technical experts are invited to assist the accrediting body International Accreditation New Zealand (IANZ) periodically.

What are we trying to achieve?

To maintain accreditation status with few or no correction action requests. (In 2018 there were four correction action requests).

What have we done?

The 2019 assessment was conducted solely by a lead assessor from IANZ over three days (26 to 28 June).

What did we find?

The assessment confirmed that the service continued to generally to meet the various requirements of accreditation.

No correction action requests (renamed from 2019 as major conformances) were raised against Radiology.

The following table lists the minor conformances in categories.

The following issues were noted regarding accommodation.

  • Accommodation had been raised in past IANZ reports with significant issues identified. The Radiology Service had been directed to initiate planning to develop the new site in Harley Gray, including the planned radiology hub at Manukau SuperClinic to increase capacity for elective imaging away from the Middlemore site and to allow space for an anticipated additional CT scanner in 2020/2021. Some funding had been allocated for the radiology relocation and Manukau SuperClinic hub construction. Furthermore, significant plans had been developed, including alternative options should the primary plan be declined or significantly amended. Due to various reasons, additional funding was being sought, with reapproval by senior management having been granted, and awaiting further regional committee and Ministry of Health approval for final sign-off. Provision of quarterly reports to IANZ to ensure progress in the capital approval process and adoption of proposed plans to a fruitful resolution is required.
  • The Accident and Emergency Mangere site included an X-ray unit. The GP practice owned and managed the equipment. However, the unit was operated by onsite MRTs and the images were reported by DHB radiologists. A review of the records and QHP reports indicated this unit was suboptimal, with many radiologists raising significant concerns. Although the site was not yet IANZ accredited, the service was responsible for its management and oversight. During the assessment, the assessor was informed that the Accident and Emergency practice had agreed to purchase a new X-ray unit. As all aspects the service had oversight for was accredited, the service is required to append a disclaimer to final examination reports to clearly indicate the examinations from this site remained unaccredited. Alternatively, extending the scope of accreditation to include this site once the new X-ray unit is installed and operational is required.

The Radiology Service is expected to inform IANZ on progress made in these areas.

In addition high numbers of staff vacancies, particularly for MRTs , were an ongoing issue, and various strategies were being employed to attract trained staff. This shortage impacted on workload and wait lists.

How did we make a difference?

Radiology continues to improve the management of its document control, with some modalities further along than others. Reducing the use of hard copy has been put forward as a two-year project, with the aim to give all access to electronic versions in the CMH document management system Objective.

Not all QC results are recorded electronically – an initiative expected to be implemented across the service.  

Where to from here?

Diagnostic mammography had been included as part of the accreditation process for Radiology since 2007.

The Breast Screen Counties Manukau Breast Imaging Service, which provided diagnostic mammography services on behalf of the Radiology Department was difficult to separate. Therefore, management had requested to have this modality removed from the scope of accreditation. A separate application for accreditation was expected by the Breast Screen Counties Manukau.

The service’s schedule to its certificate of accreditation will be extended to include CT scanning and general radiography at the Emergency Department in the McIndoe Building (which had been inadvertently omitted), and MR imaging at the new site in the Harley Gray building.

The Women’s Health OGUS was removed from the scope of accreditation, at the request of management.

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