The Practice Accreditation Standards – Entry Level Standards and the Full Suite of Practice Accreditation Standards
Information for practices regarding the Scheme’s Practice Accreditation Standards.
To demonstrate compliance against either the Entry Level Practice Accreditation Standards or the Full Suite of Practice Accreditation Standards practices will be required to submit an application to a Diagnostic Imaging Accreditation Scheme approved accreditor. Demonstrating compliance with the entry level standards or the full suite of fifteen Practice Accreditation Standards will require practices to collect and collate and in some cases design and develop documentary evidence. The practice’s chosen accreditor will then determine the extent of compliance with the standards by undertaking an off-site desktop audit of the documentary evidence.
Downloadable version of the Practice Accreditation Standards (PDF 47 KB) .
Stage II Diagnostic Imaging Accreditation Scheme – Standards
Part 1 Organisational Standards
Standard 1.1 Safety and Quality Governance StandardThe diagnostic imaging practice’s governance structure must be effective and comprehensive to ensure the delivery of safe, quality diagnostic imaging services.
A documented safety and quality manual for the diagnostic imaging practice which includes at a minimum:
(i) the practice’s policies and procedures regarding:
- the registration and licensing of personnel;
- diagnostic imaging equipment and servicing;
- radiation safety and radiographic technique charts;
- infection control;
- provision of diagnostic imaging services and reporting and recording image findings;
- consumer information;
- patient identification and procedure matching;
- medication management;
- diagnostic imaging protocols; and
- consumer feedback and complaints; and
(ii) the names of the persons at the diagnostic imaging practice who develop, approve, implement, maintain, and review these policies.Top of Page
Standard 1.2 Registration and Licensing Standard (Entry Level)Staff, contractors and any other practitioners providing services to the diagnostic imaging practice must have and maintain the appropriate and current registration and/or licence to undertake the diagnostic imaging procedures for which accreditation is sought in the State or Territory.
- Copies of State or Territory registration, or a registration number which can be verified, for all medical practitioners and other registered health professionals (such as dentists) employed by or providing services to the diagnostic imaging practice.
- Copies of each medical practitioner's State or Territory radiation operator’s licence, or a registration number which can be verified.
- Copies of each radiographer's State or Territory registration documentation, or a registration number which can be verified, if required in the State or Territory.
- Copies of each nuclear medicine technologist’s or similar State or Territory registration documentation, or a registration number which can be verified, if required in the State or Territory.
- Copies of each non-medical imaging practitioners’ State or Territory registration documentation, or a registration number which can be verified, if required in the State or Territory.
- Copies of the diagnostic imaging practice's radiographers’, nuclear medicine technologists' or other non-medical imaging practitioners’ State or Territory radiation operator’s licence, or a licence number which can be verified, if required in the State or Territory.
- Copies of each sonographer's statement of registration on the Australian Sonographer Accreditation Register or a registration number which can be verified for the purpose of determining registration on the Medicare Australia Register of Sonographers.
- Copies of each nurse's registration documentation or a registration number which can be verified, if the nurse undertakes or assists in the provision of a diagnostic imaging service.
- Copies of a medical physicist’s State or Territory radiation operator’s licence, or licence number which can be verified, if required in the State or Territory.
Standard 1.3 Radiation Safety Standard (Entry Level)A diagnostic imaging practice which uses ionising radiation must comply with the requirements of the current State or Territory radiation safety legislation.
- Copies of current State or Territory Radiation Safety Regulator equipment licences and registrations or registration numbers which can be verified.
- Copies of radiation safety plans and all other relevant radiation safety documents required by State or Territory radiation safety legislation.Top of Page
Standard 1.4 Equipment Inventory Standard (Entry Level)The diagnostic imaging practice must maintain a current equipment inventory demonstrating that relevant equipment used to provide diagnostic imaging services is registered with Medicare Australia and complies with specifications in the Medicare Benefits Schedule.
A current equipment inventory which includes information relating to:
- name of item, manufacturer, serial number (or other identifier); and
- registration on the Diagnostic Imaging Register (including citation of the relevant Location Specific Practice Number (LSPN)).Top of Page
Standard 1.5 Equipment Servicing StandardEquipment used to acquire or print images for diagnostic imaging procedures must be safe and appropriate for its intended use.
Records and service reports, demonstrating the equipment used to provide images is serviced by qualified persons according to manufacturer’s guidelines and the requirements of applicable radiation safety legislation, including the:
- date of service, who provided the service and their relevant qualifications, 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.Top of Page
Standard 1.6 Infection Control StandardThe diagnostic imaging practice must mitigate the risk of the transmission of infectious agents to patients, carers, healthcare workers, support staff and other visitors, by:
- assessing and managing the risk of the transmission of infectious agents;
- meeting the requirements specified in infection control guidelines/policies produced by Commonwealth, State and Territory government authorities; and
- reporting, investigating, and responding to incidents at the diagnostic imaging practice arising from the transmission of infectious agents.
- A documented policy for preventing the transmission of infectious agents to patients and carers, healthcare workers, support staff and other visitors which includes the process for assessing and managing risks; and reporting, investigating and responding to the transmission of infectious agents when they occur.
- Where relevant, documented quality improvement activities, which describe the actions taken in response to the transmission of an infectious agent(s).Top of Page
Part 2 Pre-Procedure Standards
Standard 2.1 Provision of Service StandardDiagnostic imaging procedures are only undertaken at the diagnostic imaging practice where there is an identified clinical need and:
- upon receipt of a request from a medical practitioner or a practitioner specified in the Act for the purpose of requesting services of that kind and for which a medicare benefit is payable; or
- where the practitioner interpreting the image is permitted to self determine the service for which a medicare benefit is payable under the Act.
A sample of requests or records documenting the clinical need for the diagnostic imaging procedures rendered at the diagnostic imaging practice.Top of Page
Standard 2.2 Consumer Information StandardPrior to a diagnostic imaging procedure being rendered, except in cases of emergency, the diagnostic imaging practice must ensure that:
- patients have access to information about the diagnostic imaging procedure;
- risks are advised to the patient or substitute decision maker;
- practice staff obtain and record relevant information about the patient’s health status and individual patient risk factors; and
- consent for the diagnostic imaging procedure is obtained from the patient or the substitute decision maker.
1. Examples of service specific information for the diagnostic imaging services available at the practice.
2. A sample of records documenting the patient’s health status, relevant to the diagnostic imaging procedure being undertaken, with regard to:
- previous exposure to intravenous contrast
- medical conditions such as diabetes, kidney disease or heart disease
- pregnancy status
- medications such as metformin hydrochloride
- medical devices and implanted devices such as intra- cranial aneurysm clips, cardiac pacemaker, coronary stents, intra ocular foreign bodies and cochlear implants
3. A sample of records documenting risks have been advised to the patient.
4. A sample of records of consent obtained from the patient in respect of the diagnostic imaging procedure.Top of Page
Standard 2.3 Patient Identification & Procedure Matching StandardThe diagnostic imaging practice must ensure that all patients are correctly identified when rendering a diagnostic imaging service by:
- using at least three (3) 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;
- correctly matching patients with their intended diagnostic imaging service and the anatomical site and side (if applicable) of the diagnostic imaging procedure; and
- reporting, investigating, and responding to patient care mismatching events when they occur and implementing changes, where relevant, to reduce the risk of future incidents.
- A documented policy for matching patients to their intended diagnostic imaging procedure including the report for that procedure, and through all stages of the service and when transferring responsibility of care.
- A sample of records documenting the use of three patient identifiers.
- A documented policy 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.Top of Page
Standard 2.4 Medication Management StandardThe diagnostic imaging practice must ensure that medication risks are managed by:
- correctly and safely storing, preparing and disposing of medications in accordance with manufacturer’s guidelines;
- identifying patients at risk from adverse reactions;
- administering medication safely and actively monitoring the effects of medication;
- personnel capable of providing timely and appropriate care in the event of an adverse reaction to medication; and
- reporting, investigating and responding to incidents arising from adverse reactions or medication mismanagement.
1. A documented policy describing the procedures for:
- storing, preparing and disposing of medications;
- identifying at risk patients;
- administering medications safely;
- monitoring the effects of medication; and
- reporting, investigating, and responding to adverse reactions or medication mismanagement incidents when they occur.
2. A documented management plan which identifies the procedures for managing adverse reactions at the time they occur; the type and location of resuscitation equipment and associated drugs at the practice; and the personnel certified in Cardiac Pulmonary Resuscitation (CPR) and qualified to use resuscitation equipment and drugs.
3. A sample of records for relevant diagnostic imaging procedures documenting the information collected about the patient’s medication use and/or history regarding previous reactions to medications.
4. Where relevant, documented quality improvement activities, which describe the actions taken in response to incidents related to medication management.Top of Page
Part 3 Procedure Standards
Standard 3.1 Diagnostic Imaging Protocol StandardThe diagnostic imaging practice must have documented protocols which describe the required projections and/or manoeuvres required for the acquisition of diagnostic quality images.
Documented protocols for common diagnostic imaging procedures or group of diagnostic imaging procedures rendered at the diagnostic imaging practice.
Standard 3.2 Technique Charts StandardA diagnostic imaging practice which uses ionising radiation must ensure that patient radiation exposure is kept as low as reasonably achievable (ALARA) by selecting equipment and techniques for diagnostic imaging procedures sufficient to provide the required clinical information.
A technique chart, consistent with the ALARA principle, for each unit of radiographic equipment located at the diagnostic imaging practice.
Part 4 Post Procedure Standards
Standard 4.1 Communicating with Requesting Practitioners StandardThe diagnostic imaging practice effectively communicates the results of a requested diagnostic imaging procedure by:
(a) providing timely, clear and concise written reports which address the information:
i. requested by the requesting practitioner;
ii. required by the diagnostic imaging service; and
iii. necessary for the interpretation of the images;
(b) taking all reasonable steps to personally advise the requesting practitioner (or another practitioner where necessary) about urgent and unexpected findings; and
(c) responding to feedback and requests from requesting practitioners about the content or provision of reports and/or advice provided.
- A documented policy for the provision of reports.
- A sample of 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.Top of Page
Standard 4.2 Results of Self-Determined Services StandardWhen the service is a self-determined service, information about the results of the diagnostic imaging procedure must be documented.
A sample of records documenting the image findings.
Standard 4.3 Consumer Feedback and Complaints Management StandardThe diagnostic imaging practice must provide opportunities for, and respond to, feedback and complaints from patients or carers about the provision of a diagnostic imaging service.
- 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.
- A sample of feedback and complaints received and records of the actions taken.
Guidelines to assist practices to demonstrate compliance against Entry Level and Full Suite of Practice Accreditation Standards are available for download. Available in word format are templates that can be downloaded, modified and used by practices to assist in complying with accreditation under the Scheme.
The full suite of Practice Accreditation Standards comprises three entry level standards, plus an additional twelve standards:
Standard 1.1—Safety and Quality Governance Standard
Standard 1.2—Registration and Licensing Standard (Entry Level)
Standard 1.3—Radiation Safety Standard (Entry Level)
Standard 1.4—Equipment Inventory Standard (Entry Level)
Standard 1.5—Equipment Servicing Standard
Standard 1.6—Infection Control Standard
Standard 2.1—Provision of Service Standard
Standard 2.2—Consumer Information Standard
Standard 2.3—Patient Identification & Procedure Matching Standard
Standard 2.4—Medication Management Standard
Standard 3.1—Diagnostic Imaging Protocol Standard
Standard 3.2—-Technique Charts Standard
Standard 4.1—Communicating with Requesting Practitioners Standard
Standard 4.2—Results of Self-Determined Services Standard
Standard 4.3—Consumer Feedback & Complaints Management Standard
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