Policy and related procedures for independent image interpretation by consultant/advanced radiographer practitioners (plain film) x-ray imaging (G069)

Background

Initially this policy introduced a change in clinical practice and service delivery provided within the Radiology departments at Ayr and Crosshouse Hospitals. Its purpose remains to allow suitably trained Radiographers to issue clinical reports for specific examinations in a timely manner, thus, improving the patient pathway.

In accordance with a joint publication from the Royal College of Radiologists (RCR) and the College of Radiographers (CoR), (2012), ‘Team working within clinical imaging: a contemporary view of skills mix’, there must be a protocol for Advanced Practitioner reporting set within a system of work. This should be unique to the specific area of practice for the Advanced Practitioner.

This policy aims to:

• Recognise the specialist practitioner role; carrying out plain film reporting, assessment of their own specialist workload of patients, producing and maintaining associated report/patient records.
• Ensure that Consultant/Advanced Radiographer Practitioners report radiological examinations they have been adequately trained and authorised to do so.
• Ensure reports produced adhere to best practice (appendix 1)
• Optimise resources.
• Ensure safe working practices are maintained and reports are issued within protocol requirements.

Responsibilities

The Clinical Director for the service the policy operates within and the Medical Imaging Lead are responsible for ensuring that the operation of the policy does not compromise patient safety, and is consistent with professional relationships and accountability.

The consultant in charge of the patient’s care is ultimately accountable for their care. The medical staff or non-medical practitioner is responsible for the interpretation of the examination in the given clinical context.

A consultant/advanced radiographer practitioner who is authorised under Ionising Radiation (Medical Exposure) Regulations (IRMER) to report selected radiological investigations is responsible for ensuring that they are competent to undertake their duties. They are also responsible for ensuring that they have a clear understanding of the ethical and specific legal issues surrounding requesting radiological investigations, and that the procedure is carried out within the terms of this policy and according to their code of professional practice and conduct (HCPC, 2024).

Inclusion criteria for musculoskeletal (MSK) reporting

Only those members of staff that fulfil the following criteria are permitted to report radiological investigations:

• Have undergone (or are undergoing) a Masters level course (PgC, PgC or MSc) approved by the College of Radiographers and have met the required competencies. These will be assessed and approved by a nominated mentoring Radiologist/Consultant Radiographer.
• Have Consultant/Advanced Radiographer Practitioner status or are in training.
• Are able to provide evidence of continued post-registration experience / education.

Inclusion criteria for chest reporting

• Have undergone (or are undergoing) a Masters level course (PgC, PgC or MSc) approved by the College of Radiographers and have met the required competencies. These will be assessed and approved by a nominated mentoring radiologist.
• Are able to provide evidence of continued post-registration experience / education in the form of actionable CMD credits approved by the RCR.

Record of competency

A log of appropriately trained staff will be kept by the Medical Imaging Lead for each of the clinical areas working within this policy/procedure document. It is the responsibility of the non-medical healthcare practitioner to maintain competence in the relevant skill and to comply with radiology policy and IR(ME)R. (Appendix 2)

Once the radiographers are entitled under IRMER to report MSK images they will be asked to assist in the training of others where appropriate.  

The Radiology registrars at A&A have been supported by the radiographer reporting team for several years and part of that function is for the radiographers to verify reports for the registrars and also for radiographers in training which fall within their scope of practice. 

Monitoring and audit (MSK)

In order to monitor practice an audit will be completed in collaboration with radiology and relevant clinical areas. The audit will be completed and reported within agreed timescales and recommendations for future practice will be made.

The Consultant Radiographer will review 10% of reports per month for the first 6 months and after any progression (i.e. when the practionner progresses to paediatric reporting and then non trauma)
Thereafter approximately 5% of each practitioner’s reports will be peer reviewed monthly (10 cases per week)

A summary audit will be produced every 6 months for the clinical governance group, with an expected minimum accuracy rate of 95%. The audit will examine previously determined accuracy, specificity and sensitivity levels. In addition to this the following will be carried out:

• Peer review; 30 cases total (5 per practitioner). These meetings will take place every 2 months and are also the discrepancy meeting – ToR, (appendix 3)
• Self audit via review of discrepancy spreadsheet and clinical case notes (Appendix 4)

Monitoring and audit (chest)

In order to monitor practice continuous audit will be completed in collaboration with the mentoring radiologists. Following completion of the PgC the radiographer will complete a minimum of a further 1500 cases that will be double reported by a consultant radiologist. (Appendix 5a +5b).

With the 1500 cases that are required to complete the course this will bring the total number of cases double reported to at least 3000 before the radiographer is authorised to report autonomously.

The audit will be completed and reported within agreed timescales and recommendations for future practice will be made.

The mentoring radiologists will review 10% of reports per month for the first 6 months of autonomous practice and after any progression (i.e. when the practitioner progresses to GP reporting)

Thereafter approximately 2-5% of each practitioner’s reports will be reviewed monthly.

A summary audit will be produced every 6months for the clinical governance group, with an expected minimum agreement rate of 90%. The audit will examine previously determined accuracy, specificity and sensitivity levels. In addition to this the following will be carried out:

• Self audit via review at MDT meetings.

Scope of practice (MSK)

Reporting of images by Radiographers is an established service within Ayrshire and Arran and is supported by the Clinical Director of Radiology.

Consultant/Advanced Practitioners’ scope of practice includes:
Skeletal examinations requested for patients presenting for imaging, from Accident and Emergency, General Practitioners, Wards and Out-patient Clinics on any of the acute or community hospital sites.

Consultant/Advanced Practitioners may report images for adult or paediatric patients of the; appendicular skeleton (upper limb, up to and including the shoulder girdle; lower limb (up to and including the hip joint) and the axial skeleton (including pelvic girdle, spine, skull, facial bones) for:-

• Foreign body (FB) identification in any of the above; excluding soft tissue neck (oesophageal FBs) and pre MRI scan images.
• Patients who have presented with an injury.
• Patients requiring review post operatively/ post fracture.
• Potential calcific tendonitis in the shoulder ( over 16s only)
• Potential stress fractures.
• Patients with potential bone infections referred from the Emergency Department ( over 16s only) Following additional training this can be extended to include other referral sources.
• Patients presenting with issues related to the appendicular skeleton, shoulder, pelvis and spine where there has been no trauma but the most likely cause is osteoarthritis .
• Patients presenting from rheumatology OP clinics and GP services where inflammatory arthropathy is suspected.

Consultant/Advanced Practitioners will follow the standards and procedure for reporting set out in appendices 1 and 6 and must work within any limitation to the above as agreed with the Clinical Director of Radiology.

Audits must be produced to support extension of practice to include rheumatology referrals, non-trauma spines and patients attending with potential bone infections. 

Consultant/Advanced Practitioners will follow the procedure for highlighting potentially missed abnormalities to the Emergency Department in a timely and effective manner (appendix 7) as agreed with the Clinical Director of Emergency Department.

Scope of practice (chest)

Adult chest images (over 16 years of age) from referral sources within the hospital only (Emergency Department, ward patients and patients from outpatient clinics)

Following a period of preceptorship described in the audit and mentorship section above the radiographer will report chest images which initially will present via the wards, the emergency department, the clinical assessment unit and outpatient department.

Any subsequent progression to include referrals from GPs will require additional sign off from the radiologist mentors.

Exclusions (MSK and chest)

Probationary staff will work to more limited scope which will be agreed between the Advanced Practitioner and the Consultant Radiographer.

The probationer will progress to full scope gradually, with full scope expected to be achieved no more than 6 months post qualification (appendix 8). 

The practitioner continues to be able to ask the Consultant Radiographer for a second opinion whenever required. 

Scope of practice upper gastrointestinal (UGI) reporting

Only those members of staff that fulfil the following criteria are permitted to report radiological investigations:  

•  Have undergone (or are undergoing) a Masters level course (PgC, PgC or MSc) approved by the College of Radiographers and have met the required competencies.  These will be assessed and approved by a nominated mentoring Radiologist.
• Have Consultant/Advanced Radiographer Practitioner status or are in training.
• Are able to provide evidence of continued post-registration experience / education.

Monitoring and audit (UGI)

Initially a preceptorship period will be necessary for the reporting aspect of the post. 

It’s expected that a practitioner will have a minimum of 50 cases double reported post qualification. This is to ensure the reports are meeting the required accuracy level but also that structure and content of the reports is appropriate and clinically useful. 

There is no maximum time for a preceptorship but ideally the Radiographer and Radiologist mentor(s) will meet/ discuss the progression of the practitioner at intervals until the standard is met and the practitioner is provided with a letter of entitlement and authorised to report independently. 

 Following the period of preceptorship a review of 10% of reports per month should be undertaken for the first 6 months and after any progression (i.e. when the practitioner progresses to barium meal and water soluble swallow for post laryngectomy)  Thereafter approximately 5 of each practitioner’s reports will be peer reviewed monthly (average of 20 cases per month)   

 A summary audit will be produced every 6 months for the clinical governance group, with an expected minimum accuracy rate of 95%. The audit will examine previously determined accuracy, specificity and sensitivity levels. In addition to this the following will be carried out:  

• Peer review; ~10 cases. These meetings will take place every 4 months and are also REALmeeting – ToR, (appendix 3)    
• Self-audit via review of clinical case notes (Appendix 4)  

Inclusion criteria (UGI)

Adult examinations (over 16 years of age) from the following referral sources: 

• outpatient clinics
• general practitioner (GP) 

Following a period of preceptorship described in the audit and mentorship section above the Radiographer will report barium swallow examinations which will present via the outpatient department and referrals from GPs. 

Any subsequent progression to include referrals for inpatients will require additional sign off from the Radiologist mentors. 

Exclusions (UGI)

The weekly audit and bi monthly peer review will on occasion highlight discrepant findings in verified reports. Occasionally these will be also flagged by other means.

Whenever these discrepancies are found a learning form (appendix 9) must be completed (shared drive under audits/ discrepancy forms).

If the discrepancy is radiology only - that is the abnormality has been picked up and treated clinically by the referrer - then the discrepancy will be discussed at the next peer review/ discrepancy meeting. Usually no further action needs to be taken or there will be a learning review if it was found to be a cognitive error and shared with the group as a whole.

In the event a discrepancy is discovered that has also been missed by the clinical team there will be immediate communication to the team about the discrepancy and clinical decision will be made to review or treat the patient. This discrepancy will then be discussed at the next peer review/ discrepancy meeting and any learning fed back to the whole group.

All completed forms are forwarded to the Radiologist Lead.

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patient’s/carer’s preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline; however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Toolkit.

References

• Department of Health. 2003. Radiography skills mix – A report on the four-tier service delivery model.
• Health Professions Council, 2006. Standards of conduct, performance and ethics. Available from: https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics. [Accessed 18.05.2023]
• Ionising Radiation (Medical Exposures) Regulations 2000. HMSO 2000
• The NHS Career Framework available from https://webarchive.nationalarchives.gov.uk/ukgwa/20130123205232/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123205 [accessed 18.05.2023]
• Nightingale, J and Hogg, P. 2003. Clinical practice at an advanced level: an introduction. Radiography (9) 77-83
• Royal College of Radiologists & College of Radiographers. Team working in clinical imaging. 2012. Available from: https://www.rcr.ac.uk/system/files/publication/field_publication_files/BFCR%2812%299_Team.pdf
• Royal College of Radiologists, 2002. Clinical radiology: workforce in crisis. BFCR(02)1
• Royal College of Radiologists, 2006. Standards for the reporting and interpretation of image investigations. ISBN 1905034121
• Royal College of Radiologists, 2008. Standards for the communication of critical, urgent and unexpected significant radiological findings’ ISBN 9781905034277.

Bibliography

• Nightingale, J., 2008. Developing protocols for advanced and consultant practice, Radiography (14), e55 –e60.
• Owen, A., Hogg, P., Nightingale, J., 2004. A critical analysis of a locally agreed protocol for clinical practice, Radiography (10), p.139–144.
• Paterson, A., Price, R., Thomas, A., Nuttall, L., 2007. Reporting by radiographers: a policy and practice guide, Radiography (10), p205–212.
• The College of Radiographers, 2006. Medical image interpretation and clinical reporting by non-radiologists: the role of the radiographer, 2nd Edition. ISBN 1871101220.
• The Royal College of Radiologists, 2008. Standards for the communication of critical, urgent and unexpected significant radiological findings. London: The Royal College of Radiologists. ISBN 9781905034277.

Related NHS documents

• The role extension of “radiographer reporting” within NHS Ayrshire and Arran – a requirement of the review of imaging pathways. (Horsfield D, 2008)
• Business case for AHP Consultant Roles. (Horsfield D, November 2008)
• G3 Entitlement of referrers, operators and practitioners:- NHS Ayrshire & Arran Level 2 document - standard operating procedure. http://athena/imaging/teamsite/Shared%20Documents/IRMER%20Level%202%20Documents/RG03EntitleRefPracOpR.pdf[Only available on intranet]

In January 2007, the RCR and CSOR published ‘Team working within clinical imaging: A contemporary view of skills mix’. This publication details a framework for implementing skills mix in clinical radiology departments. These are summarised below, and form the basis of this reporting policy.

Effective and efficient service delivery

In the interests of the development of appropriate, effective and safe practice, the following principles must underpin all skills mix developments. They are:

• patient benefit
• strategic context
• education and training
• continuing professional development
• clinical governance
• legal and ethical framework.

Referrals, transference and delegation of care

A request for an imaging examination includes the provision of a medical opinion. Consultant Clinical Radiologists receiving requests may delegate this to individual radiographers and do so in accordance with the guidance from the General Medical Council (GMC)(2006) in that they retain responsibility for the medical management of the patient. They should be satisfied that the radiographer to whom the examination is delegated is competent.

For many examinations, including plain radiographic studies and ultrasound investigations, reporting radiographers/sonographers can receive, implement and complete referral examinations directly. However, delivery of these tasks must have been delegated and agreed in writing by the Lead Consultant Clinical Radiologist. The GMC guidance on transfer of care will apply.

Teams and roles within teams

As individuals take on less traditional roles they need to understand the importance of working within teams. No individual should work in isolation. It is essential that there is appropriately accredited medical clinical supervision in the context of the multidisciplinary team (RCR 2018), and recognition of both a clinical and professional governance framework with continued professional development, appraisal and professional support.

Individual responsibilities

Individual practitioners need to understand that they are legally accountable for their own actions and may be deemed negligent if they fail to demonstrate due care and diligence in performing their duties, including any delegated duties. Acting within a clinical team does not absolve any individual of personal responsibility and accountability in law.

Responsibilities of the medical practitioner

Consultant Clinical Radiologists are the key personnel for the provision of radiological opinions (in both the secondary and primary care sectors). Consultant Clinical Radiologists have the breadth of training and depth of knowledge to provide flexible, high quality clinical services.

Responsibilities of the employing organisation

Employers must agree and document skills mix and role developments at the local level and accept vicarious liability for staff undertaking new roles, duties and tasks. Employers must maintain clear, accurate records of employees who are trained and deemed competent to carry out extended roles, including the nature of the roles, duties and tasks involved. Such records should be readily available to all relevant staff affected by the skills mix and role development initiative, for example, Lead Consultant Clinical Radiologists, Radiology Service Managers and the staff to whom the records relate and refer.

Under IR(ME)R 2017 and all subsequent amendments radiographers who issue independent reports on any images must be entitled by the operational IRMER lead to do so.

A record of personal entitlement is kept for all radiographers by the Imaging Services Manager.

A link to the document outline is available here: 
http://athena/imaging/teamsite/Shared%20Documents/Forms/AllItems.aspx

Section : IRMER Level 3 -Staff - training records (57) Item 14 Personal Scope of Entitlement Record.

• Following a Significant Adverse Event Review (SAER) there is a need to formalise the outputs from the peer review meetings which happen every 2 months.
• A team secretary will be appointed and they will be responsible for minutes of these meetings, adding outcomes to the cases that are reviewed and, where necessary, forwarding the discrepancy outcomes to the Radiologist lead.
• The meeting will take the form of a Radiology Event and Learning (REAL) and learning from discrepancies should be recorded where appropriate.
• These meetings will continue to be held every 2 months usually on the last Wednesday of the month.
• The meetings will be held alternately on the Ayr and Crosshouse sites.
• The standing agenda will be:
  • Peer review cases- usually 2 radiographers from the preceding 2 months.
  • Discrepancy review/ interesting cases.
  • Team discussion – subjects will vary.

Reference: The Royal College of Radiologists. Standards for radiology events and learning meetings. January 2020. Available from: https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr201-standards-for-radiology-events-and-learning-meetings.pdf

Audit and monitoring: radiographer led reporting service: service priority & driver diagram

Appendix 5a: feedback form

Appendix 5b: audit/preceptorship sheet

Procedure for practitioner reporting MSK

Procedure for dealing with a discrepancy between the imaging report and Accident & Emergency (A&E)

Procedure practitioner reporting chest

Assessment criteria/record

Case to be discussed