- Open Access
The current status of radiological clinical audit - an ESR Survey of European National Radiology Societies
© The Author(s). 2019
- Received: 12 March 2019
- Accepted: 18 March 2019
- Published: 9 May 2019
The importance of clinical audit in radiological practice is increasingly recognised and undertaking clinical audit “in accordance with national procedures” is mandatory for radiology departments within the European Union following implementation of the Basic Safety Standard Directive (BSSD), 2013/59/Euratom in 2018.
This survey, sent to all National Radiological Societies in Europe in 2018, evaluated the current status of clinical audit at national level and supporting infrastructure, and explored the potential for wider co-operation and collaboration in developing and evaluating clinical audit processes.
Responses were received from 36/47 (76.6%) National Societies. Broadly responses indicated an increasing awareness of the importance of clinical audit, but highlighted deficiencies in necessary infrastructure and resources required for enhancement and development of existing clinical audit systems. National Societies are well placed, in the context of appropriate and prioritised resource allocation, to collaborate with other European bodies, in particular the European Society of Radiology (ESR), to help lead on these important changes, with the potential to provide external direction.
- Clinical audit
- National Radiology Society
- Radiation protection
- Basic Safety Standards Directive (BSSD), 2013/59/Euratom
Effective clinical audit is a key priority for all radiology departments across Europe, with the potential to improve patient care and outcomes.
The 2018 BSSD (2013/59/Euratom) mandates undertaking radiation protection clinical audit “in accordance with national procedures” within radiology departments.
There is increasing emphasis on external direction of internal departmental clinical audit, with oversight/accreditation provided by suitable professional, or scientific national bodies.
36/47 (76.6%) of European National Radiology Societies responded to a 2018 ESR survey evaluating the current status of radiological clinical audit.
Responses revealed an appreciation of the importance and role of clinical audit, but highlighted shortfalls in necessary resourcing and infrastructure that could facilitate wider and more effective involvement of national societies.
Clinical audit is a well-established and valuable tool in modern healthcare systems, it is of particular relevance to radiologists due to its incorporation into the Basic Safety Standards Directive (BSSD 2013/59/Euratom) . Carrying out clinical audit “in accordance with national procedures” is mandatory and a legal requirement within the European Union as a result of implementation of the updated BSSD in 2018. Clinical audit also has an important role in evaluating everyday service provision and clinical practice - regulatory clinical audit is centred around radiation protection and the requirements of the BSSD, it is a priority for all radiology departments and is compulsory.
In addition to developing processes around internal departmental clinical audit, there is a drive also to set up national processes of external audit. This might involve a multidisciplinary external auditing team working with radiology departments to carry out cross-centre external audit. Another option could include internal departmental audit with external direction. Setting up an external audit system would depend upon local/national resources and priorities, with oversight/accreditation (external direction) by a suitable professional or scientific national body, separate from the national regulatory authority (and also separate to any national processes of inspection). National radiological societies would be well placed to provide necessary oversight and co-ordination, recognising the logistic and funding implications involved.
Clinical audit is a subject of high priority for the ESR, with the ESR working collaboratively with other organisations, including the Heads of European Radiological Protection Competent Authorities (HERCA) to improve patient safety and quality of care across Europe. As part of its commitment to clinical audit the ESR produced Esperanto – the ESR Guide to Clinical Audit and Clinical Audit Tool  in 2017. This was widely distributed among ESR members, with copies also sent to all National Radiology Societies across Europe. A second updated version of Esperanto is to be launched at the European Congress of Radiology (ESR) in 2019 , with an enhanced audit section and an expanded number of 30 clinical audit templates. This development and implementation of a clinical audit tool was a key action (action 6) within the ESR EuroSafe Imaging Call For Action 2018 .
To establish the logistical and administrative infrastructure available for clinical audit at local and national levels.
To evaluate awareness of Esperanto and its impact.
To explore the challenges around developing a pan-European audit/survey network.
To clarify national arrangements for BSSD implementation and development of responsibility for clinical audit.
This paper is best read in conjunction with the results and findings of another ESR survey undertaken at the same time, evaluating uptake of BSSD requirements (with an emphasis on clinical audit) across European EuroSafe Imaging Star radiology departments .
National Societies audit survey results
Yes - high priority
No - but becoming more important
No - not currently
Is the promotion and development of clinical audit currently a high priority in your national society?
In development / under consideration
Do you have an administrative facility within your national society responsible for the promotion and development of clinical audit?
Partial - some, not all
Do you have a functional means of communication (post, email, fax) with all radiology departments in your country?
Yes - but not regularly
Do you communicate on a regular basis with - and receive feedback/comments from radiology departments in your country e.g. announcement of new developments, guidelines, standards?
Some, not all
Do radiology departments in your country have adequately resourced and funded internal administrative support to support departmental participation in clinical audit?
Internal departmental resources
Industry / private finance
If the answer to question 5 is "yes", departmental audit is funded and supported, what is the usual source of this funding (you may tick more than one response)?
Yes, all departments - led by national society
Partial, some departments - led by national society
Yes / partial - national society does not lead
Is there a co-ordinated national programme of clinical audit in your country involving all radiology departments?
No (skip to Q10)
The ESR sees development and support of clinical audit as a high priority - the first edition of Esperanto, the ESR Clinical Audit Guide, was sent to national societies in Europe in 2017. Is your national society aware of this publication?
Yes - sent to all
Yes - partial distribution
No - but proposed
No - and not proposed
Unaware of this publication
Has your national society distributed the ESR Esperanto Clinical Audit Guide to radiology departments in your country?
Yes - mainly positive
Yes - mixed
Yes - mainly negative
Has your national society had feedback from radiology departments on Esperanto?
No - not at this time
In principle would your national society support a pan European survey involving all eligible radiology departments (departmental identity kept confidential) evaluating compliance with any national regulatory requirements in place and intended to transpose Council Directive 2013/59/Euratom (BSSD) requirements?
Potentially - but internal investment needed
No - not at this time
If a pan European survey was proposed, does your national society have the necessary infrastructure and administrative resources to support this project?
legal requirement with regulatory oversight
legal requirement with no specific oversight or checking
no specific provision at the moment
How has the Euratom requirement that "clinical audits are carried out in accordance with national procedures" been transposed into national law in your country?
individual pratictioner responsibility
How do your national procedures regulate responsibility for clinical audit?
ESR National Societies
47 (as of Nov. 2018 - 48 national societies in total)
As previously alluded to, the development, implementation and documentation of robust processes of clinical audit is a key priority for all radiology departments across Europe. There is an appreciation of this at national level, as demonstrated in the survey, with clinical audit seen as a high priority in 42% of respondents and becoming more important in 47% (of note 11%, 4 respondents, did not see clinical audit as a high priority).
22% of national societies have an administrative facility dedicated to clinical audit.
72% have a functional means of communication with all radiology departments within their country.
Only 36% are in regular communication with radiology departments.
In only 11% of radiology departments is there a resourced and funded administrative support for audit, or a national co-ordinated programme of clinical audit.
The ESR Clinical Audit Guide, Esperanto, is a key initiative providing practical advice and support for radiology departments, particularly those who are early on in the clinical audit development pathway. The ESR has developed an enhanced version of Esperanto (for 2019) and the ESR will need to work closely with all National Radiology Societies to improve awareness of this important publication, but also to encourage wider distribution and end-user feedback on its utility at a local level.
The BSSD is legislation aimed at European Member States and how clinical audit is developed within individual member states is not specified. If an individual country devolves responsibility for clinical audit to the hospital (or employer/undertaking - see survey findings for these responses), then there would be no legal requirement for a National Society to involve itself in the undertaking of BSSD-related clinical audit. It should be noted from the survey that 16 of the respondents (44.4%) indicated there was no specific provision for transposition of the BSSD requirements around clinical audit into national law in their country at the time of the survey (these results may be subject to change, but give a 2018 baseline).
Although there might not be a legal obligation, the increased focus on clinical audit does provide an opportunity for National Radiology Societies to lead and direct national clinical audit activity. There is considerable potential for pan-European collaboration, working with European professional bodies (in particular the ESR) to develop audit programmes and to undertake multi-centre and multi-national surveys and audits. A recognition at national society level of this potential can be seen in survey responses, with 33/36 respondents in support (in reality, or potentially) of a pan-European BSSD uptake survey. The importance and potential benefits of increased national society input into local audit processes are highlighted by the findings of the companion BSSD uptake survey amongst EuroSafe Imaging Star departments , revealing a lack of compliance in some key BSSD radiation protection requirements. It is important to acknowledge that such developments will have resource implications, with only 3 respondents considering themselves to have the necessary infrastructure in place to support such a pan-European project.
This pan-European survey of National Radiology Societies had a high response rate and is likely to be representative of European procedures and practice. The survey reveals an acknowledgement amongst National Radiology Societies of the importance of development of clinical audit processes and a desire to become more involved, working with key stakeholders like the ESR. Logistical and administrative infrastructure development is key, this will require resource prioritisation and allocation at national and local governmental level. As multi-agency co-operation and collaboration in clinical audit matures and progresses across Europe, appropriately resourced National Radiology Societies will be well placed to help lead this process.
ESR National Radiological Societies of European countries as defined by the ESR Executive Council are listed at the following link: https://www.myESR.org/about/organisation/institutional-member-societies
At the time of the survey there were 47 ESR national member societies. Subsequent to the survey a further society became ESR member. As of February 2019, the ESR counts 48 national member societies.
This paper was prepared by members of the ESR Audit and Standards Subcommittee (David C Howlett, Subcommittee Chair 2018 – present, Adrian P Brady, Chair of the ESR Quality, Safety and Standards Committee, 2017 – present, Steve Ebdon-Jackson, member ESR Audit and Standards Subcommittee, 2017 – present, Christoph D Becker, National Societies Chair and member of the Audit and Standards Subcommittee, 2016 – 2019, Monika Hierath and Rossella Curcio, ESR Office) on behalf of the European Society of Radiology (ESR).The paper was lapproved by the ESR Executive Council in February 2019.
The authors gratefully acknowledge the valuable contribution to the survey of all those National Radiology Societies who participated.
The authors declare that this article has not received funding.
Availability of data and materials
All data generated or analysed during this study are included in this published article.
The authors read and approved the final manuscript.
Ethics approval and consent to participate
Consent for publication
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