Programme Implementation

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1. Introduction
2. Site planning
3. Radiation shielding
4. Equipment selection
5. Staffing levels

Introduction

Radiological imaging has a fundamental role in accurate diagnosis and successful treatment of patients, as a result the implementation must be carefully evaluated according to the local situation. In the gradual development of the imaging capacities, different implementation scenarios may be considered, depending on the imaging needs and available resources. The implementation of a medical imaging project is a complex undertaking that requires a management strategy with significant input from all stakeholders to create a useable end product.

At present, the availability of imaging services is highly variable between countries, but also within countries, irrespective of their development status.  X ray modalities such as interventional, CT or MRI equipment are often found only in urban centres, while outlying clinical facilities are equipped with simpler technologies (X ray and ultrasound). In general, the nature of the health care infrastructure tends to dictate the level of technology required to deliver effective imaging services.

Site planning

Medical imaging requires adequate infrastructure, well-maintained equipment, and appropriately trained personnel. In addition, a quality assurance program should be implemented that ensures that diagnostically and clinically valuable information about the patient being examined is obtained with minimal radiation exposure. In addition to human and financial resources, selection of the implementation scenario is highly dependent on the local infrastructure, e.g.  electricity and water supplies, temperature and humidity control, IT infrastructure, etc. Furthermore, adequate maintenance of the equipment, service contracts and warranties and necessary software updates must be considered.

The capital cost of equipment is often seen as the primary factor in the implementation of an imaging service. However, investment in capacity building is needed to ensure there are enough trained staff capable of performing their work safely and effectively. In addition, when purchasing medical imaging equipment, it is very important to consider all costs, including spare parts, maintenance, hardware and software upgrades, and staffing costs.

In site planning, an important general rule is that maintaining long term sustainability is more complex than the original purchase and installation. As modern medical imaging is based on more complex technology, the reliability of imaging services depends even more on the sustainable quality of the building and the necessary utility systems. For example, digital imaging may require one or more computer servers and a computer network and importantly, measures must be taken to prevent loss of or damage to patient information.

The imaging procedures usually take place in a fixed location, either as part of a hospital or stand-alone facility. Planning of an imaging facility layout starts at the earliest possible stage and is based on the inputs from a team composed of relevant health professionals, architects, engineers and hospital management. At the planning stage, design of the imaging facility should consider the types of imaging to be performed, workload and patient flow. Appropriate incorporation of radiation protection and safety features should also be considered at the design stage. As imaging departments usually grow over time, it is therefore important that initial facility design allows for future expansions. An imaging facility should give easy access to both inpatients and outpatients and provide easy movement of patients and staff through the facility. Depending on the  nature of imaging modality, larger rooms are preferable to allow easy access for patients on bed trolleys, to allow for easier patient positioning and movement around equipment.

For any imaging facility, additional space to accommodate changing cubicles, reception, reporting area, server room, offices, consumable storage areas and staff rooms also needs to be considered in the design stage. Appropriate radiation safety measures should be in place, including positioning of signs and warning lights at the entrances of supervised and controlled areas. Controlling incoming light is an essential factor for a radiology reading room. Therefore, medical images should be displayed and read in rooms specifically designed areas, to facilitate their interpretation by  radiologists. 

Site planning and installation guidelines are often offered by vendors. This should include a final floor plan, with the equipment correctly placed and to scale and considering all local buildings, electrical and safety codes. Site planning depends on the size and the nature of the project, local traditions, climate and available budget.

The medical physicist plays a valuable role in assisting the medical imaging department, facility staff, planners, and architects in department design, including workflow. Furthermore, the medical physicist can be the on-site presence during construction to assure the architectural details are followed by the contractor.

Radiation shielding

All medical imaging equipment that produces X rays requires a radiation shielding plan. Facility design and shielding requirements should be compliant with relevant regulations and guidelines. A clinically qualified medical physicist is responsible for providing advice on shielding and ensuring that shielding calculations are based on relevant standards and recommendations. Shielding calculations should be performed at earliest stage of the design. Shielding requirements may be reassessed at the later stage, if the intended use of a room is changed, if equipment is upgraded or workload or surrounding room occupancy is altered.  Adequacy of shielding should be verified before clinical use of the imaging facility.

All shielding barriers, including floors and ceiling, should be designed according to requirements of relevant authorities, with viewing windows and doors meeting the shielding specification for the barrier in which they are located. With exception of fluoroscopy guided procedures, staff members should be in the protected operator control areas or rooms, not in the vicinity of the patient. The operator room may be shared by several adjacent imaging rooms. It is also very important to ensure audio and visual communication with patients in this case. 

Equipment selection

Different equipment packages may be considered, depending on the imaging needs and available resources. The medical physicist is the expert about the technical and radiation aspects of medical imaging equipment and is a key player in equipment selection, specification, and purchase process. Since a major operational cost is equipment service and repair parts, the medical physicist must manage these aspects of the equipment life cycle.

There are several prioritised recommendations for the type of imaging equipment that should be installed and operational in different healthcare facilities. With this is mind, it is important to note that the diagnostic radiology and nuclear medicine departments have close functional and operational relationships, and they are therefore frequently combined.

In addition to human and financial resources, selection of the implementation scenario is highly dependent on the local infrastructure and its sustainability, including electricity and water supplies, temperature and humidity control, IT infrastructure, etc. Furthermore, as noted above, adequate maintenance of the equipment, service contracts and warranties and necessary software updates must be considered.

The primary health care level should meet majority of the imaging needs of the population. Basic imaging equipment, as general-purpose radiography X ray and ultrasonography units are used in small hospitals or health centres at this level. More complex imaging modalities are associated with secondary health care. It includes imaging equipment used at the primary health care level and sophisticated radiography (including fluoroscopy), Doppler ultrasonography, mammography, angiography, CT, radionuclide scintigraphy or SPECT/CT. 

Finally, the tertiary health care level includes all equipment used at previously mentioned health care with the addition of magnetic resonance imaging (MRI), PET/CT and theranostics.

The functional or performance specifications link technical deliverables to the clinical properties of the technology.  The proposed system should be aligned with the organizational goals of both the radiology department and the organization, with clearly stated main objectives. This includes goals such as productivity, quality of service and efficiencies. Additional details to consider include the expected workload, required image quality, types of radiation monitors, time needed to retrieve an image or examination of a defined type from a server, etc.

The technical specification provides a detailed description of technical requirements for imaging equipment, including specific acceptance criteria, stated in terms suitable to form the basis for the design of the equipment and its operational characteristics. Technical requirements should focus on core technical issues.

Staffing levels

Different health professionals have roles in diagnostic radiology, which typically includes radiological medical practitioners, i.e. radiologists, medical radiation technologist (radiographers, radiological technologists) and medical physicist (specialized in diagnostic radiology), nurses, IT specialist, and service engineers. This multidisciplinary team works collaboratively in the imaging facility.  Minimal staff qualifications, education and training should meet relevant national regulation and international guidelines. Staffing level shall be sufficient to meet the objectives of the radiology service. Resources for staff education and training should be taken into consideration at planning stage of an imaging facility.

Depending on the size of the facility, IT expertise must be considered. In smaller facilities on-site support from the IT personnel during planning and installation stage and off-site at later stage may be sufficient. For larger and more complex facilities, on-site presence of IT staff to ensure reliable operation of the computing technologies used at the facility may be required. When PACS is used to manage request, images and reports, in particular if this is combined with RIS, an appointment of PACS administrator may be required.

Based on best practice, international guidelines describe the number of clinically qualified medical physicists required for medical physics services. Considering the need for quality and safety in radiology services, the Agency developed an algorithm capable of estimating the number of clinically qualified medical physicists needed in radiology. The algorithm has been tested under several field conditions to verify its general applicability.