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Report of the Assessment of Compliance with Medical Exposure to Ionising Radiation Regulations

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Report of the Assessment of Compliance with Medical Exposure to Ionising Radiation Regulations Health Information and Quality Authority Report of the assessment of compliance with medical exposure to ionising radiation regulations Name of Medical University Hospital Limerick Radiological Installation: Undertaking Name: Health Service Executive Address of Ionising St Nessan's Road, Dooradoyle, Radiation Installation: Limerick Type of inspection: Short Notice Announced Date of inspection: 11 June 2020 Medical Radiological OSV-0007379 Installation Service ID: Fieldwork ID: MON-0029586 Page 1 of 24 About the medical radiological installation: University Hospital Limerick (UHL) is a Level 4 Hospital in the University of Limerick Hospitals Group (ULHG). The radiography governance at UHL incorporates Croom Orthopaedic Hospital and the Maternity Hospital. The Radiology Department is primarily demand driven, serving all of the departments within UHL, Croom and Maternity Hospitals. There is a limited out-patient service across most modalities as the priority for the hospital is inpatient activity due to demands on inpatient beds. There are Clinical Specialist Radiographers in all of the modalities. These radiographers run the operational side of their service. The imaging modalities using ionising radiation include: General x-ray: including dental x-rays Computed Tomography (CT) Mammography Nuclear Medicine Interventional Radiology Interventional Cardiology Suites (Cardiac Cath Labs) Dual-energy X-ray absorptiometry (DEXA) Scanning Fluoroscopy service. Page 2 of 24 How we inspect This inspection was carried out to assess compliance with the European Union (Basic Safety Standards for Protection against Dangers Arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019. The regulations set the minimum standards for the protection of service users exposed to ionising radiation for clinical or research purposes. These regulations must be met by each undertaking carrying out such practices. To prepare for this inspection, the inspector1 reviewed all information about this medical radiological installation2. This includes any previous inspection findings, information submitted by the undertaking, undertaking representative or designated manager to HIQA3 and any unsolicited information since the last inspection. As part of our inspection, where possible, we: . talk with staff and management to find out how they plan, deliver and monitor the services that are provided to service users . speak with service users4 to find out their experience of the service . observe practice to see if it reflects what people tell us . review documents to see if appropriate records are kept and that they reflect practice and what people tell us. About the inspection report In order to summarise our inspection findings and to describe how well a service is complying with regulations, we group and report on the regulations under two dimensions: 1. Governance and management arrangements for medical exposures: 1 Inspector refers to an Authorised Person appointed by HIQA under Regulation 24 of S.I. No. 256 of 2018 for the purpose of ensuring compliance with the regulations. 2 A medical radiological installation means a facility where medical radiological procedures are performed. 3 HIQA refers to the Health Information and Quality Authority as defined in Section 2 of S.I. No. 256 of 2018. 4 Service users include patients, asymptomatic individuals, carers and comforters and volunteers in medical or biomedical research. Page 3 of 24 This section describes HIQA’s findings on compliance with regulations relating to the oversight and management of the medical radiological installation and how effective it is in ensuring the quality and safe conduct of medical exposures. It outlines how the undertaking ensures that people who work in the medical radiological installation have appropriate education and training and carry out medical exposures safely and whether there are appropriate systems and processes in place to underpin the safe delivery and oversight of the service. 2. Safe delivery of medical exposures: This section describes the technical arrangements in place to ensure that medical exposures to ionising radiation are carried out safely. It examines how the undertaking provides the systems and processes so service users only undergo medical exposures to ionising radiation where the potential benefits outweigh any potential risks and such exposures are kept as low as reasonably possible in order to meet the objectives of the medical exposure. It includes information about the care and supports available to service users and the maintenance of equipment used when performing medical radiological procedures. A full list of all regulations and the dimension they are reported under can be seen in Appendix 1. This inspection was carried out during the following times: Date Times of Inspector Role Inspection Thursday 11 June 10:58hrs to Kay Sugrue Lead 2020 15:02hrs Thursday 11 June 10:58hrs to John Tuffy Support 2020 15:02hrs Page 4 of 24 Governance and management arrangements for medical exposures University Hospital Limerick (UHL) is a Model 4 hospital in the University of Limerick (UL) Hospitals Group. This short notice announced inspection was initiated due to non compliances identified during a routine announced inspection at Nenagh Hospital on 12 February 2020. The extent of medical physics staffing levels impacted regulatory compliance at Nenagh Hospital with possible greater implications on compliance at its parent hospital UHL, given the scale and complexity of the services provided there. Inspectors found the level of Medical Physics Expert (MPE) resources available for UHL and the wider hospital group was not appropriate for the level of radiological services provided. At the time of the inspection, the Medical Physics Department located at UHL had two MPEs and one basic grade physicist for consultation and specialist advice on matters relating to radiation physics. Inspectors noted that the Medical Physics Department at UHL was established in January 2018 but had not been adequately resourced from the outset. Inspectors found through documentation review and discussion with staff that there was a strong awareness amongst staff of the substantive issues related to medical physics staffing and resulting effects on compliance with regulations. Medical physics staffing deficiencies had been recorded as a high level risk on the corporate risk register since 2017. Inspectors saw sufficient documentary evidence to show the gaps in medical physics staffing were escalated through radiation protection governance structures and upwards to hospital group and Health Service Executive (HSE) level. However, efforts to increase the identified deficiencies since 2017 had been limited up to the time of this inspection. In discussions with staff, inspectors were told that a recruitment process to increase MPE resources was ongoing with plans to increase medical physics staffing levels by two whole time equivalents by the end of 2020. In addition, the hospital also planned to outsource the quality assurance (QA) of medical radiological equipment for 2020 with the aim of alleviating pressure on the Medical Physics Department. Inspectors found that areas significantly impacted by deficiencies in medical physics staffing levels related to continuity of MPE service. Staff stated that contingency arrangements were not in place for the continuity of MPE expertise should the need arise. Capacity issues were also found to impact on the MPE involvement in medical radiological practices. Staff stated that there was potential to expand the involvement of the MPE in line with the requirements of Regulation 21 should the MPE resource deficiencies be addressed. In addition, further improvements were required with respect of Regulation 20 relating to MPE responsibilities to ensure full regulatory compliance. Inspectors found there was scope to improve MPE role in optimisation, diagnostic reference levels, training and a prospective QA programme Page 5 of 24 of equipment. This finding was acknowledged and accepted by staff and management during discussions held at the time of the inspection. Inspectors found that governance arrangements at UHL had evolved in a significant way since 2019. Inspectors were satisfied that overall responsibility for radiation protection at the hospital and for the wider UHL Group was at the appropriate level resting with the Chief Executive Officer (CEO). From discussions with staff, it was clear to inspectors that staff were very aware of recently revised governance and reporting structures at the hospital and within the hospital group. However, it was apparent that the re allocation of governance responsibilities and oversight was an evolving process and more work needed to be done. For example, membership of the Radiation Safety Committee (RSC) needed to be finalised to ensure appropriate clinical and directorate representation and attendances at the RSC meetings. Draft RSC terms of reference reflecting these changes were due to be approved at the next scheduled RSC meeting. Inspectors found that hospital radiation safety procedures needed to be revised to ensure alignment with current regulations and be reflective of updated governance arrangements and expanding radiological services provided at the hospital. Following on from this inspection, these local procedures should be updated as a priority for the benefit of radiology staff and to ensure the radiation protection of service users within the hospital. Overall, inspectors found
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