What the new Quality Standard for Imaging
means for patients

The College of Radiographers (CoR) Patient Advisory Group (PAG) was established in 2007. Formerly the Patient and Public Liaison Group (PPLG), its main objective is to bring the patient voice into the work of the Society and College of Radiographers (SCoR).

Members of the PAG are patients and lay people from all over the UK, who bring a range of skills and experience. We voluntarily give our time to influence and support radiographic education and practice. We are delighted to have been able to contribute to the 2021 Quality Standard for Imaging (QSI)¹ and we discuss what we feel its value is to patients and the public accessing radiology services.

The QSI, developed jointly by the CoR and The Royal College of Radiologists, began life as the Imaging Services Accreditation Scheme (ISAS). It serves as a benchmark for all diagnostic imaging services to ensure patients receive safe and effective care that is continuously improving for the benefit of its service users and staff. Services are independently assessed by the UK Accreditation Service (UKAS).

First published in 2009, the QSI has been reviewed and revised every four years, culminating in the most extensive revision to date, released in 2021. The standard and supporting resources are aimed at those delivering imaging services, but the outcomes are intended primarily for the benefit of the patient and to provide a robust assurance framework.

One of the founding members of the PPLG, Linda Samuels, was invited to join the UKAS team as a lay assessor. For this role, the principal focus is on the patient experience and involves not only looking at the environment in which patients are cared for but also speaking to patients and soliciting their views on the service and the treatment they receive. The two colleges have always laid emphasis on the importance of the role of the lay assessor and the knowledge, experience and skills they bring to the accreditation process.

During the latest iteration of the QSI, an external consultancy was employed to manage a wide-scale review and several groups of subject matter experts were formed. The PAG was officially represented on the steering group by Liz Doran, who has a special interest in this area. All members of the PAG later had an opportunity to contribute to the consultation, which was formally completed by the PAG chair, Philip Plant, and Linda Samuels.

From the patient’s perspective, the review of the 2019 standard presented an opportunity to strengthen the contribution of the patient voice and we feel this has been achieved. The PAG appreciates how well the standard articulates what patients can expect from services that are either working towards QSI 2021 or have previously attained accreditation.

The PAG particularly wants to reflect on the impact of the Covid-19 pandemic over the past two years and the contribution we feel having effective leadership and governance has made. Prior to the pandemic, it might have been unimaginable that people would be denied access to healthcare for fear of making existing conditions worse. We have been guided by science and the best efforts of our national leaders and advice givers to reasonably interpret the evidence at the pace it emerged. Regardless of whether we were told it was safe to attend or whether we were told to stay away, during the pandemic a new and very real fear emerged for many people. The fear that stepping foot inside a hospital, for either a diagnostic test or medical treatment, might increase the risk of a worse outcome. To some extent, people have had to choose between a risk where the odds were fairly well understood and another far less certain but potentially deadly risk.

Reassurance that service providers were taking every conceivable precaution to protect their staff from Covid-19 infection and, therefore, to reduce the risk of transmission between each other and to their patients became paramount. Infection prevention and control, something we may previously have taken for granted before the pandemic, became the first question people wanted answering – “How will you make sure I don’t catch Covid if I come to hospital?” The availability of PPE became daily headline news and any reports of it not being available, or not being distributed as it should, added to the growing fears of people entering the hospital. The threshold for seeking medical advice was suddenly raised. The NHS² and large organisations, such as Cancer Research UK³, issued guidance about attending for tests and treatment but, as patients, we had decisions to make about our own health – and the health and safety of our loved ones – in ways never previously experienced. We needed to know that everyone was working to the same standard of care and had the resources needed to deliver that standard. The general view of the PAG during this time was that service users were impressed by the speed at which measures were put in place to protect them from the risk of infection from Covid-19. It seemed as if underpinning attitudes and good governance were embedded in everyday practice and that all staff were able to adapt to a new way of working. We feel that the drive to embed standards, as defined by the QSI, has undoubtedly improved patient experience amid all the surrounding uncertainty.

The PAG wishes to acknowledge the huge sacrifices, physical and emotional labour, and compassionate care demonstrated by the radiographic workforce over the past two years. It is against a background of rapid and unprecedented change that the PAG considers the QSI 2021. With this in mind, we would suggest that while, in some ways, a quality standard leads service change and development, in other ways it must necessarily reflect it.

As patients we expect, at the very least, to receive care that meets a minimum safe requirement. The QSI offers a benchmark of quality that goes beyond this. As patients using an accredited service, we should hope to receive this quality level of care. We recognise that the metrics for meeting a standard may differ between the criteria used by service assessors and an individual’s perception of their personal experience. To this end, we value the inclusion of a lay assessor on each review and on all the inspection and assessment teams.

Reviewing QSI 2021 has been a chance to reflect on what has changed since ISAS 2017. The PAG acknowledges that any standard or policy is only as good as the people who deliver it. In The Independent Review of Diagnostic Services for NHS England⁴, Professor Sir Mike Richards reported an increase in the backlog of patients waiting more than six weeks for diagnostic tests and made several recommendations for major reform of diagnostic services. The report highlighted the urgent need for a significant increase in the diagnostic workforce. It recognised that the pandemic intensified the case for change and highlighted some of the key changes that were undoubtedly accelerated by the pandemic, such as the availability of online consultations.

The QSI is very technical in its content, and we recognise the reason for this. It reflects legal requirements as well as national and professional body guidance, and patients may feel assured that the care they receive, from services that have achieved accreditation, is lawful and evidence based. We also recognise that things can change quickly. Accreditation is not a one-off seal of approval. It should reflect the culture of an organisation, its dedication, and the measures it has in place to continually reflect and deliver improvement. Accreditation to the QSI is reviewed on a continual four-year cycle and services must demonstrate their ongoing commitment to meeting the standard. This provides long-term assurance to patients of a commitment to perpetual evaluation and improvement.

The PAG is satisfied that the revised structure of the QSI, using a quality statement, outcome measures and indicative inputs for each service area, offers a practical framework by which services can assess themselves. While there are generic standard statements that apply to all services, where there are particular requirements for each department within imaging, such as CT, MRI or ultrasound, these are well defined.

To highlight the key benefits to patients and the public of service accreditation to QSI 2021, a patient-facing poster has been developed (see Figure 1). Written from a patient’s perspective, it features some of the key assurances of the QSI in terms of what matters to patients. It aims to empower patients and the public to be enquiring in the event of a shortfall in care.

_{Figure 1: A patient-facing poster to highlight the key benefits of service accreditation to QSI 2021}

The PAG welcomes the addition of the poster for use as a promotional and educational tool. During our discussions, we agreed that some of the standards, such as leadership, do not need to be promoted to patients because we take it for granted that NHS and other healthcare providers are well led by people with the appropriate skills and knowledge. This is fundamental to us, as is the fact that only people with appropriate education and training are employed in patient-facing and other roles and that they uphold the standards required of their profession.

While many people in society have endless access to health and wellbeing information via the internet, it is acknowledged that this is not always the case. Access to online services enables people to research their symptoms or conditions and, as a result, they may be better informed than they were a few years ago. Services should acknowledge this but also be aware that those who are unable to access online information may experience wider health inequalities as a result. It is important to us as patients that healthcare professionals do not make assumptions about what knowledge we have of our health and care needs, and to respect that, at times, we may wish to know more about our care.

Patients may wish to contribute to service design, development and improvement and we often have valuable insight to share based on our experiences. QSI encourages services to ask patients about this and involve us in their plans rather than seeking feedback after they have made a change. We therefore especially welcome the inclusion of standard XR-109 – patient, carer and service partnerships.

The PAG recognises that displaying a measure of success, such as the Standard Accreditation mark, is likely to offer reassurance to patients. It should be recognised that alongside this hard-earned achievement, services should signpost patients to where they can seek help if the level of care they receive falls short of this standard. Patients who have had reason to be dissatisfied with their personal experience may feel less inclined to question the information or care they receive, or make suggestions for improvement, if it seems as if a service is not open to collaboration. Services that rightly promote accreditation should balance this by displaying clear opportunities for patient involvement, feedback and complaint. Ideally, they should demonstrate how patient involvement directly contributes to improving their standards and how it has assisted them to achieve accreditation. In turn, it is hoped this will lead to wider public engagement and collaboration at the highest organisational level.

We understand that the first services to be accredited to the new QSI will begin to emerge over the coming year. It should be noted that patients have an expectation that the joint Colleges will be able measure the impact of the new standard on patient experience and that this will inform the continued direction of the QSI. We await this data with interest.

Philip Plant is Chair of the CoR PAG.

Linda Samuels is a member of the CoR PAG.

Alex Lipton is Professional Officer, Senior Service Managers, and Cross-Sectional Imaging Lead at the SCoR.

Lynda Johnson is Professional Officer Clinical Imaging at the SCoR.

References

1. The College of Radiographers and The Royal College of Radiologists. Quality Standard for Imaging 2021.

2. NHS. Using the NHS and other health services during coronavirus (COVID-19). 2022. Available at www.nhs.uk/conditions/coronavirus-covid-19/using-the-nhs-and-other-health-services/ Accessed 19 January 2022.

3. Cancer Research UK. Going into hospital during the coronavirus pandemic. 2019. Available at www.cancerresearchuk.org/about-cancer/cancer-in-general/coronavirus/going-into-hospital Accessed 19 January 2022.

4. Richards M. Diagnostics: Recovery and Renewal – Report of the Independent Review of Diagnostic Services for NHS England. October 2020.