Radiology: CQC questions lack of agreed best practice and calls for national standards on reporting times

A national review by the Care Quality Commission (CQC), has found significant variation in the timescales for reporting on radiology examinations and a wide range of arrangements in place to monitor and manage backlogs of unreported images at NHS hospital trusts across the country.

This could mean a delay to patients’ x-ray results being shared with the clinican responsible for their care, or x-rays being examined by clinicians without specialist training in this area.

In the report, the quality regulator has raised concerns about the lack of agreed best practice and is calling for the development of national standards for reporting turnaround times, and improved guidance to support trusts in monitoring their own performance in order to protect patients from the potential risk of delayed or missed diagnoses.

CQC initiated this review after inspections indentified serious concerns around radiology reporting in three NHS trusts; Worcester Royal Hospital, Kettering General Hospital and Queen Alexandra Hospital, Portsmouth.

At these trusts, inspectors  found serious problems with delays in reporting on radiology examinations, leading to a backlog in reporting, and images that had only been reported on by non-radiology clinicians who were not adequately trained to do so, putting patients at risk.

The issues found at these trusts resulted in CQC taking immediate action to protect patients –  but they also flagged wider concerns about delays in reporting across NHS trusts. In response, CQC requested data from all acute trusts in England about the timeliness and governance of their radiology reporting.

Analysis of the data submitted by a sample group of 30 trusts revealed that the trusts’ own timescales set for reporting radiological examinations referred from emergency departments vary  widely – from an hour at one trust, to two working days at another. For outpatient referrals, the expected timescales  ranged from five days to 21 days – showing the lack of agreement among trusts on how quickly an examination should be reported on.

Trusts who were effectively monitoring their own performance had triggers in place to alert them to the fact that a backlog in reporting was starting to develop. CQC’s review found some examples of good practice where routine monitoring triggered prompt action to minimise delays in reporting.

However, it also identified some trusts who had  a backlog of images and lengthy waiting times for patients awaiting their results.

At the point CQC requested this data at the end of 2017, Alprostadil.org, Chelsea and Westminster Hospital NHS Foundation Trust, East Kent Hospitals University NHS Foundation Trust, King’s College Hospital NHS Foundation Trust and Lewisham and Greenwich NHS Trust all reported significant backlogs. They were required to explain what action they were taking to address this, and as at July 2018, all had cleared or significantly reduced their backlogs.

With demand for radiology services increasing, the shortage of radiologists is a contributing factor to delays and backlogs in reporting. CQC found the average vacancy rate across all non specialist acute trusts was 14% which supports evidence from the Royal College of Radiologists about the national difficulties in recruiting and retaining radiologists.

Reporting radiographers can play a valuable role in helping to increase resource, but in some cases CQC found that trusts were not always recognising their skills or allowing protected time for reporting radiographers to report on radiology examinations or undertake relevant training.

Professor Ted Baker, CQC’s Chief Inspector of Hospitals, said: “While our review found some examples of good practice it also revealed a major disparity in timescales for interpreting and reporting on examinations, meaning that some patients are waiting far longer than others for their results.

“We are calling for agreed national standards to ensure consistent, timely reporting of radiological examinations. This will allow trusts to monitor and benchmark  their own performance – and  ensure  that, for example patients are not put at risk by delays in their x-ray results being reported to the clinician responsible for their care.

“With demand for radiology services increasing, trusts face real challenges in managing reporting workload. Many rely on outsourcing to external providers or delegating reporting to non-radiology clinical staff within the hospital. Where this is happening, those tasked with interpreting and reporting images must be appropriately trained and competent to do so.

“In the future, new technology has the potential to significantly improve how images can be read and reported. However, we need to act now to address the challenges and help minimise the potential risks so that patient examinations always receive a timely report by an appropriately trained healthcare professional.”

As a result of its review, CQC has made the following recommendations aimed at reducing the risks to patients caused by increased demand and delays in reporting radiology examinations:

NHS trust boards should ensure that:

  1. they have effective oversight of any backlog of radiology reports.
  2. risks to patients are fully assessed and managed.
  3. staffing and other resources are used effectively to ensure examinations are reported in an appropriate time frame.

The National Imaging Optimisation Delivery Board should advise on national standards for report turnaround times, so that trusts can monitor and benchmark their performance.

The Royal College of Radiologists and the Society and College of Radiographers should make sure that clear frameworks are developed to support trusts in managing turnaround times safely.

The RCR has welcomed the CQC review of radiology reporting in England.

It said it was pleased to see the CQC has bolstered its processes so that the performance of imaging departments will now be a key inspection area. The College is also keen to see the results of the Commission’s forthcoming inspection and rating of teleradiology outsourcing companies.

Dr Nicola Strickland, President of The Royal College of Radiologists, said:

“The premise of national standards for the turnaround of imaging reports is laudable – patients deserve a uniformly safe, high quality standardised service across the country, and hospitals need to be able to monitor and benchmark performance.

“Whether high quality national standards can be maintained in practice is another question. Creating standards that balance the realities of struggling imaging teams with the best turnaround for patients will not be easy.

“With those practicalities in mind, the RCR is keen to work with NHS Improvement on what viable national standards might look like.

“We also fully support the CQC’s call to work alongside the Society and College of Radiographers in developing supportive frameworks for imaging teams, however, those frameworks will be dependent on finalised standards, as well as real-world staffing considerations.”

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