clinical photography, design and video in healthcare

Quality Assurance Standards (QAS) HandbookPhotography • Art • Graphic Design • Video

Institute of Medical IllustratorsQuality Assurance Standards

Contents

Introduction 2

Contacts 3

Audit procedure 4 -5

Level 1 & 2 Standards Criteria (Audit Evidence) 6 - 15

Patient Experience Criteria 6 6 - 7

Service Management Criteria 6 8

Human Resources Criteria 9 9 -10

Policy & Procedure Criteria 2 11

Communication Criteria 1 11

Safety & Risk Management Criteria 2 12

Information & Department Governance Criteria 5 13

Finance & Resources Criteria 4 14

Cross Reference Guide

(Original QAS & updated Standards) 15

Appendices

Finance pro forma 16

Audit Review Form 17

2

Institute of Medical IllustratorsQuality Assurance Standards :

Introduction

These Quality Assurance Standards provide a systematic framework to measure the implementation and effectiveness of quality initiatives in Medical Illustration units across the UK. It is intended that they will complement, but not duplicate, existing quality assurance programmes and provide an opportunity to share and disseminate good practice.

Audit processThe framework has been designed to enable self-assessment by the service manager with an online submission in the first instance, which is audited independently by two external auditors followed with a site visit by a third auditor.

Definition of usersThe term ‘users’ within the Quality Standards refers to patients, carers, visitors, service purchasers and other service providers within the organisation.

Sample sizeThe auditors will ask staff to respond to a series of questions associated with each standard in order to ascertain whether or not the department has met the criteria. A cross-section of staff by grade or professional group may be asked to answer questions. Examination of documentation and the number of staff questioned will vary, depending on the number of staff employed in the department.

ComplianceThe auditor will examine a sample of the supporting evidence for each criterion before registering compliance the majority of which will be submitted in electronic format..

Any non-compliance with a standard will be identified and advice on appropriate action to rectify the issue is given. The award is then deferred until the criteria are met. Any standard that is deemed to be ‘not applicable’ will be registered with a ‘N/A’ in the appropriate column. Justification for the non-applicability of a specific standard should be outlined in the auditor’s written comments.

There are 35 standards in Level 1 and 2, under the same categories, but examined in more depth. During a Level 2 audit, Level 1 criteria will be re-examined.

Accreditation is awarded for a set period only, after which renewal will be necessary.

3

Institute of Medical IllustratorsQuality Assurance Standards : Contacts

Standards Team

Bolette JONES (Lead)Medical Illustration Service ManagerEmail: bolette.jones@wales.nhs.ukAddress: University Hospital of Wales Media Resources Centre University Hospital of Wales Heath Park, Cardiff CF14 4XWTelephone: 029 2074 4601

Auditors

Katy HAMILTON & Laura Jackman (QAS Administrators)Clinical PhotographerEmail: Clinicalphotography@uhb.nhs.ukAddress: Department of Clinical PhotographyUniversity Hospital Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Edgbaston, Birmingham, B15 2GWTelephone: 0121 371 2460

Nigel BEARDSMOREMedical Illustration ManagerEmail: nigel.beardsmore@nhs.netAddress: New Cross Hospital New Cross Hospital, Wednesfield Road Wolverhampton, West Midlands, WV10 0QPTelephone: 01902 695377

Jill FELLHead of DepartmentEmail: jill.fell28@me.comAddress: East Kent Hospitals University NHS Foundation Trust Dept. Medical Photography & Illustration Kent & Canterbury Hospital Ethelbert Road, Canterbury Kent, CT1 3NGTelephone: 01227 866461

Carol M. FLEMINGInstitute of Medical IllustratorsEmail: secretary@imi.org.ukAddress: 24 Comfrey Close, Harrogate, North Yorkshire. HG3 2XBTelephone: 07587 702046

Tim ZOLTI Medical Illustration Service ManagerEmail: t.zolti@leeds.ac.uk Address: Medical & Dental IllustrationLeeds Dental Institute, Clarendon Way, Leeds, West Yorkshire, LS2 9LUTelephone: 01423 500504

Jane TOVEYMedical Illustration Service ManagerEmail: Jane.Tovey@uhb.nhs.ukAddress: Department of Medical IllustrationUniversity Hospital Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Wolfson Building, Edgbaston, Birmingham, B15 2GWTelephone: 0121 371 6499

Shay GunstoneClinical PhotographerEmail: shay.gunstone@nbt.nhs.ukAddress: North Bristol NHS Trust, Level 3, Gate 38, Brunel Building, Southmead Hospital, Bristol, BS10 5 NBTelephone: 01174 146500

Nicola Kelley-CarrickClinical PhotographerEmail: nlk3@hotmail.comAddress: University Hospital of Wales Media Resources Centre University Hospital of Wales Heath Park, Cardiff CF14 4XWTelephone: 029 2074 4601

Stephen J. PALMERInstitute of Medical IllustratorsEmail: spalmer555@outlook.comAddress: 7 Bryestone Avenue, Newton Mearns, Glasgow. G77 5SH Telephone: 07860130352

Simon BrinkworthClinical PhotographerEmail: simon.brinkworht@uhbristol.nhs.ukAddress: University Hospital Bristol NHS Foundation Trust, Medical Illustration, Marlborough Hill Workshops, Bristol, BS2 8HWTelephone: 01173 427366

4

Institute of Medical IllustratorsQuality Assurance Standards : Introduction

Institute of Medical Illustrators Quality Assurance Standards (QAS) Standards Group

Standards Lead: Bolette Jones(Lead) Katy Hamilton(Standards Administrator)Auditors: Jill Fell Laura Jackman (Standards Administrator) Carol Fleming Tim Zolti Nigel Beardsmore Shay Gunstone Jane Tovey Nicola Kelley-Carrick Stephen J. Palmer Simon Brinkworth

The Quality Assurance Standards were originally developed by members of the Institute, having investigated a number of national schemes from both industry and the healthcare sector. The chief benefits of a scheme designed for a specific service are that the audits are tailored to suit the needs of the profession and the criteria provide a benchmark for all to follow.

Advantages include: • Standards are appropriate to the service. • Our auditors are all qualified medical illustrators • QAS Level 1 provides a baseline for departments who undertake training and therefore ensure that students are provided with all that is required to meet their training needs. All organisations placing work experience students will require a guarantee that work placements are fit for purpose. QAS Level 1 provides that guarantee. • QAS Level 2 is designed to examine overall organisational excellence, testing not only that systems are in place, but also that knowledge and understanding of policies, procedure and protocols are apparent. • QAS certification can contribute to other auditable healthcare quality standards set by the NHS across the UK.

Healthcare is increasingly evidence-based, centering decisions on the benefits of improving the patient care pathway. A well-structured Medical Illustration service contributes to the care pathway at various stages with the provision of standardised photography or the production of high-quality patient information. These outcomes are supported by well-tested working practices which are ultimately recognised through the QAS scheme.

Audit costs for IMI members, non-member and for those departments who require a re-audit after a 3 year period can all be found on the website. www.imi.org.uk.

Purchase orders are raised by the requesting organisation and then the invoices are raised by the IMI Hon.Treasurer and sent direct to the organisation requesting the audit.

If you require any further information or wish to have an informal discussion about the QAS scheme please do not hesitate to contact any of the auditors listed here.

5

Institute of Medical IllustratorsQuality Assurance Standards : Audit Procedure

The following procedure is initiated when a department requests an audit:

Prior to the AuditThe department : • Email QAS@imi.org.uk to request an audit • Fill out the finance pro forma to request an invoice & send to Treasurer@imi.org.uk • Uses the check-list to examine thoroughly all work procedures, policies and protocols. The majority of evidence will need to be submitted prior to the audit. A file naming protocol and other advice is available from the QAS Administrator.

On the day of the QAS audit

• Two auditors will review the electronic submission and a third will undertake the site visit. • Auditors will ask direct or indirect questions to individual members of staff during their normal working routines, but appreciate patients and service users must take priority and therefore will try and lesson the disruption as much as possible. • Auditors will ask to see documentary evidence of individual standards or ask to be shown where an individual member of staff can find the information for themselves. • All enquires are carried out in a friendly, approachable manner. During the audit, questioning is designed not to intimidate personnel and feedback forms are available following the audit so that individuals can comment on their experience. • Results are generally determined on the day of the audit and confirmed the outcome with the Head of Department. • Audits may be successful at this stage, or may be subject to a referral. A referral may simply mean that minor issues need to be addressed before a certificate is issued; this can usually be done by e-mail within a few days and does not warrant a return visit by the auditors. • If a department fails an audit, all issues will be discussed with the Head of Department and an indication of what further work is required is sent at a later date. • Following a successful audit a full written report is sent to the Head of Department by the audit team to confirm findings. Shortly after this a certificate is issued. • Level 2 is audited in the same way but, as the standards are covered in more depth, it inevitably takes longer. Interviews of a more formal nature may be required to ascertain the knowledge and understanding of individual personnel.

6

IMI Q

ualit

y A

ssur

ance

Sch

eme

Pati

ent

Expe

rien

ce

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l2

(mee

t crit

eria

from

leve

l 1 p

lus)

PEC

1T

he s

ervi

ce is

acc

essi

ble

to a

ll pa

tient

s/vi

sito

rsTh

e se

rvice

is c

ompl

iant

with

the

Disa

bilit

y D

iscrim

inat

ion

Act (

DD

A)

Ope

ning

hou

rs a

nd a

cces

s to

ser

vice

info

rmat

ion

is ap

prop

riate

ly di

spla

yed

Any

cond

ition

s pr

even

ting

a pa

tient

usin

g th

e se

rvice

are

iden

tified

an

d ha

ndle

d pr

ompt

ly

Tran

slatio

n, sig

ning

ser

vices

ava

ilabl

e.

Nam

ed s

afeg

uard

ing

child

/adu

lt pe

rson

kno

wn

to a

ll st

aff.

PEC

2R

elev

ant

info

rmat

ion

is

com

mun

icat

ed e

ffect

ivel

y to

pa

tient

s an

d cl

ient

s

Patie

nts

have

the

oppo

rtun

ity to

disc

uss

the

proc

edur

e or

ser

vice

with

a m

embe

r of

sta

ff

Dep

artm

ent c

ode

of c

ondu

ct is

cle

arly

disp

laye

d fo

r pa

tient

s

Info

rmat

ion

is av

aila

ble

to p

atie

nts

in p

aper

or

elec

troni

c fo

rmat

w

ith p

atie

nt s

pecifi

c ne

eds

take

n in

to a

ccou

nt

PEC

3Pa

tient

s’ p

riva

cy a

nd d

igni

ty is

re

spec

ted

Patie

nts

requ

ired

to re

mov

e cl

othi

ng a

re o

ffere

d a

priva

te a

rea

for

disr

obin

g

All p

hoto

grap

hers

sho

uld

be p

olite

, con

sider

ate

and

treat

eac

h pa

tient

fairl

y w

ith d

ue c

onsid

erat

ion

Proc

ess

in p

lace

to d

eal w

ith g

ende

r sp

ecifi

c re

ques

ts

Phot

ogra

pher

s m

ust s

how

an

unde

rsta

ndin

g of

cul

tura

l se

nsiti

vitie

s (r

elat

ing

to p

atie

nt p

hoto

grap

hy) t

hat t

hey

are

likel

y to

en

coun

ter

PEC

4Va

lid p

atie

nt c

onse

nt fo

r th

e pr

ocur

emen

t an

d us

e of

med

ia

is ob

tain

ed

A pr

oces

s is

in p

lace

to r

ecor

d an

d va

lidat

e pa

tient

co

nsen

t

Phot

ogra

pher

s ar

e aw

are

of o

rgan

isatio

nal c

onse

nt

polic

y or

gui

delin

es

An in

form

ed d

iscus

sion

rega

rdin

g co

nsen

t tak

es p

lace

bef

ore

any

proc

edur

e

A pr

oced

ure

is in

pla

ce to

dea

l with

with

draw

al o

f con

sent

, bot

h at

th

e tim

e of

visi

t and

pos

t visi

t

Stan

dard

ope

ratin

g pr

oced

ure

for

the

colle

ctio

n an

d st

orag

e of

co

nsen

t is

in p

lace

and

up

to d

ate

All p

hoto

grap

hers

can

sho

w a

n un

ders

tand

ing

of U

K le

gisla

tion

rele

vant

to o

btai

ning

con

sent

(e.g

. Men

tal C

apac

ity A

ct 2

005,

M

enta

l Hea

lth A

ct 2

007

etc.

)

7

IMI Q

ualit

y A

ssur

ance

Sch

eme

Pati

ent

Expe

rien

ce

PEC

5Se

rvic

e fe

edba

ck is

han

dled

ap

prop

riat

ely

All s

taff

are

awar

e of

org

anisa

tiona

l com

plai

nts

/ co

mpl

imen

t pro

cedu

re a

nd h

ow to

adv

ise p

atie

nts

in

its u

se

Patie

nt s

urve

y/qu

estio

nnai

re is

und

erta

ken

with

a d

ocum

ente

d pr

oced

ure

for

follo

w u

p ac

tions

.

PEC

6C

hape

rone

s to

acc

ompa

ny

patie

nts

whe

re n

eces

sary

All s

taff

are

awar

e of

org

anisa

tiona

l cha

pero

ne

proc

edur

e

Chap

eron

e av

aila

ble

if re

ques

ted

A ch

aper

one

is ve

rbal

ly of

fere

d to

all

vuln

erab

le

patie

nts

Stan

dard

ope

ratin

g pr

oced

ure

for

chap

eron

ing

is in

pla

ce fo

r th

e de

part

men

t.

Not

ices

disp

laye

d to

info

rm p

atie

nts/

rela

tives

and

car

ers

of th

e pr

oced

ure.

Evid

ence

that

cha

pero

nes

used

hav

e un

derg

one

appr

opria

te

train

ing

8

IMI Q

ualit

y A

ssur

ance

Sch

eme

Serv

ice

Man

agem

ent

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l 2

(mee

t crit

eria

from

leve

l 1 p

lus)

SM1

Cle

arly

defi

ne o

rgan

isat

iona

l and

m

anag

emen

t st

ruct

ures

Org

anisa

tiona

l and

dep

artm

ent c

hart

ava

ilabl

e to

st

aff a

nd p

atie

nts

Dep

artm

enta

l aim

s an

d ob

ject

ives

defin

ed a

nd d

ocum

ente

d fo

r cu

rren

t yea

r

Stra

tegi

c ob

ject

ives

for

the

orga

nisa

tion

are

com

mun

icate

d to

st

aff

SM2

Serv

ice

revi

ews

are

regu

larl

y un

dert

aken

Serv

ice a

ctivi

ty d

ata

is re

cord

ed a

nd a

udita

ble

The

serv

ice is

revie

wed

ann

ually

and

out

com

es a

re d

ocum

ente

d (e

.g. r

ecor

ds o

f mee

ting,

key

perfo

rman

ce in

dica

tors

, qua

lity

stan

dard

s as

sess

men

t, se

rvice

revie

w d

ocum

enta

tion,

1:1

staf

f re

view

s et

c.)

SM3

Qua

lity

stan

dard

s ar

e de

fined

an

d m

onito

red

Ther

e is

a st

anda

rd o

pera

ting

proc

edur

e fo

r m

onito

ring

the

qual

ity o

f wor

k pr

oduc

ed

The

qual

ity o

f wor

k is

revie

wed

on

an a

d-ho

c ba

sis

Qua

lity

of im

ages

, dat

a qu

ality

, dat

a in

tegr

ity a

nd

stan

dard

isatio

n pr

oces

ses

are

asse

ssed

and

ass

essm

ents

are

do

cum

ente

d

SM4

The

ser

vice

pro

file

is ou

tline

dTh

e se

rvice

pro

file

is av

aila

ble

to c

lient

s on

req

uest

Serv

ice p

rofil

e pu

blish

ed (e

.g. w

ebsit

e, le

afle

ts, p

oste

rs e

tc.)

SM5

All

depa

rtm

ent

staf

f co

mm

unic

ate,

wor

k co

nstr

uctiv

ely

and

dele

gate

ef

fect

ivel

y

Ther

e is

evid

ence

of d

epar

tmen

tal c

omm

unica

tions

Task

s ar

e de

lega

ted

to a

ppro

pria

tely

qual

ified

and

ex

perie

nced

sta

ff

All s

taff

are

treat

ed fa

irly

and

with

res

pect

Regu

lar

depa

rtm

enta

l mee

tings

or

com

mun

icatio

n w

ith

docu

men

tatio

n av

aila

ble

to a

ll st

aff

Ther

e ar

e ac

tion

plan

s in

pla

ce fo

r gr

oup

proj

ects

and

evid

ence

of

gro

up c

omm

unica

tion

SM6

Des

crip

tions

of w

ork

unde

rtak

en in

all

area

s of

ser

vice

ar

e do

cum

ente

d

Tech

nica

l wor

k in

stru

ctio

ns a

re a

vaila

ble

to a

ll st

aff

for

the

use

of s

pecia

list e

quip

men

t and

clin

ical

phot

ogra

phy

stan

dard

isatio

n

Det

aile

d ad

min

istra

tive

stan

dard

ope

ratin

g pr

oced

ures

ar

e av

aila

ble

to a

ll st

aff (

e.g.

tele

phon

e an

swer

ing,

send

ing

lette

rs o

r ap

poin

tmen

ts, t

akin

g cli

ent r

eque

sts

etc.

)

Stan

dard

dep

artm

ent p

roce

sses

hav

e be

en d

ocum

ente

d fo

r al

l ar

eas

of s

ervic

e (p

roce

ss m

aps

and

SOP’s

for

all t

asks

can

be

prov

ided

)

9

IMI Q

ualit

y A

ssur

ance

Sch

eme

Hum

an R

esou

rces

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l 2

(mee

t crit

eria

from

leve

l 1 p

lus)

HR

1A

ll st

aff h

ave

a cl

earl

y de

fined

Jo

b D

escr

iptio

nAl

l sta

ff ha

ve a

job

desc

riptio

n Al

l sta

ff ha

ve a

n up

-to-d

ate

job

desc

riptio

n (in

clud

ing

defin

ed ro

les

and

resp

onsib

ilitie

s)

whi

ch is

regu

larly

revie

wed

HR

2St

aff u

nder

go in

duct

ion

All s

taff

atte

nd o

rgan

isatio

nal i

nduc

tions

All s

taff

atte

nd d

epar

tmen

tal i

nduc

tion,

incl

udin

g em

erge

ncy

plan

ning

and

sum

mon

ing

assis

tanc

e pr

otoc

ols

(e.g

. cra

sh te

am, r

epor

ting

a fir

e et

c.)

HR

3A

ll st

aff p

erso

nal a

ppra

isal

s an

d m

aint

ain

cont

inui

ng p

rofe

ssio

nal

deve

lopm

ent

(CPD

)

All s

taff

have

had

per

sona

l app

raisa

ls

Clin

ical I

llust

ratio

n st

aff m

ust h

ave

a CP

D p

ortfo

lio

Prof

essio

nal s

taff

have

a C

PD p

ortfo

lio in

an

appr

oved

form

at (i

.e. A

HCS

)

HR

4A

ll C

linic

al P

hoto

grap

hic

staf

f sh

ould

be

on t

he A

cada

my

for

Hea

lthca

re S

cien

ce A

ccre

dite

d R

egist

er o

r w

orki

ng t

owar

ds it

.

All c

linica

l pho

togr

aphe

rs h

ave

obta

ined

(or

are

wor

king

tow

ards

)a le

vel

of q

ualif

icatio

n th

at m

akes

them

elig

ible

for A

HCS

reg

istra

tion

All c

linica

l pho

togr

aphe

rs a

re r

egist

ered

and

ac

tive

on th

e AH

CS r

egist

er

HR

5St

aff a

dher

e to

legi

slat

ion

and

loca

l pol

icie

s ap

plic

able

to

thei

r w

ork

All s

taff

are

able

to lo

cate

rel

evan

t leg

islat

ion

and

loca

l pol

icies

All s

taff

can

com

mun

icate

a c

lear

un

ders

tand

ing

of le

gisla

tion

and

loca

l pol

icy

that

is r

elev

ant t

o th

eir

role

(e.g

. men

tal

capa

city

act,

data

pro

tect

ion,

safe

guar

ding

, pa

tient

cha

pero

ning

)

HR

6D

iscl

osur

e an

d Ba

ring

Ser

vice

(D

BS)

Che

ck is

obt

aine

d fo

r ap

prop

riat

e st

aff

All s

taff

mee

t loc

al o

rgan

isatio

n sc

reen

ing

polic

y in

c. D

BSAl

l pat

ient

-facin

g st

aff u

nder

go a

n ap

prop

riate

le

vel D

BS c

heck

10

IMI Q

ualit

y A

ssur

ance

Sch

eme

Hum

an R

esou

rces

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l 2

(mee

t crit

eria

from

leve

l 1 p

lus)

HR

7T

here

is a

str

uctu

red

appr

oach

to

any

tra

inin

g or

wor

k-ex

peri

-en

ce p

rogr

amm

es

Gui

delin

es h

ave

been

est

ablis

hed

for ‘

shad

owin

g’ qu

alifi

ed s

taff

(if

appl

icabl

e)

Trai

nees

hav

e ac

cess

to d

epar

tmen

t pro

toco

ls an

d st

anda

rd o

pera

ting

proc

edur

es

Wor

k ex

perie

nce

and

train

ee c

andi

date

s ar

e gi

ven

the

oppo

rtun

ity to

pr

ovid

e fe

edba

ck a

nd p

rogr

amm

es a

re r

egul

arly

revie

wed

All w

ork

expe

rienc

e an

d tra

inee

can

dida

tes

unde

rgo

depa

rtm

enta

l in

duct

ion

and

sign

a no

n-di

sclo

sure

agr

eem

ent

Dai

ly ac

tiviti

es o

f wor

k ex

perie

nce

and

train

ee

cand

idat

es a

re p

lann

ed a

nd d

ocum

ente

d

A st

ruct

ured

or

com

pete

ncy

base

d tra

inin

g sy

stem

is in

pla

ce fo

r tra

inee

s pe

rform

ing

spec

ialis

t tec

hniq

ues

or c

linica

l pro

cedu

res

HR

8T

here

is e

vide

nce

of s

taff

trai

ning

All s

taff

have

atte

nded

any

org

anisa

tiona

l man

dato

ry tr

aini

ng (e

.g. f

ire

safe

ty a

nd m

anua

l han

dlin

g)

Staf

f can

acc

ess

depa

rtm

ent p

roto

cols

and

stan

dard

ope

ratin

g pr

oced

ures

All s

taff

are

awar

e ho

w to

req

uest

furt

her

train

ing

A st

ruct

ured

or

com

pete

ncy

base

d tr

aini

ng

syst

em is

in p

lace

for

spec

ialis

t te

chni

ques

or

clin

ical

pro

cedu

res

Skill

mix

rev

iew

is u

nder

take

n an

d st

aff

trai

ning

/ d

evel

opm

ent

plan

s ar

e in

pla

ce

HR

9T

he h

ealth

and

wel

lbei

ng o

f st

aff i

s su

ppor

ted

All s

taff

are

info

rmed

of o

rgan

isatio

nal h

ealth

and

wel

lbei

ng s

ervic

es

(e.g

. occ

upat

iona

l hea

lth a

nd s

taff

supp

ort s

ervic

es)

All s

taff

are

awar

e of

how

to a

cces

s or

gani

satio

nal

heal

th a

nd w

ellb

eing

ser

vices

Supp

ort i

s pr

ovid

ed fo

r co

lleag

ues

who

hav

e pr

oble

ms

with

thei

r pe

rform

ance

, con

duct

or

heal

th

11

IMI Q

ualit

y A

ssur

ance

Sch

eme

Polic

y an

d P

roce

dure

s

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l 2

(mee

t crit

eria

from

leve

l 1 p

lus)

PP

1D

epar

tmen

t co

pyri

ght

and

cons

ent

polic

ies

are

esta

blis

hed

Phot

ogra

phic

copy

right

and

con

sent

pol

icies

are

av

aila

ble

to a

ll de

part

men

t sta

ff D

epar

tmen

t can

pro

vide

proo

f of o

btai

ning

con

sent

that

co

mpl

ies

with

org

anisa

tiona

l and

dep

artm

ent p

olic

y

Phot

ogra

phic

copy

right

and

con

sent

pol

icies

are

ava

ilabl

e to

al

l sta

ff in

the

orga

nisa

tion

PP

2O

rgan

isat

iona

l pol

icie

s ar

e ac

cess

ible

by

all s

taff

Staf

f are

abl

e to

acc

ess

all l

ocal

org

anisa

tiona

l po

licie

sTh

e de

part

men

t has

pro

cedu

res

in p

lace

to c

ompl

y w

ith

orga

nisa

tiona

l pol

icies

(e.g

. acc

ess

to h

ealth

reco

rds

requ

ests

, in

fect

ion

prev

entio

n an

d co

ntro

l, cod

e of

con

duct

etc

.)

Com

mun

icat

ion

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l 2

(mee

t crit

eria

from

leve

l 1 p

lus)

CO

M1

Dep

artm

ent a

dmin

istra

tion

and

com

mun

icatio

n is

cons

istan

t for

bot

h pa

tient

s an

d cli

ents

.

All s

taff

have

kno

wle

dge

of a

dmin

istra

tive

proc

edur

es

(e.g

. tel

epho

ne a

nsw

erin

g, se

ndin

g le

tters

or

appo

intm

ents

, tak

ing

clien

t req

uest

s et

c.)

Adm

inist

rativ

e pr

oced

ures

are

regu

larly

revie

wed

and

upd

ated

ac

cord

ingl

y w

hen

com

mun

icatio

n fa

ults

are

iden

tified

12

IMI Q

ualit

y A

ssur

ance

Sch

eme

Safe

ty a

nd R

isk

Man

agem

ent

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l 2

(mee

t crit

eria

from

leve

l 1 p

lus)

SRM

1A

ll ar

eas

of s

ervi

ce a

dher

e to

or

gani

satio

nal h

ealth

and

saf

ety

polic

y

All s

taff

com

plet

e or

gani

satio

nal h

ealth

and

saf

ety

train

ing

(fire

, man

ual h

andl

ing,

infe

ctio

n co

ntro

l)

All s

taff

are

awar

e of

org

anisa

tiona

l pro

toco

l for

cal

ling

for

assis

tanc

e in

an

emer

genc

y an

d w

orki

ng a

lone

Evid

ence

can

be

prov

ided

of s

ervic

e he

alth

and

saf

ety

audi

ts o

r m

onito

ring

and

actio

n pl

ans

for

the

curr

ent y

ear

The

depa

rtm

ent h

as id

entifi

ed in

divid

uals

resp

onsib

le fo

r he

alth

and

saf

ety,

first

aid

, infe

ctio

n pr

even

tion

and

cont

rol,

or s

taff

are

awar

e of

org

anisa

tion

lead

s

SRM

2R

isk

asse

ssm

ents

are

und

erta

ken

for

all a

reas

of s

ervi

ce a

nd

regu

larl

y ev

alua

ted

The

depa

rtm

ent c

ompl

ies

with

org

anisa

tiona

l risk

m

anag

emen

t and

clin

ical g

over

nanc

e pr

oced

ures

Iden

tified

risk

s po

sed

to o

r by

pat

ient

s / s

taff

are

hand

led

prom

ptly

All s

taff

are

awar

e of

dep

artm

enta

l / o

rgan

isatio

nal

prot

ocol

for

repo

rtin

g ris

ks a

nd a

ccid

ents

Staf

f wor

king

in c

linica

l are

as fo

llow

org

anisa

tiona

l in

fect

ion

cont

rol p

roce

dure

s an

d re

gula

tions

Evid

ence

can

be

prov

ided

of r

isk a

sses

smen

ts a

nd a

ctio

n pl

ans

for

depa

rtm

ent f

or th

e cu

rren

t yea

r

The

depa

rtm

ent h

as id

entifi

ed a

sta

ff m

embe

r re

spon

sible

fo

r ris

k as

sess

men

t and

man

agem

ent

13

IMI Q

ualit

y A

ssur

ance

Sch

eme

Info

rmat

ion

and

Dep

artm

ent

Gov

erna

nce

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l 2

(mee

t crit

eria

from

leve

l 1 p

lus)

GO

V1

Dep

artm

enta

l gov

erna

nce

– re

sour

ces

and

data

are

man

aged

in a

dire

cted

and

co

ntro

lled

man

ner

All s

oftw

are

licen

ces

are

up t

o da

te

Cont

rols

are

in p

lace

to p

rote

ct p

rivac

y an

d co

nfide

ntia

lity

of

iden

tifiab

le p

atie

nt in

form

atio

n

Staf

f th

at h

andl

e pa

tient

dat

a ha

ve a

ttend

ed

orga

nisa

tiona

l inf

orm

atio

n go

vern

ance

and

saf

egua

rdin

g tr

aini

ng

Agre

emen

ts a

re in

pla

ce fo

r th

e co

ntin

uity

of

nece

ssar

y IT

and

ser

vice

syst

ems

Conf

iden

tialit

y ag

reem

ents

are

in p

lace

for

orga

nisa

tions

tha

t ha

ndle

sen

sitive

pat

ient

da

ta o

n be

half

of a

dep

artm

ent

(ie.

mai

nten

ance

of

imag

e m

anag

emen

t sy

stem

s)

GO

V2

Org

anis

atio

nal g

over

nanc

e –

mai

ntai

n pa

rtne

rshi

p an

d co

mm

unic

atio

n w

ith

gove

rnin

g or

gani

satio

n

All s

taff

are

awar

e of

info

rmat

ion

and

clini

cal g

over

nanc

e po

licie

s an

d ca

n lo

cate

them

Ther

e is

a pr

oces

s in

pla

ce to

rep

ort g

over

nanc

e iss

ues

to

gove

rnin

g or

gani

satio

n

The

serv

ice s

its in

an

orga

nisa

tiona

l str

uctu

re

with

acc

ess

to g

over

nanc

e co

mm

ittee

Dep

artm

ent c

linica

l inf

orm

atio

n an

d cl

inica

l go

vern

ance

lead

s ar

e na

med

IG1

Med

ia is

sto

red

appr

opri

atel

y (e

.g. a

udio

, vi

deo,

stil

l)Al

l med

ia is

sto

red

secu

rely

Dig

ital m

edia

is s

tore

d on

an

orga

nisa

tion

IT

cont

rolle

d se

rver

or

othe

r se

cure

dig

ital a

sset

m

anag

emen

t sys

tem

IG2

Acc

ess

to m

edia

and

dat

a is

con

trol

led

Acce

ss to

dat

a an

d m

edia

is c

ontro

lled

and

rest

ricte

d to

au

thor

ised

pers

onne

l

Ther

e is

an a

gree

d de

part

men

t pol

icy /

proc

edur

e de

tailin

g ac

cess

to d

ata

and

med

ia

Cont

rolle

d ac

cess

incl

udes

an

audi

t tra

il

IG3

Con

sent

for

obta

inin

g an

d st

orin

g m

edia

is

reco

rded

app

ropr

iate

lyPa

tient

con

sent

is o

btai

ned

and

reco

rded

Patie

nt c

onse

nt is

reco

rded

and

sto

red

alon

gsid

e m

edia

14

IMI Q

ualit

y A

ssur

ance

Sch

eme

Fina

nce

and

Res

ourc

es

Cri

teri

a C

ode

Cri

teri

aLe

vel 1

Leve

l 2

(mee

t crit

eria

from

leve

l 1 p

lus)

FR1

The

dep

artm

ent

com

plie

s w

ith

orga

nisa

tiona

l sta

ndin

g fin

anci

al

inst

ruct

ions

Staf

f are

aw

are

of fi

nanc

ial p

olici

es a

nd p

roce

dure

s an

d kn

ow h

ow to

loca

te th

em

Ther

e is

evid

ence

that

sta

ndin

g fin

ancia

l in

stru

ctio

ns a

re fo

llow

ed.

Cont

rol a

nd a

utho

risat

ion

proc

esse

s re

gard

ing

serv

ice fi

nanc

es a

re in

pla

ce

FR2

The

dep

artm

ent’s

bud

get

is m

anag

ed

effe

ctiv

ely

Ther

e is

a na

med

dep

artm

ent b

udge

t hol

der

Nam

ed b

udge

t hol

der

docu

men

ts b

udge

t pla

nnin

g

Dep

artm

ent s

taff

are

invo

lved

dire

ctly

or

indi

rect

ly w

ith b

udge

t pla

nnin

g

Serv

ice le

vel a

gree

men

ts a

nd g

ener

ated

in

com

e ar

e m

onito

red

and

revie

wed

FR3

An

agre

ed p

roce

ss is

in p

lace

for

the

orde

ring

, pur

chas

e &

rec

eivi

ng o

f goo

ds

and

serv

ices

Ther

e is

a pr

oces

s in

pla

ce fo

r or

derin

g co

nsum

able

s an

d eq

uipm

ent

Ther

e is

cont

rol o

f ord

erin

g an

d pu

rcha

se

auth

orisa

tion

whi

ch m

eets

the

orga

nisa

tiona

l po

licy

guid

elin

es

Doc

umen

ted

stoc

k co

ntro

l of c

onsu

mab

les

is ev

iden

t

FR4

All

depa

rtm

ent

asse

ts a

re d

ocum

ente

dAn

equ

ipm

ent a

sset

regi

ster

has

bee

n es

tabl

ished

Cl

ear

evid

ence

of f

orw

ard

plan

ning

for

asse

t lif

espa

n w

hich

follo

ws

orga

nisa

tion

polic

y

The

asse

t reg

ister

is d

etai

led

(e.g

. incl

udes

va

lue,

lifes

pan

etc.

)

IMI Q

ualit

y A

ssur

ance

Sch

eme

2016

15

Ori

gina

l QA

S R

ef L

evel

1N

ew

QA

S R

ef1

SM1

2PE

5, S

M1,

3SM

4

4C

OM

1

5H

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6H

R8

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1

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R1

9H

R2

10H

R2

11H

R3

12H

R4

13C

OM

1

14PP

2

15H

R10

16PE

C1

17PP

1

18te

leph

one

19te

leph

one

20PE

C5

21H

R9

22PE

C1

23PE

C1

24SR

M1

25PE

C6

26SR

M1

27SR

M1

28SR

M2

29SR

M1

30SM

6

31SM

6

32G

OV

1

33G

OV

1

34G

OV

1

35PE

C6

36G

OV

1

Ori

gina

l QA

S R

ef L

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2N

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QA

S R

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2SM

1

3SM

1

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8SM

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9SM

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10G

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12SM

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2

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1

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2

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4

Bra

nd N

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Stan

dard

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QA

S R

efR

egis

trat

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HR

6

Med

ia s

ecur

ityIG

1

Imag

e ac

cess

IG2

Con

sent

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: Le

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New

: Le

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, Lev

el 2

= 3

5

Quality Assurance StandardsAppendices

16

Institute of Medical IllustratorsQuality Assurance Standards : Finance pro forma

For completion by department requesting audit.

Request for invoice for Quality Assurance Audit.Please complete and send to the address below:

Medical Illustration Department requesting audit:

Address ..............................................................................................................................................................................................................................................................Post code........................................................................Contact Name .............................................................. (Head of Medical Illustration Service)Telephone No................................................................E-mail...............................................................................Date of Audit: ……./……./……. (or yet to be arranged)Audit arranged with:.................................................................

Official Order number or Reference:...................................

Guideline for payment request

• Complete the above pro forma and send a copy to the following:

1. Geoff Gilbert – IMI Hon.Treasurer - Treasurer@imi.org.uk 2. The QAS Administrator - QAS@imi.org.uk Keep a copy yourself

• Raise an official order within your organisation addressed to ‘Institute of Medical Illustrators’, requesting an audit, stating date of audit, QAS Level required (1 or 2), and associated costs.• Once an invoice has been raised and the audit successfully achieved, please complete the relevant paperwork to ensure prompt payment.

Mr Geoff Gilbert, Honorary Treasurer IMI, 14 Middle Avenue Carlton Nottingham NG4 1PG

17

Quality Assurance Standards Level ........ : Audit Review Form

Please comment on the following:

Did you find the auditors approachable?

Yes Further comments.......................................................................................................................................

No .........................................................................................................................................................................

Did you feel that the auditors were responsive to the comments you made?

Yes Further comments.......................................................................................................................................

No ........................................................................................................................................................................

Were the questions asked:

Understandable? Yes No Further comments............................................................................ ............................................................................................................... ...............................................................................................................

Challenging? Yes No Further comments............................................................................ ................................................................................................................ ...............................................................................................................

Relevant? Yes No Further comments............................................................................ ................................................................................................................ ...............................................................................................................

After the audit exercise, did you feel that you fully understood the audit process?

Yes Further comments.....................................................................................................................................

No ........................................................................................................................................................................

Signed : .........................................................................................................................

Department : ...............................................................................................................

Your details will not be revealed Please return this review form to: Standards Lead (see Appendix, p.1)

Registered Office: Registered Office: 12 Coldbath Square, London, EC1R 5HL. Registered No. 933565

Des

igne

d by

the

Med

ical

Illu

stra

tion

depa

rtm

ent a

t Uni

vers

ity H

ospi

tals

Birm

ingh

am. E

-mai

l: gr

aphi

cs@

uhb.

nhs.

uk

www.imi.org.uk