Algorithm A fixed process containing a number of steps which when followed systematically should produce a desired result. Algorithms may be illustrated as flow charts, e.g. the steps which should be taken when investigating a patient presenting with a particular set of symptoms.

Clinical Audit Systematic, critical analysis of the quality of medical or clinical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient. Our current three stage terminology “structure, process, outcome” derives from work published by Alevis Donabedian in 1966 (Ref. 41).

Medical Audit A clinical audit examining the work of doctors. Audit was divided by Donabedian into three aspects for analysis

Structure: the availability and organisation of resources (human and material) required for the delivery of a service: For example, Gonad Protection I, measures the % of rooms with a complete set of gonad protection equipment and with purpose-specified gonad shields: it is therefore a structure audit.

Process: the activity undertaken (what was done? how well was it done? what should have been done?). For example, Gonad Protection II, measures the % of examinations which comply with the departmental protocol for gonad protection: it is therefore a process audit

Outcome (patient health): an alteration in the health status of an individual patient directly attributable to clinical action (or inaction). It is customarily abbreviated to “outcome” although this may lead to confusion in blurring distinction between patient-based measures and other metrics. WHO defines “health” as a complete state of physical, mental and social wellbeing, and classified under four heads:

•  quantity of life (e.g. 5 year survival);

•  process-based measures (e.g. complication and readmission rates);

•  quality of life (e.g. measures of pain, handicap, depression);

•  satisfaction, entitlement to privacy, courtesy, etc. (e.g. score on a satisfaction survey).

Outcome audits look at what is done as a whole from the patient's point of view. Problems that such an audit may reveal (e.g. 25% chance that diagnosis is not correct) may prompt audits of each link in the whole diagnostic chain. These would be process audits.

Audit assistant One of several possible titles used to describe a member of staff employed to provide support for audit activities. Responsibilities include advising on methodology, collection and analysis of data, the preparation of results for presentation at audit meetings, as well as the provision of technical and computer assistance. Other titles include Audit Officer, Audit Facilitator and Audit Co-ordinator.

Audit cycle The basic framework upon which all audit projects are based. An audit topic is chosen and a standard to be met is defined. Data is collected to identify what is really happening and this is compared with the standard. If the required standard is not achieved, changes are introduced to improve performance. The cycle should then be repeated to assess whether changes have led to the standard now being met.

Audit Lead The Royal College of Radiologists' description of the named radiologist coordinating audit within a radiology department or directorate

Audit spiral A graphical illustration emphasising that the audit process is a series of repeating cycles (see diagram in How to Use menu)

Blitz audit A simple audit carried out, usually without warning, to examine a single facet of practice. It should be possible to complete the first stages of a blitz audit in a very short time. eg checking your department for quantity, placement and suitability of items of resuscitation equipment.

Clinical guidelines Statements of principle and good practice developed in order to assist practitioner and patient decisions about appropriate health care in specific clinical circumstances Guidelines are usually produced and agreed by a national body.

• Royal College of Radiologists (RCR)
• National Institute for Health and Clinical Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)

Local Guidelines – Guidelines may be developed and introduced locally. They are commonly adaptations of national guidelines designed to meet local conditions and constraints. The process of developing a local guideline involves consensus of all relevant clinicians

Closing the loop Completion of the full audit cycle. Practice is changed following the initial audit and the audit is repeated to ensure that the changes introduced have been effective.

Criterion A single metric selected to allow measurement of an element of care. Criterions may be qualitative or quantitative. It must be possible to define, measure, and determine whether present or not. For example: drugs used to treating a contrast reaction should be available in all rooms where IV contrast medium is given. The criterion here is the presence of all these drugs.

Critical incident audit An audit arising from a particular problem or error. eg a carcinoma is found on colonoscopy but had been overlooked on a recent barium enema. Here the critical incident might lead to audit of all barium enemas performed around that time.

Data Items of information, observations or measurements organised for analysis. Your collection should aim to ensure that the data are complete, representative, relevant and valid. In audit studies, data may be collected prospectively over a period of time, for a predetermined number of cases - or retrospectively from existing information sources. Prospective collection can ensure that all required information is obtained, but the process of collection may then influence behaviour of participants. Retrospective collection from records may conversely find such records to be incomplete.

Effectiveness The extent to which application of a technology or intervention brings about a desired effect. eg change in diagnosis, altered management plan, improvement in health. It is a measure of the degree of conformity between the actual result and the desired outcome Effectiveness is not synonymous with efficacy.

Efficacy The technical relationship between a technology or intervention and its effect - whether it actually works. This term is not synonymous with effectiveness. For example a barium enema may be expected to identify tumours when the whole colon has been outlined in double contrast - it is efficacious. However, in patients with challenging colon a tumour may be missed if optimal visualisation is not achieved. An efficacious technology is thus not always effective.

Efficiency Assessment of efficiency determines whether acceptable levels of efficacy and effectiveness are achieved when using a prudent or optimal set of resources. eg when a barium enema has adequately shown the whole colon in double contrast further radiographs will yield no additional diagnostic information. They would increase cost and time of the procedure and thus decrease its efficiency.

Elements of care Basic items which together describe all the significant aspects of an episode of care, e.g. adequate bowel preparation and a foam mattress on the fluoroscopy table are two elements of care for a barium enema examination.

Evaluation A systematic and ideally scientific process determining the extent to which planned intervention(s) achieve predetermined objectives. eg in a barium enema audit, the enemas are the planned interventions, demonstrating colonic carcinomas is our objective, and determining the percentage of proven lesions which have been demonstrated and reported is the evaluation.

Indicator A quantitative criterion. It should be a measurable element of care amenable to change. An indicator, or series of indicators, should be identified within an audit project to clarify and simplify the process of data collection.

Loop See Audit Cycle and Closing the Loop .

Medical audit See Audit .

Outcome See Audit .

Peer review Refers to a process in which a group of doctors or other health care professionals discuss together patients they have managed, and give a judgement, by consensus, as to whether or not the management of each individual patient was appropriate. Discussion must be full, frank, open and honest

Performance The quality of care achieved, judged by both the process and outcome of that care.

Process See Audit .

Protocol (1) A system of rules about the correct way to act in formal situations. (2) An adaptation of a clinical guideline designed to meet local conditions and constraints). This is the same as a local guideline. (See Clinical Guidelines ).

Quality The level of excellence. Many attempts have been made to define the quality of medical and health care (Ref. 66). In general, six aspects are usually emphasised: access to services; relevance to need; effectiveness; equity; social acceptability; efficiency/economy.

Quality assurance The managed process whereby the comparison of care against predetermined standards is guaranteed to lead to action to implement changes, and ensuring that these have produced the desired improvements (Ref. 41). For example: a Quality Assurance programme for double contrast barium enemas would include such parameters as radiographs obtained, image quality, adequacy of bowel preparation and radiation dose to the skin.

Random case analysis The detailed review of the care of a particular patient, who has been chosen at random from a list of cases. If any problems are identified, then this can be the starting point for a more detailed audit project. For example: an individual patient's radiological care may be followed from the time of receipt of the request card to the provision of the final report. This analysis may identify problem areas which warrant further investigation.

Research A systematic investigation to establish facts or principles, and collect valid information on a subject. Research explores new ideas with the aim of defining and setting the standards of care for best clinical practice (Ref. 9). This can be contrasted with audit, which aims to establish whether the actual care given to patients meets set standards. Research identifies what can and should be done, whilst audit identifies whether it is actually being done. For example, a study to determine whether endoscopic stent insertion or open surgical by-pass provides the better palliation for malignant biliary obstruction, is research . However, a study to determine whether the palliation of malignant biliary obstruction at a given hospital is carried out in accordance with the Association of Hepato-biliary Surgeons' guidelines would be audit.

Risk management Programmes or activities developed in order to anticipate and thus prevent injury or misadventure to patients, staff and the public, and thereby minimise the effects of such episodes should they occur (Ref. 91). For example: Radiologist staffing levels should be adequate so as to allow the prompt reporting and performance of radiological examinations.

Making the best use of Clinical Radiology services : is now in its 6th edition. MBUR's primary objective is to improve clinical practice, and it works best when used with a clinico-radiological dialogue, and when subjected to regular audit. The guidelines carry substantial multi-disciplinary approval and have been endorsed by the Executive of the NHS for England and are available on the RCR website Making the best use of clinical radiology services RCR 6th Edition (Ref. 95).

Sample A subgroup of a population selected for audit in such a way as to allow inferences to be made about the whole population, i.e. a representative subgroup. The method of choosing the sample is crucial to the validity of the audit.

Standard A conceptual model against which the quality or excellence of a particular activity may be assessed. It is the specification of process and/or outcome against which performance can be measured. In the context of health care, a standard indicates the best practice of clinical care to which all patients should be entitled. This may be determined by research, consensus statements, local agreement or recommendations from learned societies. For example, in an audit of barium enemas for colonic carcinoma, the standard may be that 100% of colonic carcinomas should be demonstrated on double contrast barium enema when present at the time of examination.

Target Specification of the expected level of achievement which performance should meet or exceed.

ABBREVIATIONS and ACRONYMS

A&E Accident and Emergency (colloquially Casualty).

AP Antero-Posterior, a radiographic projection, in which the x ray beam passes through the patient from front to back.

ASiT - Association of Surgeons in Training

BMA British Medical Association

BMJ British Medical Journal

CCU Coronary Care Unit.

CEO Chief Executive Officer (eg of an NHS Trust)

cGy/cm 2 centi Gray per square cm (a unit of radiation flux)

CME Continuing Medical Education. These are schemes introduced by the various Medical Royal Colleges, to ensure that all consultant medical staff keep up to date with current medical developments. Most UK doctors are required to undertake a specified number of hours of CME over a cycle of several years

COAD Chronic Obstructive Airways Disease.

CPD Continuing Professional Development. CME is now more commonly used

CPR Cardio Pulmonary Resuscitation

CRASC Clinical Radiology Audit Sub-Committee of the Royal College of Radiologists

CT Computed Tomography. A radiographic examination which produces cross sectional images

CTPA CT of the pulmonary arteries

CXR Chest Radiograph, colloquially Chest X Ray.

DCBE Double Contrast Barium Enema, a radiographic examination to outline the colon using barium sulphate suspension and air (or carbon dioxide) introduced via the rectum.

DH (sometimes DoH), Department of Health.

DPA Data Protection Act. The statute governing electronic use of personal information in the UK

DVT Deep Venous (or Vein) Thrombosis. Blood clot in major veins, commonly legs

ERCP Endoscopic Retrograde Cholangiopancreatogram. A radiographic examination to outline the common bile duct and the pancreatic duct, introducing contrast medium through the Ampulla of Vater using a side-viewing endoscope.

ESR Erythrocyte Sedimentation Rate.

FHSA Family Health Services Authority.

FNA Fine needle aspiration - a type of biopsy

FRCR Fellowship of The Royal College of Radiologists. The British professional examination in Clinical Radiology or in Clinical Oncology. Successful candidates become Fellows.

FSD Film Source Distance, the distance between the focus of the anode of the x ray tube and the radiographic receiver.

GMC General Medical Council

GP General Practitioner, i.e. family doctor.

Gy Gray, the SI unit of absorbed dose of radiation. 1 Gray = 1 Joule per kilogram. May be prefixed e.g. cGy = milliGray = 1/1000 Gray

Gy/cm2 Dose Area Product Measurement. Dose area product meters, e.g. the Diamentor fitted to the diaphragm housing of x ray sets. Provide a useful guide to the performance of both the equipment and the radiographer in keeping patient dose to a minimum.

HIS Hospital Information System - (see also RIS)

HMSO Her Majesty's Stationary Office

HSE Health and Safety Executive.

ICRP International Commission on Radiation Protection.

ICU Intensive Care Unit (also known as ITU, see below).

ID Identity or Identification, as in ID card. (From Latin “Id”)

IP In-Patient.

IPEMB Institution of Physics and Engineering in Medicine and Biology (this is the current name of the merged IPSM (see below) and Biological Engineering Society).

IRMER Ionising Radiation (Medical Exposure) Regulations – governing regulations operative from 2002 - Replaced POPUMET

ITU Intensive Care Unit see ICU

IUCD Intra-Uterine Contraceptive Device.

IV Intravenous, as in IV injection.

IVC Inferior Vena Cava.

IVU Intravenous Urography. A radiographic examination to outline the urinary tract using an intravenous injection of a water soluble radiographic contrast medium. Also known as Intravenous Pyelography (IVP) or Excretion Urography (EU).Increasingly replaced by CT scanning

kVp A radiographic exposure factor, indicating the peak kilovoltage between the cathode and anode of an Xray tube

LP Lumbar Puncture

LPO Left Posterior Oblique (Position).

MAAG Medical Audit Advisory Group. A committee responsible for the organization of audit in primary care, consisting of General Practitioners, Practice Nurses,and hospital representatives.

Majax Major Accident (generally referring to the plan of a health organization's plan for dealing with this)

mAs – Xray tube current in milliAmperes x time in seconds. One of many factors determining output of an Xray tube.

MBUR6 - Making the Best use of Clinical Radiology services – RCR publication. 6th edition released in 2007

mGy milliGray – a unit of X-ray dose. See also mSv

MRI Magnetic Resonance Imaging, a technique that produces sectional images through a patient, using a strong magnetic field and pulses of radiofrequency energy.

mSv milliSievert – unit of x-ray dose, adjusted for its biological effect

NHS National Health Service

NM Nuclear Medicine.

NRPB – National Radiological Protection Board taken into H&SE in 2005

OP Out-Patient.

PACS Picture Archiving and Communications System

PE – Pulmonary Embolism

PGME Post-Graduate Medical Education.

RAO Right Anterior Oblique (position).

RCA Royal College of Anaesthetists.

RCR The Royal College of Radiologists

RIS – Radiology Information System (see also HIS)

RPA Radiation Protection Advisor.

RPO – Radiation Protection Officer (or right posterior oblique)

RT LAT Right Lateral.

RTO Resuscitation Training Officer.

SAE – Stamped Addressed Envelope

SCOPME Standing Committee on Postgraduate Medical Education.

SCVIR – Society of Cardiovascular and Interventional Radiology

SIGN Scottish Intercollegiate Guidelines Network - roughly equivalent to NICE in England and Wales

Sv Sievert, the SI unit of dose equivalent. Not all ionising radiation has the same biological effect, so the absorbed dose is multiplied by a Quality Factor (QF) to give the dose equivalent: Dose equivalent (Sv) = absorbed dose (Gy) x QF The QF of x rays and gamma rays is 1.

SXR Skull radiograph. Colloquially Skull X Ray. Now a rare examination as CT is preferred

TIA - Transient Ischaemic Attack (brief self-limiting stroke)

TLD Thermo-luminescent Dosimeter, device to measure absorbed dose of radiation.– generally to determine staff exposure to radiation

UK United Kingdom .

US Ultrasound, a technique that produces images using pulses of high frequency sound.

V/Q Scan, VQ Ventilation and Perfusion Lung Scan, a Nuclear Medicine technique that compares the ventilation and perfusion of the lungs. Usually used for the diagnosis of pulmonary embolism.

WTE Whole Time Equivalents (measure of the number of staff members).

XR Radiograph, colloquially X-ray.

Further Reading

The following three publications have provided a rich source of inspiration. We strongly recommend that these references be read in full.

1 de Lacey G et al. Audit: an Instrument for Change. Hospital Update , 1992; June – November (six articles on aspects of audit).

2 Samuel O, Grant J, Irvine D. Quality and Audit in General Practice. Meanings and Definitions . London: Royal College of General Practitioners, 1994.