quality assurance standards (qas) handbook...imi quality assurance scheme patient experience pec5...
TRANSCRIPT
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clinical photography, design and video in healthcare
Quality Assurance Standards (QAS) HandbookPhotography • Art • Graphic Design • Video
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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
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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.
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3
Institute of Medical IllustratorsQuality Assurance Standards : Contacts
Standards Team
Bolette JONES (Lead)Medical Illustration Service ManagerEmail: [email protected]: 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: [email protected]: Department of Clinical PhotographyUniversity Hospital Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Edgbaston, Birmingham, B15 2GWTelephone: 0121 371 2460
Nigel BEARDSMOREMedical Illustration ManagerEmail: [email protected]: New Cross Hospital New Cross Hospital, Wednesfield Road Wolverhampton, West Midlands, WV10 0QPTelephone: 01902 695377
Jill FELLHead of DepartmentEmail: [email protected]: 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: [email protected]: 24 Comfrey Close, Harrogate, North Yorkshire. HG3 2XBTelephone: 07587 702046
Tim ZOLTI Medical Illustration Service ManagerEmail: [email protected] Address: Medical & Dental IllustrationLeeds Dental Institute, Clarendon Way, Leeds, West Yorkshire, LS2 9LUTelephone: 01423 500504
Jane TOVEYMedical Illustration Service ManagerEmail: [email protected]: Department of Medical IllustrationUniversity Hospital Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Wolfson Building, Edgbaston, Birmingham, B15 2GWTelephone: 0121 371 6499
Shay GunstoneClinical PhotographerEmail: [email protected]: North Bristol NHS Trust, Level 3, Gate 38, Brunel Building, Southmead Hospital, Bristol, BS10 5 NBTelephone: 01174 146500
Nicola Kelley-CarrickClinical PhotographerEmail: [email protected]: 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: [email protected]: 7 Bryestone Avenue, Newton Mearns, Glasgow. G77 5SH Telephone: 07860130352
Simon BrinkworthClinical PhotographerEmail: [email protected]: University Hospital Bristol NHS Foundation Trust, Medical Illustration, Marlborough Hill Workshops, Bristol, BS2 8HWTelephone: 01173 427366
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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.
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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 [email protected] to request an audit • Fill out the finance pro forma to request an invoice & send to [email protected] • 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.
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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
R7
6H
R8
7PP
1
8H
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
evel
2N
ew
QA
S R
ef1
SM1
2SM
1
3SM
1
4SM
1
5H
R5
6SM
2
7G
OV
1
8SM
3
9SM
3
10G
OV
1
11G
OV
2
12SM
5
13SR
M2
14SR
M1
15H
R7
16SR
M1
17G
OV
1
18PP
2,
CO
M2
19PP
2,
CO
M2
20C
OM
1
21G
OV
2
22SM
2
23FR
1
24FR
2
25FR
1
26FR
1
27FR
2
28FR
4
Bra
nd N
ew
Stan
dard
sN
ew
QA
S R
efR
egis
trat
ion
HR
6
Med
ia s
ecur
ityIG
1
Imag
e ac
cess
IG2
Con
sent
rec
ords
IG3
DIY
imag
esIG
5
Secu
rity
con
trol
sIG
6
Ord
erin
gFR
3
Imag
e qu
ality
st
anda
rds
SM3
Serv
ice
docu
men
ted
SM6
Orig
inal
: Le
vel 1
= 3
6, L
evel
2 =
28
New
: Le
vel 1
=35
, 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 - [email protected] 2. The QAS Administrator - [email protected] 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