A Review of the Regulatory Framework for the Practice of MRI

Review Context

The MRTB

– The primary responsibility of the Board is to protect the health and safety of the public in respect of medical imaging and radiation therapy services

– Legislative responsibilities under the Health Practitioners Competence Assurance Act 2003

– Regulate the competence and fitness to practise of individual practitioners

Core Functions• Defining scopes of practice and associated qualifications (sections11 – 13)

• Setting competencies/standards of practice (sections 11; 16)

• Regular reviews of regulatory mechanisms (section 14)

• Registration and issuing practising certificates (sections 15 – 33)

• Monitoring ongoing competence (sections 34 – 44)

• Managing professional standards notifications (sections 34 – 51; 64 – 71)

• Accrediting qualification programmes (section 12)

Under the Health Practitioners Competence Assurance Act 2003 4

Principles that Underpin Our Work• Consideration of potential risk of harm or serious harm to the public

• We are accountable to the public, Parliament and the Minister of Health

• We are accountable to the profession for the efficient use of funds

• As an independent regulator our decision making is not determined by external bodies (see notes)

• Ensure the most effective, efficient, and consistent regulation of the profession

• Ensure our policies and standards are current in the NZ health environment through an ongoing programme of review

• Work collaboratively and constructively with key stakeholders

Regulation Workforce

Health Regulation

Health Workforce

Health Outcomes

MRI from an International Aspect

A Stocktake of the Regulation of MRI

• MRTB commissioned an independent literature review (Waipiata Consulting) looking at global picture for practice of MRI:

– New Zealand compared with 5 other countries with comparable health systems:

• Australia

• United Kingdom

• Canada

• South Africa

• USA

Terms of Reference• How are MRI practitioners regulated in those countries?

• The various training frameworks

– Level of study (courses/undergraduate/postgraduate)

– Learning hours

– Academic and clinical components

– Critical subject matter

• How is clinical competence assessed?

• What competencies are entry-level MRI practitioners expected to have?

• How does each country manage the regulation of overseas-trained MRI practitioners?

Australia• Regulation:

– No separate registration for practitioners practising MRI

• Training in MRI:– MRPBA (Medical Radiation Practice Board of Australia) requires MRI component within

undergraduate medical imaging programmes

– Legislation does not restrict practice. Practice only limited by what the practitioner is educated for and competent to do

– As a minimum would need to have workplace training in MRI and preferably that would include formal study (MRPBA)

– Majority of training is postgraduate: AIR (Australian Institute of Radiography) the largest provider

– Current registration is a pre-requisite to course entry

– MRI certification through AIR

• Workplace Practice:

– MRI competencies embedded into the Diagnostic Radiographer standards and professional capabilities

– Must apply MRPBA Code of Conduct when practising MRI

• Regulation of Overseas-Trained Practitioners:

– Overseas-trained practitioners must meet MRPBA professional capabilities and Code of Conduct

– Entry via TTMRA or an online examination

– “High Risk” countries: examination plus supervised practice

United Kingdom• Regulation:

– No separate registration for practitioners practising MRI

• Training:

– MRI physics and principles taught within undergraduate MI qualifications

– No expectation that new Radiographers will practise MRI

– Expectation that MRI practitioners will have postgraduate qualification

– 8 postgraduate MRI courses

– 2½ -3 days week in MRI dept. with supervisor to monitor clinical practice

– Focus of qualifications is theoretical and technical knowledge

– Current registration is a pre-requisite to course entry

• Workplace Practice– “High trust” model (refer to notes)

– Practical training for MRI generally provided in-house within a hospital setting

– Majority of employers require some form of postgraduate qualification in MRI but there is no absolute requirement

– No prescribed number of hours to be deemed competent in MRI

– Clinical component of in-house hospital training is up to the individual department

• Regulation of Overseas-Trained Practitioners:– HCPC (Health and Care Professions Council) is the national regulator

– Standard process for all international applicants

– Employers: Relevant PG qualification and experience. Code of Conduct and working within scope of practice

Canada• Regulation:

– Medical imaging regulated in some provinces but not all

– CAMRT (Canadian Association of Medical Radiation Technologists) is the national professional association and certifying body for MRT’s

– 4 disciplines of MRT practice each with their own entry-level competency profiles:

• Magnetic Resonance

• Nuclear Medicine

• Radiation Therapy

• Radiological Technology

• Training:– Approved/accredited MRI qualifications: 6 diplomas and 1 certificate

– Entry to all programmes (except one) is post graduate

– Current registration is a pre-requisite to course entry

– Includes both academic curricula and clinical practicum

• Workplace Practice:– Standards of practice determined through regulatory framework

• Regulation of Overseas-Trained Practitioners:– Self-Assessment Tools

– Voluntary Orientation Course

– Clinical Competency Assessment National Certification Exam

USA• Regulation:

– 5 disciplines of “radiologic technology” recognised including MRI

– ARRT (American Registry of Radiologic Technologists) is the registration body

– ASRT (American Society of Radiologic Technologists) is the professional body and provides both a Practice Standard and Curriculum Guidelines for the practice of MRI

– Only 3 states regulate MRI Technologists by modality

• Training:– 2 pathways for MRI:

• Primary Pathway – an accredited educational programme approved by ARRT

• Post-Primary Pathway – qualified and registered MRT plus MRI clinical experience requirements plus 16 hours of structured education

• 30 ARRT recognised educational programmes in MRI

• Workplace Practice:– Significant variation across states as to employers’ requirements

• Registration of Overseas-Trained Practitioners– Certification examinations required in most states

South Africa• Regulation:

– Health Professions Council of South Africa (HPCSA) regulates the professions of radiology and clinical technology

– Professional Board for Clinical Technology and Radiography (PBCTR) sits within the HPCSA

– 3 scopes of practice:• Diagnostic radiography (including MRI)

• Nuclear medicine radiography

• Radiation therapy

– HPCSA regulates radiographers in respect of registration, education and training, professional conduct and ethical behaviour

• Training:– 1 post graduate MRI programme recognised by the PBCTR

• 1-year certificate in MRI. 2 x fulltime academic semesters

• Requires clinical placement with 600 hours logged in the MRI unit

– HPCSA accredits training facilities for clinical experience for undergraduate programmes

• Workplace Practice:– Standards of practice determined through regulatory framework

• Registration of Overseas-Trained Practitioners:– HPCSA is the national regulator

– Standard process for all international applicants

Overseas MRI Practice: An Overview• MRI regulated as a separate modality in some of the countries surveyed while in others

it is amalgamated into other regulated scopes

• Australia – UK – Canada typically expect MRI practitioners to have a post-graduate qualification.

– In the large part assessment of clinical experience sits with the employer

• Entry into the majority of MRI courses have a pre-requisite of a medical imaging qualification

• All countries surveyed have explicit entry criteria for overseas-trained practitioners

MRI in NZ

Regulation:• MRTB regulates practice of MRI as a separate scope of practice

• 2 MRI scopes of practice have been defined under the HPCAA:

– MRI Technologist

– Trainee MRI Technologist

Training:– Post graduate diploma studied part-time over a maximum of 4-years (most

complete in 2-years)

– Clinical placement in MRI unit requirement of the PG Diploma

– Includes both academic curriculum and clinical competence assessment

– Current registration pre-requisite to registration as a Trainee MRIT

New Zealand

• Workplace Practice:– Entry-level standards of practice are determined through the regulatory framework

– All practising MRI Technologists must hold a current practising certificate (APC)

– Engagement in CPD is a requirement for renewal of APC

• Regulation of Overseas-Trained Practitioners– Applicants must meet the MRTB standards of competencies in MRI

– Require a qualification in MRI that has been assessed as being substantially equivalent to the NZ MRI programme accredited by the MRTB

– Option to sit a Registration Examination Assessment if qualification deemed not equivalent but applicant has sufficient MRI clinical experience

The Numbers: APC Holders

2016 2015 2014 2013 2012 2011 2010 2009 2008 2007

MRI Technologists 213 197 178 169 152 136 111 77 50 38

Trainee MRI Technologists 36 39 43 39 58 78 89 106 108 94

% Trainees to MRI Technologists

17% 20% 24% 23% 38% 57% 80% 138% 216% 247%

The Numbers: MRI Registrations

Declined Approved Offered REA2016 5 16 22015 2 22 22014 5 18 42013 2 25 12012 1 22 -2011 - 31 12010 1 34 -2009 - 41 22008 1 27 -2007 2 37 -

Total 19 273 12

The Numbers: MRI Registrations by Country2012 – 2016 (APC Year) 2007 – 2011 (APC Year)

Approved Declined Offered REA Approved Declined Offered REA

New Zealand 52 - 76

Australia 28 - 1 80 1

United Kingdom 18 - 3 12 1

Canada 1 1 4 2 2

USA 4 2 1

South Africa 1 1

India 5

Philippines 4

Jordan 1

France 1

Not Identified 2

Total 103 15 9 170 4 3

The Numbers: REA

Country 2012 -2016 2007 - 2011

Pass Fail Pass Fail

Australia 1 2Canada 1 1 1NZ 1UK 3USA 2 1

Taking the Regulation of MRI into the Future

Regulation of MRIMRI will continue to be regulated as a separate scope of practice

• The Board has made this decision in recognition that:

– MRI has potential to cause risk of harm to the public

– Allows for consistency in practice standards across all MRI units in NZ

– Separate regulation is a robust mechanism for protecting the health and safety of the public

• While regulation of MRI will continue to be managed through a separate scope of practice, the Board is looking into other measures to help reduce potential barriers to MRI Technologist registration (refer to slides 30, 31, 32)

Training of MRI TechnologistsQualification for MRI is to remain at post-graduate level

– From a regulatory perspective training needs to support protection of health and safety of public through ensuring entry-level practitioners have sufficient and appropriate MRI knowledge and skills that align with entry-level

– The Board will look into whether there are options for reducing the length of time of the postgraduate programme which could then potentially enable employers to assist more practitioners to complete the training

– The Board has had a preliminary discussion with the relevant education provider and has agreed to take a collaborative approach to investigating if there may be ways to shorten the postgraduate training framework without compromising the quality of academic learning and clinical skills of entry-level graduates

Regulation of Overseas-Trained Practitioners

Online Registration Examination

• MRTB looking to introduce an online examination as a mechanism for managing registration applications from overseas-trained practitioners (all scopes)

• Likely to supersede the REA

• May still be instances of practitioners requiring period of supervised practice (in addition to the exam)

• A viable option to resolve many of the barriers associated with REA process

• Exam questions practical in nature, looking for clinical reasoning and aligned to the entry-level competencies for relevant scope of practice

• Opportunity to learn from the MRPBA experience

Recognition of Overseas Qualifications

• Work with Australian and UK jurisdictions with a view to reciprocal recognition of MRI qualifications

– The majority of overseas MRI applicants come from these two countries

– Begin with Australia

Practitioner Questions

Question:Responses to the Board’s consultation were largely in favour of retaining MRI as a separate scope of practice. Why has the Board ignored the results of its own survey and pushed ahead with looking at MRI as a separate scope of practice?

Response:The survey results were not ignored. They were taken into consideration (along with findings from independent research) to provide the Board with the industry’s perceived overview of professional requirements for safe practice

Question:Is the Board aware of the international concerns in MRI and the lengths the USA are undertaking to ensure the safe practice of MRI?

Response:The Board is aware of the situation in the USA and notes that the level of academic MRI education is significantly lower than the NZ entry-level requirements. The Board’s primary focus always has been, and remains to be, safe practice so as to protect the health and safety of the public

Question:Why has the Board suggested ceasing MRI as a separate scope of practice but not Sonography or Nuclear Medicine?

Response:The Board has never categorically stated it was proposing to cease with MRI being regulated as a separate scope of practice. We did advise that this was one aspect the Board would look into, taking into account that a number of other countries with comparable health systems do not regulate MRI as a separate scope. In those same countries nuclear medicine has always been regulated as a distinct scope/modality as has sonography (although regulation of the latter is not always done within a legislative framework but rather is self-regulated). We also considered other factors such as workforce issues and considered these from the perspective that the regulatory framework is not presenting unnecessary barriers to the regulation of MRI practitioners.

The Board is committed to, and indeed is legislatively obliged to undertaking regular reviews of each scope of practice. As a result of the 2008 review of the HPCA Act, all regulatory authorities were advised by the Ministry of Health that good practice regulation would require them to undertake such reviews on at least a 3-yearly cycle. The review of the MRI scope sits within that requirement.

Question:What’s different about the MRI environment now that back when it was decided that MRI should be a separate scope?

Response:When the Board made the decision to make MRI a separate scope it was when MRI was an emerging technology and there was not a lot of scope for including more MRI-specific training into the undergraduate qualification programmes. Having MRI as a separate scope gave the Board a platform to set standards at a national level for a relatively new technology.

The Board is aware that a number of other countries with comparable health systems have chosen to not regulate MRI as a separate scope and it was considered reasonable that the Board should explore whether this could be considered within NZ.

Question:What, if any, training options are in place to ensure radiation therapists use MRI safely within their scope of practice? Would the Board accept that conducting RT planning MRI’s fall into the scope of a RT and if so what training/credentialing is required to do this safely?

Response:The Board recognises the challenges resulting from the “blending” of many medical imaging and radiation therapy technologies. As an example some NM Technologists have been enabled to perform diagnostic CT through completing specific training courses that have been assessed and endorsed by the Board. In these instances the practitioners remain as NM Technologists but with a condition on their APC allowing them to perform diagnostic CT. Another example is where a RT is able to perform mammography as a condition on their APC.

Similar scenarios would be possible for a RT to perform RT planning MRI provided they have completed an appropriate course as assessed and approved by the Board.

Question:Why a “Roadshow”?

Response:The Board has taken time out to present its findings as the profession deserves that the concerns they have raised be addressed with transparency. Initial feedback indicated there were a number of assumptions and misunderstandings about the Board’s review of the MRI scope and that a roadshow was the best way for the issues to be taken to the profession