JustificationGroup 1

Facilitators: Felipe Caseiro Alves, Denis Remedios

Group 1 participants

Countries:• Portugal, Brazil, Angola, East Timor, Cape

Verde, Sao Tome and Principe,

Professions • Regulators, radiologists, radiographers,

medical physics

Common barriers: Resource

• Cape Verde, E Timor - Resources limited • Cape Verde- old equipment and old technology• Brazil- hospitals not all computerised• Brazil - large with vast difference in income- v.

Poor areas / better off areas. Non-uniform.• Brazil- differences in infrastructure for therapy.

Based on old BSS ’96.• Cape Verde- Frequently only radiographers in

departments, not enough radiologists. Only 1 physicist.

Common barriers: Education

• Brazil- university training programme without teaching of justification, should share information re justification

• Cape Verde has no universities• Cape Verde- lack of training for radiographers

Common barriers: governmental support

• Brazil- 2 regulatory bodies: health, radiation• Cape Verde- no legal requirement for

justification so no incentive for medial referrers to justify.

• Cape Verde- lack of political support• Guidelines use limited even in Europe... but not

necessarily measure of value

Common barriers: Clinician support

• E Timor- Difficulty with clinicians requesting inappropriate exams

• Need for a user friendly system with better communication re justification decisions

Suggested solutions and examples of good practice: Education

• All- Education of GPs and medical undergraduates needed• Portugal- Education of GPs to request the appropriate test first.• Brazil - integration of radiology into curriculum of medical

students in one university. Wish to roll out to all universities for undergraduate education.

• Angola- asks for help for material for education in radiation safety

• Sao Tome and Principe- need educational initiatives and keen to have help from this group.

• Print version of guidelines needed for non-computerised hospitals

Suggested solutions and examples of good practice: clinician collaboration

• GPs are common referrer and helped by referral guidelines in Portuguese

• Portugal- ED allows change in the requested investigation- radiologist has the ability to modify request.

• E Timor- Doctors from many countries with differing backgrounds bring good practices but non-uniform.

• Angola - MDT approach to therapy. Ad hoc but should be regular practice.

• E Timor- MDT approach will include radiologist otherwise the interaction with clinicians. Ad hoc but should be routine practice.

• Brazil- essential to have clinicians on board for justification & for all to embrace principle of justification- safety culture

• Maria Perez WHO- patient advocates need to be included to help with awareness

Monitoring• Portugal- Team working essential for referrers,

radiologists and radiographers. Local practice improved by oversight by senior colleague.

• Brazil- Monitoring of equipment and service provision rather than patient care. Documentation of processes and procedures useful. Accreditation should include practice of justification.

• Brazil- ANS agency quality standard and quality certification for private sector. Public sector (52 university) hospitals have management change to increase awareness of safety

Individual Health Assessment

• Brazil- forbidden to perform exam without request but still happens. Not recorded.

• Brazil- Patient pressure to perform inappropriate exams compounded by defensive practice. Legal proceedings against doctors not acceding to request for radiology procedure.

Self referral by radiologist

• Mainly in private sector• Angola- Patient pressure for exam leads to

consultation with a referring doctor to provide request driven by financial reasons. Type of exam determined by cost/affordability.

Patient expectations

• Portugal – radiologist should reduce expectations of patient, and refer back to requesting clinician when challenged

• All- need for patient awareness

Radiologist as gatekeeper

• Portugal – Radiologist sometimes “invisible”- disadvantage as he may not be perceived as a doctor

• Patients need to be informed and given information about exam so justification decision better understood

• Patient advocates / groups should be engaged to improve awareness

Improved Justification:Suggestions for the way forward

1. Educational initiatives– University undergraduate curricula to include safety material– Radiographer training– GPs and Emergency physicians.

2. Help from professional bodies– Referral guidelines in Portuguese– Clinician involvement through awareness and education– Acceptance of the principle of a request for an opinion

3. Help from national governmental agencies– Endorsement/Support of professionally led initiatives– Resource to support local training and infrastructure– (legislation)

4. Help from International agencies– Educational material in Portuguese – Technical co-operation- Local training courses/workshops– Liaison with ministries of health and competent authorities