» Imaging Accreditation at West Suffolk Hospital

10 January, 2016

While not in the pilot phase of the accreditation of Imaging services, the radiology service at West Suffolk Hospital was a fairly early implementer, achieving initial accreditation in April 2011. Year 1 accreditation was achieved in November 2011 and year 2 in 2013 after a site visit in January 2013.

The West Suffolk Hospital is a 441 bed district general hospital, and the radiology department has four general rooms, two fluoroscopy rooms (one of which is interventional), one A&E room, two CT scanners, one MRI scanner and five ultrasound rooms (three in the obstetric and gynaecology unit). There is a breast imaging department with three mammography units, all digital, and a mobile breast screening unit, and a nuclear medicine department. Breast screening and nuclear medicine are currently out of scope, but we plan to bring nuclear medicine within scope at the end of year four as we begin a new accreditation cycle with a full site visit.

Why Accreditation?

Accreditation takes time and resource. At a time when both are in short supply is it worth committing them to UKAS accreditation? At the time we started, the two biggest reasons for getting going were:

  • We felt that time and resource were not likely to become more plentiful in the future, so the sooner we could make a start, the better.
  • We were impressed by the focus on patient experience, with one of the domains devoted to patient experience, and a lay assessor on site visits, it was clear that the patient is at the centre of the standard.


At West Suffolk Hospital radiology was part of imaging services, which includes endoscopy, for which accreditation (Joint Advisory Group on GI endoscopy) is mandatory. The model here was to enrol a project manager to oversee the accreditation project. This went well, and accreditation was achieved, but without really involving staff below the senior team. Preliminary discussions with the UKAS representatives, however, strongly recommended a team based approach, and, on reflection, this is the path that we felt we should follow, with pairs of staff working on each dimension in four Domain teams each chaired by a senior member of staff.

Accreditation and the Francis Report

As the story surrounding the disaster at the Mid-Staffordshire NHS Foundation Trust, and the ensuing report by Lord Francis has unfolded, the wisdom of this team-based approach has become apparent. If you put a microphone in front of any of the patients or carers affected by the Mid-Staffs issues it won’t be long before they say the word ‘culture’. They may mean the culture of the NHS but, in reality, the NHS is far too big to have its own culture and what is important is the culture that exists at ward or service level.

A key benefit of accreditation to us has been the very positive impact that it has had upon the culture of the department. The outworking of this team based approach is to develop both expertise and leadership amongst the staff so that the awareness of the correct, safe, and compassionate way to work is held and owned at ‘shop floor’ level rather than imposed from on high. Staff themselves process patient feedback, or audit data, as they go about their day to day work and produce their regular ‘outcome measures’, and so they are feeding information up rather than having performance information fed down to them.

This can have surprising results. I have, for example, an e-mail from a band 6 general radiographer to the Superintendent Sonographer and the radiology matron because she is collating information about appraisal and could they please ensure that their appraisals are up to date in time for the assessment visit! Far from asking ‘who does she think she is?’ the more senior staff just get on and sort it because that is how accreditation works in our department. I also regularly see e-mails from my staff to senior staff in the Trust asking them to update their policy documents! One radiographer said to me, “Accreditation is hard work, time-consuming, but it is good to know that we have our ducks in a row, and it is good to know the right thing to do.”

Empowered, motivated, ‘can-do’ staff aren’t just good for an annual accreditation exercise, they are good for the patients who use the service, good for clinical governance in general, and good for the reputation of the hospital and the wider NHS.