Working towards the implementation of an international accreditation programme in a Nuclear Medicine Department of a South African teaching hospital

Introduction: Quality assurance in Nuclear Medicine is of utmost importance in order to ensure optimal scintigraphic results and correct patient management. A customised Quality Management System (QMS) should be documented and implemented by following the international guidelines set by the International Standardisation Organization (ISO). Materials & Methods: A Quality Control Manual (QCM), defining the departmental quality policy, mission, vision and objectives was customised following the framework of a tried and tested design. As ISO focuses on client satisfaction and staff harmony, the following departmental objectives were audited in working towards the accreditation of the Nuclear Medicine Department of Tygerberg Hospital: referring physician satisfaction, patient satisfaction as well as staff satisfaction and harmony. Information was collected by means of questionnaires completed by referring physicians and staff members. One-on-one interviews were executed on patients. An international ISO accredited Nuclear Medicine department was visited to establish the suggested path to follow en route to successful ISO accreditation and certification. Results: Referring physicians indicated overall satisfaction with service provision, but a need for electronic report and image transfers seemed too dominant. The patient satisfaction survey resulted into overall satisfaction with personal service providing, but the provision of written and understandable information, long waiting times and t equipment must receive attention. Staff questionnaires indicated a general lack of communication between different professional groups and the need for interpersonal loyalty and team building. Improvement measures were identified to ensure the continuous improvement of the QMS by focusing on these quality parameters. Conclusion: The department has QA procedures in place, but does not meet all criteria for external accreditation. In order to ensure departmental harmony and sustainability of client and staff satisfaction, the departmental objectives in measured and improved where needed. The successful implementation and continuous improvement of a customised QMS, following the guidelines outlined in the QCM will lead to successful accreditation. (author)