1. Justification Group 1 Facilitators: Felipe Caseiro Alves, Denis Remedios

2. Group 1 participants Countries: Portugal, Brazil, Angola, East Timor, Cape Verde, Sao Tome and Principe, Professions Regulators, radiologists, radiographers, medical physics

3. 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.

4. 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

5. 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

6. Common barriers: Clinician support E Timor- Difficulty with clinicians requesting inappropriate exams Need for a user friendly system with better communication re justification decisions

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. Patient expectations Portugal – radiologist should reduce expectations of patient, and refer back to requesting clinician when challenged All- need for patient awareness

13. 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

14. 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