Justification Group 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