Raising the standard

Radiography manager Clare Hutton describes how Hull Uni Teaching Hospitals’ radiotherapy dept. became the 1st to gain MPACE CT accreditation

Published: 05 July 2022 Radiotherapy

The Hull University Teaching Hospitals NHS Trust radiotherapy department is the first radiotherapy service to be awarded accreditation to the BS 70000:2017 (MPACE) standard in CT localisation planning. The UK Accreditation Service (UKAS) auditors and technical assessors initially visited when the radiotherapy physics team participated in the pilot for BS 70000 accreditation in October 2018. We have a combined Quality Management System (QMS) and UKAS initially proposed that the service consider a different accreditation standard, the Quality Standard for Imaging (QSI) for CT, which is a quality standard in radiology accreditation and not transferable to the radiotherapy CT setting, so the decision was made to test the MPACE scope (initially written with medical physics services in mind) to include CT localisation. UKAS identified a therapeutic radiographer as a technical assessor to audit the service, along with a lay assessor, who acted as the patients’ advocate. Radiotherapy services have been ISO9001 certificated for many years, with this standard designed to ensure there is a good level of process management against a pre-determined criteria. The key difference with accreditation standards is that they are very service specific and seek to provide assurance relating not just to process performance but to technical competence and, therefore, independent evidence of “fitness for purpose” for a given area. This is why MPACE assessors require a full understanding and clinical experience of the areas under assessment.

The assessment took place in July 2021 and positive feedback was received from the assessors, who said the staff were welcoming, open, honest and very professional. The process of an accreditation assessment is very challenging, especially when you are asked to provide evidence that your practice meets the required standard, and are then asked further questions to explain why processes are designed in certain ways. The staff were fantastic in responding to this challenge and open to testing their thought processes and considering other ways of improving our service for patients.

The key factor is improving patient care and the team kept this as their focus when the findings were formally discussed. At the end of the audit, the report was shared with the whole team to support departmental development and understanding. Lyndsay Smith, advanced practitioner for professional education, said: “Being assessed is not something to be terrified of. You are doing your job just as you would any other day but you are doing it with a few friendly, professional and questioning representatives. They are not there to catch you out but to ensure the service you believe you are delivering matches up to the service you are delivering.”

The outcome of the audit was a recommendation for accreditation once the eight findings had been addressed and evidence provided to assure UKAS. The formal response deadline was 19 October 2021 and the service received accreditation in January this year.

A limited number of therapeutic radiographers had been involved in the initial audit for a subset of radiotherapy physics processes, however, more members of the team were involved in this audit. The intention was to develop this approach to continually improve our service and patient care across the entire radiotherapy pathway by holding ourselves up to the highest level of challenge from external auditors and quality standards.

Working together

Lyndsay said: “I feel very proud of the whole multidisciplinary team who worked hard to achieve this accreditation and who will continue to work together to ensure accreditation is maintained in the future while maintaining the high level of care we strive to achieve. Since being granted accreditation, we have had several patients ask about and comment on this. It shows that patients do pay attention to these things and are reassured by the MPACE accreditation we have achieved and how it impacts on them as patients.”

I would like to acknowledge our teams that participated in the audit, the booking co-ordinators, radiotherapy clinical support workers, therapeutic radiographers and our quality manager. In addition to this were our key leads, who prepared for – and participated in – the audit and have acted upon the findings. These were the pre-treatment and treatment therapeutic radiographer team leader, the therapeutic radiographer advanced practitioners, the deputy radiotherapy manager and our quality manager for radiotherapy and radiotherapy physics.

Thank you for guiding us through this process, being the auditor and keeping us on track to achieve – we would not have been this successful without your hard work and support.

L-R: Clare Hutton, radiotherapy manager; Lyndsay Smith, advanced practitioner for professional education; Paula McLoone, pre-treatment team leader, and Sammie Armitage, clinical support worker


Charlotte Poisman, therapeutic radiographer, said: “Going forward with the localisation accreditation was nerve-racking to begin with but also exciting. As a department, we know we do things well but this process would ultimately confirm this. Our physics department had already gone through the UKAS accreditation process and had very few findings so the pressure was on.

“Working through the standards and having regular catch-ups with the MPACE team really helped to keep us on target for the assessment, especially when some of the standards felt like a foreign language.”

I feel very proud of the department’s achievement and especially all the staff for coming together and working as a team through the assessment process at one of the most difficult times for the NHS.

The feedback from UKAS and the technical assessors was extremely positive. They commented on how staff were open and responsive to questions. They also described a situation with a very complex patient, which required consideration and interventions to ensure an appropriate CT planning scan was acquired for treatment planning with a position that would be accurately reproduced for each treatment.

The feedback from the assessors related directly to the team’s professional and logical approach by which they could explain what they were doing with justifications. When you are being audited, it is often assumed that you will want an “easy” or “straightforward” patient set up. However, this situation provided the assessors with more assurance of our practice and how the staff professionally managed the complex situation.

Paula McLoone, pre-treatment team leader, said: “The ultimate aim of becoming accredited is to improve patient care. It is very easy to remain in the status quo and not question the service you already provide. I am very proud of the team we have, they are open to challenging themselves, whether this is in writing QMS documents, providing feedback to peers or putting new ideas forward to give high-quality care.

“In preparation for a next audit, UKAS and the technical assessors have said they would like us to consider any themes and trends to emerge in the patient feedback we have received, and to use evidence to show how we have responded.”