Guidance

Example templates of employer's procedures

Updated 27 September 2024

Applies to England

The following 2 templates provide examples of how an employer’s procedure could be presented. The detail provided is not intended for direct adoption in the clinical environment. Clinical departments should adapt the template to reflect NHS Breast Screening Programme guidance and local practice.

1. Identification of the women to be exposed (Schedule 2 (a) employer’s procedure)

The operator performing the medical exposure is responsible for the correct identification of the woman prior to the exposure.

Objective

The objective is to provide a procedure for operators to follow to correctly identify the woman attending for screening mammography.

Procedure

The operator must verbally ask the woman attending for screening the following questions:

• what is your full name?
• what is your date of birth?
• what is the first line of your address?

The mammographer carrying out the examination must confirm the woman’s identification by cross checking with the data supplied on the client screening form/day list. The woman’s details and NHS number must also be checked against the worklist on the acquisition workstation. The operator must sign their initials on the screening form to indicate that both identification checks have been completed.

If there is any doubt that the woman is not the intended recipient of the exposure, the examination must not proceed.

Alternative methods for identification:

Women who lack capacity and/or are unable to respond

If the woman is unable to answer the above identification questions, her personal details should be checked by asking the following questions to an accompanying adult relative or carer:

• what is the woman’s full name?
• what is the woman’s date of birth?
• what is the woman’s first line of their address?

Women with sensory impairment

Women who have hearing impairment must be provided with written questions and materials to verify their identification. Any additional documentation relating to the identification (ID) checks must be attached to the screening form and kept as a permanent record.

Women who require an alternative language to communicate

If there is an accompanying adult with the woman who can speak English ask them to confirm the full name, date of birth and first line of the woman’s address, as above. If necessary, the services of an interpreter can be arranged through the telephone interpretation service, which provides a facility for eligible women who cannot speak English or who are not fluent in English.

Cards may be available with name, address, date of birth, screening history and previous surgery in foreign languages relevant to the population of the area. These can be used when checking the woman’s identity.

Discrepancy in the identification process

If there are any identification discrepancies these must be clarified before the examination can commence. The operator must:

• ask the woman to state her full address and/or telephone number for checking against the client screening form
• check details of previous visits
• check photo identification (if available)
• check all information against previous records on the national breast screening system (NBSS)

Once verified, the woman’s correct details must be written clearly on the screening form. If the woman’s details cannot be clarified the examination must not go ahead.

Author: [name]
Issue date: [date]
Version: [number]
Review date: [date]

2. Procedure to identify individuals entitled to act as referrer, practitioner and operator for exposures (schedule 2 (b) employer’s procedure)

Entitlement is the process of endorsement, by an appropriate and specified individual within an organisation, to ensure each Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) duty holder has been adequately trained and is deemed competent to carry out their specific duty holder role within their defined scope of practice.

Objective

The objective is to:

• outline the method for entitling individuals as duty holders under IR(ME)R
• ensure that each individual is adequately trained, appropriately qualified, registered and competent before entitlement may be given to act as referrer, practitioner and/or operator

Responsibilities

Employer

The overall responsibility for ensuring that the IR(ME)R are complied with in the [name] breast screening service lies with the chief executive officer (CEO) of the [name] Trust. The employer delegates the task of entitlement to appropriately trained and experienced individuals within the breast screening service.

These individuals must have the required knowledge and experience to authorise the entitlement of a duty holder. They are responsible for ensuring that an up-to-date record of training and competencies for each IR(ME)R practitioner and operator are in place prior to entitlement.

Duty Holder

Each duty holder must have a clear statement of entitlement to act as an IR(ME)R referrer, practitioner or operator issued by the appropriate individual. They must act within the scope of their entitlement which will be defined by their scope of practice. Each duty holder is responsible for maintaining their own personal training records which must contain evidence of continuing professional development and training.

Process of entitlement

Within the [name] breast screening service the CEO has entitled the director of breast screening and the site lead mammographer within their areas of responsibility to entitle duty holders under IR(ME)R.

For each individual IR(ME)R duty holder (referrers, practitioners or operators) the scope of entitlement must be specified and supported by training records which demonstrate that the individual is competent to undertake specific tasks. Entitlement is demonstrated by the individual authorising the entitlement, signing the entitlement form. The duty holder must sign this document and also sign to confirm they have read and will comply with the employer’s procedures.

Referrer entitlement

Referrers must be registered healthcare professionals who are entitled to refer women for mammography. The director of breast screening will entitle medical referrers and outline their scope of entitlement to refer for breast assessment screening.

The lead mammographer will entitle all non-medical referrers. Their scope of entitlement will be outlined in their individual scope of practice.

Records of entitlement are held by the director of breast screening.

Example of staff entitled as IR(ME)R referrers

Director of Breast Screening

Expected level of training: General Medical Council (GMC) registered
Scope of referral: all mammography examinations
Entitled by: CEO

Consultant Breast Radiologist

Expected level of training: GMC registered, Fellowship of the Royal College of Radiologists (FRCR) leading to certificate of completion of training (CCT) in mammography
Scope of referral: all mammography examinations
Entitled by: CEO

Non-medical referrer (radiographer)

Expected level of training: Health and Care Professions Council (HCPC) registration
Scope of practice: all mammography examinations
Entitled by: lead mammographer

Entitlement of IR(ME)R practitioner

The IR(ME)R practitioner must be a registered healthcare professional who is adequately trained and assessed as competent to act in this role. Their primary role is to justify the mammography exposure.

The CEO and director of breast screening will ensure the individual is adequately trained and deemed competent to carry out the intellectual task of justification. Their entitlement should be reviewed at annual appraisal.

Example of staff entitled as IR(ME)R practitioners

Director of Breast Screening

Expected level of training: GMC registered
Scope of practice: all mammography examinations
Entitled by: CEO

Locum Breast Radiologist

Expected level of training: GMC registered
Scope of practice: all mammography examinations
Entitled by: director of breast screening

Radiographer

Expected level of training: HCPC registration, recognised postgraduate qualification in mammography
Scope of practice: all mammography examinations
Entitled by: lead mammographer

Entitlement of operator

There is no requirement for the operators to be a registered healthcare professional, but they must be adequately trained and assessed as competent. The role of the operator is to carry out the practical aspects of an exposure. Entitlement to act as an operator is specific to the individual’s scope of practice. Training and competency records must be assessed prior to entitlement and reviewed at annual appraisal. Trainee radiographers and assistant practitioners may perform operator roles provided they work under the supervision of an appropriate entitled operator.

Example of staff entitled as operators

Reporting radiologist/reporting radiographers

Expected level of training: CCT in mammography/HCPC registered/PgCert in image interpretation and reporting
Entitled by: site lead mammographer

Radiographers/assistant practitioners

Expected level of training: HCPC registered, College of Radiographers (CoR) approved education course
Entitled by: site lead mammographer

Medical physics expert (MPE)

Expected level of training: HCPC registered
Entitled by: director of breast screening

Author: [name]
Issue date: [date]
Version: [number]
Review date: [date]

3 Schedule 2 Employer’s procedure (n)

Procedure to establish appropriate dose constraints and guidance for the exposure to carers and comforters

Carers and comforters are defined as individuals who are knowingly and willingly exposed to ionising radiation by supporting women undergoing a mammography examination.

Support from a carer or comforter should only be sought where it is considered necessary in order to achieve a diagnostic mammogram, or where lack of support may mean that the exposure is not possible or has to be repeated. The support required may be physical or emotional.

Objectives

• clarify the process of justifying an exposure to a carer and comforter
• outline the roles and responsibilities of the mammographer when carer or comforter is required
• ensure the carer and comforter is fully informed of the benefits of providing support and the implications of the risk of the exposure
• establish a dose constraint for the carer and comforter

Procedure

• the mammographer must establish the carer or comforter is over 18 and not pregnant
• the mammographer should establish whether the carer and comforter can understand and follow instructions and be able to provide verbal consent
• the carer and comforter must knowingly and willingly take on this role and have the right to withdraw support at any time during the examination
• the carer and comforter must be provided with information on the benefits and risks of performing this role, prior to the exposure.
• the benefits to the woman having a carer and comforter present during her mammogram is likely to outweigh any small risks incurred by the carer or comforter from the exposure.
• exposures to carers and comforters must be justified by an IR(ME)R practitioner (or mammographer authorising to guidelines) prior to the exposure
• physical support should only be given where the objectives cannot be achieved by mechanical or other means for example, by imaging the woman in a chair
• emotional/cognitive support may be given by the carer and comforter while standing behind a protective screen such as the console panel
• the carer and comforter must wear a radiation protective lead apron during the exposure, if providing physical support
• the mammographer will instruct the carer and comforter on where to stand to avoid the primary beam
• a record of the carer and comforter details should be made on the carer and comforter consent form
• doses to carers and comforters should be kept as low as reasonably practicable and should not exceed the dose constraint of 0.3mSv per year
• both the mammographer and carer and comforter must sign and date the form before it is scanning onto the IT system