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Closing the Loop

Project Added:
18 March 2016
Last updated:
17 October 2016

Closing the Loop


Prince of Wales Hospital developed a communication pathway that reported incidental findings, unexpected findings and changes to provisional medical imaging reports back to the referring clinician within an agreed timeframe.


To reduce delays in communicating medical imaging results to referring clinicians, so that diagnosis and treatment can be undertaken in a timely manner.


  • Reduces unnecessary delays in providing test results to referring clinicians.
  • Improves communication and collaboration between medical imaging and clinician teams.
  • Allows patients to be diagnosed and treated in a timely manner.
  • Improves patient experience and satisfaction with the medical imaging service.
  • Improves staff satisfaction and provides clarification on processes, roles and responsibilities.
  • Improves patient flow through the medical imaging department.
  • Reduce the risk of adverse outcomes and associated litigation.


Historically, imaging reports were only released to the referring clinician once authorised by the radiologist. Due to the increasing demand for imaging services and the need for faster results as a result of voice recognition software and electronic medical records (eMR), this process led to pressure points within the imaging department at Prince of Wales Hospital.

Over time, these pressures caused communication challenges between imaging teams and referring clinicians. There was also a growing recognition that providing results in a timely manner was part of the radiologist’s duty of care. There were instances where this did not occur, resulting in significant delays in diagnosis and treatment which impacted patient outcomes.


  • The following objectives were created as the scope of the project:
    • Tier 1: Incidental, significant findings to be sent within one working day
    • Tier 2: Unexpected, non-urgent findings to be sent within five workings days
    • Tier 3: Significant changes to a provisional or previous report to be sent within one working day of the change.
  • The existing system for communicating critical findings was effective and therefore outside the scope of this project.
  • An early warning notification system will be developed, similar to ‘Tsunami’ that is currently in use at Liverpool Hospital’s Medical Imaging Department.
  • An administration clerk will communicate directly with referring clinicians and develop an escalation pathway that will be actioned when ‘failure to notify’ occurs.
  • A database of clinicians’ preferred method of contact will be created, to improve timely communication between departments.
  • A clinical business rule will be developed, to provide governance on processes, roles and responsibilities. This will include methods of acknowledgement, receipt and documentation of communications back to the referring clinician.
  • The trial is due to commence in May 2016.

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Project dates

  • May 2015 – September 2016

Implementation sites

  • Prince of Wales Hospital, Sydney Local Health District


  • Clinical Leadership Program


  • Incident Information Management System (IIMS) events will be monitored following implementation of the project.
  • Compliance with the business rule will be measured six-months following implementation of the project.
  • All stages of the communication pathway will be recorded, to provide an electronic audit that will determine the project’s success and measure quality assurance.
  • Focus groups and a referrer survey will be conducted six months following implementation of the project, to measure qualitative results.

Lessons learnt

To date, the key challenge has been finding the time to plan and implement the project in a way that promotes sustainable change.

Further reading

  • Berlin L. Communicating radiology results. The Lancet 2006; 367: 443-445.
  • Berlin L. Malpractice and ethical issues in radiology: the duty to communicate. American Journal of Roentgenology 2011; 197: 962.
  • Berlin L. Electronic communication of significant radiological findings. American Journal of Roentgenology 2011; 196: 850.
  • Berquist TH. Communication: the needs of the patient come first. American Journal of Roentgenology 2009; 192(3): 557-559.
  • Dutta S, Long WJ, Brown DF et al. Automated detection using natural language processing of radiologists recommendations for additional imaging of incidental findings. Annals of Emergency Medicine 2013; 62: 162-169.
  • Garvey CJ, Connolly S. Radiology Reporting: where does the radiologist’s duty end? The Lancet 2006; 367: 443-445.
  • Goergen SK. What do radiologists do all day? Quantifying workload and planning production in a medical imaging department. Journal of Medical Imaging and Radiation Oncology 2013; 57: 527-528.
  • Krupinski EA, Hall ET, Jaw S et al. Influence of radiology report format on reading time and comprehension. Society for Imaging Informatics in Medicine 2012; 25: 63-69.
  • Lacson R, O'Connor SD, Sahni VA et al. Impact of an electronic alert notification system embedded in radiologists’ workflow on closed-loop communication of critical results: a time series analysis. British Medical Journal of Quality and Safety 2015; 0: 1-7.
  • Reiner BI. Strategies for radiological reporting and communication – Part 1: challenges and heightened expectations. Society for Imaging Informatics in Medicine 2013; 26: 610-613.
  • Reiner BI. Strategies for radiological reporting and communication – Part 3: patient communication. Society for Imaging Informatics in Medicine 2013; 26: 995-1000.
  • Reiner BI. Strategies for radiology reporting and communication – Part 4: quality assurance and education. Society for Imaging Informatics in Medicine 2014; 27: 1-6.
  • Ryan M. Policy and procedure on the communication of critical, urgent and clinically unexpected significant radiological findings in Cork University Group. Cork University Hospital; 2011.
  • Royal Australian and New Zealand College of Radiologists. Radiology Written Report Guidelines; 2011.
  • Dimigen M, Zogovic B, Saks A et al. ‘Tsunami’ radiology notification system: a low cost method in improving communication between the imaging department and clinicians'. Presented at Radiological Society of North America, Chicago, 1 November 2012.
  • American College of Radiology (ACR). The process of developing ACR practice parameters and technical standards; 2014.
  • The Royal College of Radiologists. Standards for the communication of critical, urgent and unexpected significant radiological findings (2nd Ed); 2012.


Margaret Allen
Nurse Manager, Medical Imaging
Prince of Wales Hospital
South Eastern Sydney Local Health District
Phone: 02 9382 0350

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