Performance audit, Medical Radiologic Technology Board of Examiners

              PERFORMANCE AUDIT
MEDICAL RADIOLOGIC TECHNOLOGY
BOARD OF EXAMINERS
Report to the Arizona Legislature
By the Auditor General
May 1996
Report # 96- 4
STATE OF ARIZONA
DOUGLAS R. NORTON, CPA OFFICE OF THE
AUDITOR GENERAL AUDITOR GENERAL
May 20,1996
Members of the Arizona Legislature
The Honorable Fife Symington, Governor
DEBRA K. DAVENPORT, CPA
DEPUTY A Y D I T O I GENEIaL
Mr. Aubrey V. Godwin, Chairman
Medical Radiologic Technology Board of Examiners
Transmitted herewith is a report of the Auditor General, A Performance Audit of the Medical
Radiologic Technology Board of Examiners ( MRTBE). This report is in response to a May 29,
1995, resolution of the Joint Legislative Audit Committee. The performance audit was
conducted as part of the sunset review set forth in A. R. S. $ 541- 2951 through 41- 2957.
We found that the Arizona Radiation Regulatory Agency ( ARRA), and not the MRTBE, can
best protect the public from unqualified radiation technicians. MRTBE has no inspectors to
detect unqualified practitioners and can take little or no enforcement action when such
practitioners are discovered. ARRA, on the other hand, can protect the public from
unqualified practitioners as part of its regulation of the facilities that employ technicians.
ARRA is required to inspect these facilities on a regular basis and can issue penalties against
facilities that employ unqualified practitioners and, if necessary, can suspend or revoke a
facility's license or impound a facility's x- ray machine. However, ARRA is currently working
to address a backlog in its inspechons. Therefore, we recommend continuing MRTBE for three
years to allow ARRA to address this backlog. Once the backlog is addressed, MRTBE can be
sunset and ARRA assigned the responsibility of regulating radiation technicians.
My staff and I will be pleased to discuss or clanfy items in the report.
This report will be released to the public on May 21, 1996.
Sincerely,
Enclosure
Douglas R Norton
Auditor General
I' 2910 NORTH 44TH STREET . SUITE 4 1 0 m PHOENIX, ARIZONA 85018 rn ( 6 0 2 ) 5 5 3 - 0 3 3 3 . FAX ( 602) 553- 0051
SUMMARY
The Office of the Auditor General has conducted a performance audit and sunset review of
the Medical Radiologic Technology Board of Examiners ( MRTBE), pursuant to a May 29,1995,
resolution of the Joint Legislative Audit Committee. This audit was conducted as part of the
sunset review as set forth in Arizona Revised Statutes ( A. R. S.) 5541- 2951 through 41- 2957.
The MRTBE was established in 1977 as a division of the Arizona Radiation Regulatory
Agency ( ARRA) in light of evidence suggesting that knowledgeable radiation technicians can
reduce unnecessary patient exposure to radiation. MRTBE is statutorily empowered to
determine minimum competency standards for users of sources of radiation. MRTBE issues
licenses to those who: 1) meet minimum standards of training and experience established by
the Board or by statute; 2) pass an examination administered by the Board or an acceptable
certificate- granting body; 3) submit an application and pay a fee; and 4) meet other statutory
requirements such as demonstration of good moral character. The Board consists of ten board
members and employs two full- time staff.
Regulation of Radiation Technicians Can
Be Accomplished Without MRTBE
and Its Licensing Activities
( See pages 7 through 11)
Public protection from unqualified practitioners operating x- ray machines can be achieved
without the need for the Medical Radiologic Technology Board of Examiners ( MRTBE).
The Arizona Radiation Regulatory Agency ( ARRA) and entities such as the Arizona
Department of Health Services also confirm that practitioners possess adequate
qualifications as part of their inspections of facilities that employ radiation technicians.
Currently, the Board adds little to public health protection through its enforcement efforts.
Because MRTBE employs no full- time inspectors and its enforcement powers are limited,
it can do little to detect or sanction unqualified practitioners. The enforcement actions it
does take are primarily limited to sanctioning those who are late in submitting their
renewal fee, and sending letters to facilities ( whom they have no enforcement authority
over) whose employees practice outside the scope of their license.' In contrast, ARRA is
able to detect and sanction unqualified practice through its inspection and regulation of
the facilities.
1 MRTBE learns about such unqualified practice through complaints it receives.
i
The Legislature should consider eliminating MRTBE and rely instead on ARRA to confirm
radiation technnologists' qualifications. Eighteen other states, such as South Carolina,
Michigan, Kansas, and Missouri, either do not regulate technologists, or rely on agencies
I
that regulate facilities to confirm technologists' qualification. However, before terminating
MRTBE, the Legislature needs to ensure that ARRA's inspections backlog and other 1
performance deficiencies noted in our October 1995 report ( Report N;. 95- 8) are
addressed.
Table of Contents
Paae
Introduction and Background . . . . . . . . . . . . . . . . . . . . . . . . . 1
Finding I: Regulation of Radiation
Technicians Can Be Accomplished
Without MRTBE and Its
Licensing Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Other Entities Also Confirm
Technicians' Qualifications ..................................... 9
ARRA Can More Effectively
Enforce Against Unqualified Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Once ARRA Addresses Its Inspections
Backlog, the Legislature Should Consider
Relying on ARRA to Regulate
RadiationTechnicians ........................................ 9
Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Sunset Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Agency Response
Figure
Figure 1 MRTBE Active Certificates by Type
( as of August 1995) ................................... 4
iii
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INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a performance audit and sunset review
of the Medical Radiologic Technology Board of Examiners ( MRTBE), pursuant to a May
29, 1995, resolution of the Joint Legislative Audit Committee. The audit was conducted
under the authority vested in the Auditor General by Arizona Revised Statutes ( A. R. S.)
# 41- 2951 through 41- 2957.
Board's Purpose
The Medical Radiologic Technology Board of Examiners ( MRTBE) was established in 1977
as a division of the Arizona Radiation Regulatory Agency ( ARRA) in order to protect the
public from the harmful effects of excessive and improper radiation exposure. According
to the National Research Council, ionizing radiation's " well demonstrated [ long term]
effects include the induction of cancer, genetically determined ill- health, developmental
abnormalities, and some degenerative diseases such as cataracts."'
The Legislature formed MRTBE in light of evidence suggesting that knowledgeable
technicians can reduce unnecessary patient exposure to radiation. Laws 1977, Ch. 145 § 1
declare that:
"[ radiation] protection can in some major measure be accomplished by requiring adequate
training and experience of persons uperating x- ray equipment in each particular case under the
direction of licensed practitioners. . ."
Accordingly, the Legislature created MRTBE to " establish standards of education, training and
experience and to require the examination and certification of operators of x- ray equipment."
A ten- member Board appointed by the Governor is charged with carrying out MRTBE's
mission. State law requires that the Board include four practicing radiologic technologists,
two public members, two licensed practitioners ( including one radiologist), and one
practical technologist. The Director of the Arizona Radiation Regulatory Agency ( ARRA)
serves as the board chairman and tenth board member.
1 Health Eficts ofExposure to 1mezing Radiationl National Research Council, National Academy Press, Washington,
D. C, 1990.
1
Board Responsibilities
MRTBE is statutorily empowered to determine minimum competency standards for
technicians and others who work with sources of radiation. A. R. S. 532- 2811 states that " no
person may use ionizing radiation on a human being unless the person is a licensed
practitioner or the holder of a certificate."' Statutes mandate that MRTBE issue such
certificates to applicants who: 1) meet minimum standards of training and experience
established by the Board or by statute; 2) pass an exam administered by the Board or an
acceptable certificate- granting body; 3) submit an application and pay a fee; and 4) meet
other statutory requirements, such as demonstration of good moral character.
The Board is also responsible for disciplining certificate holders who violate statutory
standards of conduct. In addition, A. R. S. 532- 2824 authorizes MRTBE to conduct
inspections for purposes such as 1) assuring only certified individuals or those exempt
from certification requirements operate ionizing radiation machines; and 2) determining
whether certified individuals are practicing beyond the scope of their certificate.
MRTBE issues eight certificate types to people who work with sources of radiation. The
eight types of certificates issued include:
Radiologic Technologist- These certificate holders can perform x- rays on any part of
the body. Certificates are issued to people who complete two years of specialized
training at an accredited school and pass a test given by the American Registry of
Radiologic Technicians ( ARRT).
Radiation Therapist- Those who hold this certificate can apply machine radiation for
therapeutic purposes. Radiation therapists must complete two years of specialized
training at an accredited school and pass a test given by ARRT.
Practical Technologist - Those who hold this certificate can only perform x- rays of
the chest and extremities. MRTBE issues this certificate to those who receive 6 to 9
months of training with a minimum of 210 classroom hours and 12 weeks of clinical
training. These certificate holders must also pass an ARRT or state- administered exam.
Practical Technologist Unlimited- Those who hold this certificate can perform x- rays
on any part of the body. MRTBE issues this certificate to technologists who were
performing x- rays when the MRTBE was created in 1977.
Podiatry- MRTBE issues this certificate to applicants who complete 32 hours of
specialized training, pass an MRTBE exam, and successfully conduct x- ray exams
1 The law states that licensed practitioners such as doctors, dentists, osteopaths, podiatrists, chiropractors, and
others do not have to hold certificates. Dental hygienists and dental assistants holding a valid certificate in
dental radiology are also not required to hold a certificate.
under the supervision of a podiatrist. The MRTBE and the State Board of Podiatry
Examiners both review x- rays the applicant takes during a clinical trial before issuing
a certificate.
Mammography- This certificate allows radiation technologists to perform mammo-grams.
The Board issues this certificate to certified radiographic technologists who also
pass either a specialized exam in mammography offered by the ARRT or undergo
extra training in mammography and an MRTBE exam.
Temporary- MRTBE issues various temporary certificates to applicants whose
permanent certification or recertification may be pending. Such certificates are valid
for limited amounts of time, depending on factors such as the certificate type and date
of the next applicable exam.
Special- MRTBE issues special certificates exempting individuals from licensing
requirements when there is an absence of certified practitioners in a locality.
Each of the certificates ( with the exception of special and temporary certificates) is valid
for two years, at which time it must be renewed. MRTBE does not currently require that
those renewing a certificate take an examination, demonstrate that they have practiced
radiography, or have current ARRT certification. However, technologists renewing a
mammography certificate must complete eight hours of continuing education during the
past two years for certification renewal.
MRTBE reported 3,846 certificate holders as of August 17, 1995, as shown in Figure 1,
page 4.
Figure 1
MRTBE Active Certificates by Type
( as of August 1995)
Radiologic
Practical
Technologist
Unlimited - 101
7
v, Thhdeiraat i~ oins - t 115
nporaw - 145
Mammography - 518
Total Certificates Issued: 3,846
Source: Report from MRTBE database and files of certificate holders.
Staffing and Budget
MRTBE is a division of the Arizona Radiation Regulatory Agency ( ARRA). The Board
employs two full- time equivalent employees ( FTEs), a program manager, and an
administrative secretary, who oversee MRTBE operations. Their job duties include
responding to inquiries from those who are interested in or already hold a certificate;
collecting fees; issuing and renewing licenses; and investigating complaints and preparing
recommendations for disciplinary actions to the Board.
MRTBE is self- supporting. The Legislature approved $ 105,800 for MRTBE operations in
fiscal year 1995- 96. Such funds are appropriated from the state radiologic technologist
certification fund, which derives its revenue from amounts MRTBE charges for
applications, examinations, license renewals, and fines. The Fund's balance at the end of
fiscal year 1994- 95 was $ 186,577.
Audit Scope and Methodology
This audit focuses on the need for the Medical Radiologic Technology Board of Examiners,
its ability to detect and deter uncertified practice, and the effectiveness of disciplinary
actions taken by the Board.
Our fieldwork included a review of other states' regulation of radiographic technicians
and studies about the need for such regulation. We also contacted parties affected by or
involved in regulation and training of technicians, such as hospital administrators;
certificate holders; professional associations, such as the American Registry of Radio-graphic
Technologists ( ARRT) and the Arizona Chapter of the American Society of
Radiologic Technologists ( ASRT); state and federal agencies, such as the Arizona
Department of Health Services, and the U. S. Department of Health and Human Services;
and schools that train radiation technicians. We also reviewed disciplinary actions taken
by MRTBE from January 1, 1992, to August 10, 1995. Furthermore, we examined the
adequacy of MRTBE's rules, the efficiency of its fee collection process, and its ability to
resolve complaints.
The audit was conducted in accordance with generally accepted government auditing
standards.
The Auditor General and staff express appreciation to the Medical Radiologic Technology
Board of Examiners, the Board Chairman, and MRTBE staff for their cooperation and
assistance throughout the audit.
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FINDING I
REGULATION OF RADIATION TECHNICIANS
CAN BE ACCOMPLISHED WITHOUT MRTBE
AND ITS LICENSING ACTIVITIES
Public protection from unqualified practitioners operating x- ray machines can be achieved
without the Medical Radiologic Technology Board of Examiners ( MRTBE). The Arizona
Radiation Regulatory Agency ( ARRA) and others already confirm radiation technician
qualifications during inspections of facilities that employ technicians. Moreover, ARRA
can better ensure that only qualified practitioners operate x- ray equipment since it
employs full- time inspectors and can sanction facilities that allow unqualified technicians
to practice. After ARRA addresses its inspections backlog, the Legislature should consider
eliminating MRTBE and licensing of radiation technicians, relying instead on ARRA to
protect the public through its regulation of facilities that employ x- ray technicians.'
Other Entities Also Confirm
Technicians' Qualifications
MRTBE's licensure of radiation technicians is not needed to confirm technician
qualifications. The Arizona Radiation Regulatory Agency ( ARRA) checks radiologic
technician qualifications as part of its x- ray machine inspection process. In addition, other
government agencies and health care insurers also confirm technician qualifications, thus
further ensuring that technicians possess state- required qualifications.
ARRA confims qualifications- ARRA already confirms radiation technician qualifica-tions
as part of its regulation and inspection of facilities that operate x- ray equipment.
State law requires ARRA to adopt rules requiring adequate training and experience for
radiation technicians. Currently, ARRA rules require that a facility's technicians be
MRTBE- certified in order to be deemed adequately qualified. However, ARRA could
adopt a rule requiring that other evidence, such as certification by the American Registry
of Radiographic Technologists, serve as proof that technicians possess adequate
qualifications. Certification by the Registry is already accepted as proof of qualification
by MRTBE.
MRTBE rules and statutes refer to the regulation of radiation technicians as certification. MRTBE also issues
" certificates" to radiation technicians. However, the regulation of radiation technicians is more accurately
referred to as licensure since regulation makes it illegal for anyone other than a certificate holder to practice
radiation technology.
Others con* qualifications - Other government agencies, credentialing organizations,
and health care insurers also confirm technician qualifications. Such agencies include:
Arizona Department of Health Services ( ADHS)- ADHS confirms technician
qualifications as part of its licensure and inspection of health care and Medicare
facilities. ADHS inspectors confirm that facilities comply with state qualification
requirements for radiation technicians. ADHS also ensures that the facilities are in
compliance with ARRA.
Health Insurers and JCAHO- Health insurers such as Blue Cross Blue Shield monitor
whether hospitals comply with state qualification requirements for radiation
technicians. In addition, the Joint Commission on Accreditation of Healthcare
Organizations ( JCAHO), which accredits 80 percent of the nation's hospitals, ensures
that hospitals comply with state qualification requirements.
ARRA Can More Effectively Enforce
Against Unqualified Practice
In addition to MRTBE's unnecessary role in confirming practitioner qualifications, it adds
little to public health protection through its enforcement efforts since its authority and
resources are limited. In contrast, ARRA possesses greater ability to identify, sanction, and
deter unqualified practice through its regulation of the facilities that employ such
technicians.
MRTBE's powers limited- MRTBE can do little to protect the public from unsafe radiation
exposure. Currently, MRTBE has difficulty identifying unlicensed, unqualified practitioners
because MRTBE employs no inspectors. In addition, the program manager states that he
has little time to conduct inspections himself.
Even when MRTBE does identify unqualified practitioners, it can do little to sanction or
stop such practice. MRTBE has no authority to sanction facilities that employ radiation
technicians, though such facilities may encourage unqualified employees to handle
radiation. MRTBE can also do little to sanction individual radiation technicians. Although
MRTBE can statutorily pursue criminal penalties against unlicensed technicians, the
program manager says that county attorneys often choose not to prosecute such cases. As
a result, MRTBE often does not attempt to seek penalties.
Since MRTBE can do little to sanction unqualified practice, the enforcement actions it does
take are less directly linked to protecting the public's health. For example, of the 37
disciplinary actions MRTBE took between January 1,1992, and August 10,1995 ( over 3%
years), none involved a licensee exposing a patient to unnecessary radiation. Instead:
w 14 actions involved licensees who allowed their license to expire and were late in
submitting their license renewal fee.
9 actions involved a technician performing beyond the scope of his or her license. In
all but one of the cases, the Board merely sent a letter notifying the facility that such
actions are illegal.
7 actions involved MRTBE taking an action against licensees who engaged in
unprofessional conduct ( such as drug abuse or a criminal offense) after the facility or
law enforcement had already sanctioned the individual.
6 actions involved someone practicing without a license. For three of the six cases,
MRTBE merely sent a letter to the facility that employed them.
1 action was limited to MRTBE placing a letter in the file of a licensee who inappropri-ately
misstated her credentials.
ARRA more eflective- Compared to MRTBE, ARRA can better protect the public from
unqualified practitioners through its regulation of the facilities that employ practitioners.
ARRA possesses statutory authority to sanction facilities that use unqualified employees
to operate x- ray machines. In one case, ARRA issued a $ 2,000 penalty against a facility that
employed unlicensed technologists. ARRA may also suspend or revoke a facility's
registration or impound a facility's x- ray machines if it fails to comply with ARRA rules
pertaining to technician qualifications. Furthermore, ARRA can more effectively detect
unqualified practitioners initially, since it employs full- time inspectors who can conduct
surprise inspections if necessary. In fact, MRTBE relies on ARRA inspectors to conduct
investigations when it receives complaints concerning unlicensed practice.
Once ARRA Addresses Its
Inspections Backlog, the Legislature
Should Consider Relying on ARRA to
Regulate Radiation Technicians
Evidence suggests that the State could rely on a well- functioning ARRA to ensure that
radiation technicians are adequately qualified. The Legislature could eliminate MRTBE
and licensure of all radiation technicians, relying instead on ARRA to confirm radiation
technician qualifications through its inspection and regulation of facilities that operate x- ray
equipment. However, before the Legislature terminates MRTBE, it should ensure that
ARRA addresses its inspections backlog and corrects other performance deficiencies noted
in a previous Auditor General report ( Report No. 95- 8).
ARRA could effectively regulate- Evidence suggests that relying on ARRA to regulate
radiation technicians could be effective. Other states either do not regulate their technicians,
or use the x- ray programs to verify technician qualifications. Of the 18 states that do not
certify or license radiation technicians, 11 states, including South Carolina, Kansas,
Michigan, and Missouri, rely on agencies that regulate facilities to confirm technician
qualifications.'~
Other evidence also suggests that relying on ARRA to confirm technicians' qualifications
can work in Arizona. Currently, one category of radiation technicians is not licensed by
the MRTBE. Nonetheless, even though nuclear technicians ( the professionals who
administer nuclear medicines for therapeutic purposes) are not licensed, ARRA is able to
confirm technician qualifications as part of its inspections of facilities that handle
radioactive materials. Hence, nuclear technician qualifications are confirmed without the
need for MRTBE licensure.
MRTBE should be eliminated - Since ARRA already confirms technician qualifications as
part of its inspection of registered x- ray facilities, the Legislature should consider
eliminating MRTBE and all licensure of radiation technicians. Instead, the State could rely
on ARRA to ensure that radiation technicians are qualified.
To ensure that technicians possess adequate qualifications, ARRA could require that
facilities keep on file documentation of employees' qualifications. One such type of
documentation that many states require is certification from the American Registry of
Radiographic Technologists. The Registry certifies radiologic technologists, radiation
therapists, and mammography technologists. Those who possess a certificate from the
Registry have 1) graduated from an accredited school; 2) passed a competency test; and
3) not been cited by the Registry for unprofessional conduct. The Registry renews
certificates for those who possess continuing education credits. MRTBE itself currently
recognizes the Registry certification as proof that license applicants possess adequate
qualifications during its initial licensure of applicants. Indeed, MRTBE used the Registry
certification as proof that license applicants were adequately qualified for 80 percent of
all MRTBE license applicants in fiscal year 1995.
' Seven states, including Alabama, South Dakota, North Carolina, Alaska, Minnesota, Arkansas, and Oklahoma,
currently do not regulate radiation technicians. However, beginning January 1,1997, Minnesota will require
radiation technicians to pass a national or regional certification exam. Inspectors for the State's x- ray compliance
program will confirm qualifications.
Not all states regdate every type of technician that Arizona currently regulates. In addition, some of the
radiation control program directors in other states reported difficulty confirming qualifications since regulations ,
requiring facilities to document qualifications were too vague. Conversely, in states where regulations were
more speafic such as South Carow Michigan, and Missouri, the radiation control program directors reported
that they do confirm qualifications as part of inspections.
ARRA could also adopt rules requiring that facility files contain additional types of proof
of technician qualifications required by other states, such as:
H Documentation of job- related experience and/ or training;
Proof that the technologist passed a national certification exam, such as the one that
has been developed for practical technologists by the Registry;
w Documentation of a review from another Board, such as the State Board of Podiatry
Examiners.
The Legislature could specifically revise ARRA's statutes to ensure that radiation
technologists would still be required to possess the same qualifications, education, and
experience currently required by MRTBE rules and state law,
ARRA needs to improvefivst- Before the Legislature terminates MRTBE and relies solely
on ARRA to confirm qualifications, ARM needs to address its current inspections backlog
and other performance deficiencies. In the October 1995 report on ARRA ( Report No. 95- 8)
by the Auditor General, we found that ARRA was having considerable difficulty keeping
up with its timetable for inspections and needed to improve its productivity.
ARRA's Director believes that eliminating MRTBE at this time would place an additional
time burden on the Agency. He believes the current workload of MRTBE, which requires
two FTEs to accomplish, would have to be absorbed by ARRA at a time when ARRA is
struggling with its own workload. However, much of the MRTBE workload involves
licensing and testing which would no longer be necessary if ARRA were to rely on the
Registry to certify technicians. Checking to see if technicians have such a certification would
not appreciably extend an ARRA facility inspection. ARRA does, however, still have a
backlog of inspections. Therefore, the Legislature should consider giving ARRA reasonable
time to improve before terminating MRTBE.
RECOMMENDATION
The Legislature should consider continuing MRTBE for three years. Before MRTBE's
extension expires, the Legislature should assess ARRA's progress in addressing its
performance deficiencies and inspections backlog. If improvements have occurred, the
Legislature should consider terminating MRTBE, relying instead on ARRA to confirm
radiation technician qualifications.
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SUNSET FACTORS
In accordance with A. R. S. 541- 2954, the Legislature should consider the following 12 factors
in determining whether the Medical Radiologic Board of Examiners should be continued
or terminated.
1. Objective and purpose in establishing the Board.
The Legislature created MRTBE in 1977 to protect the public's health and safety
against the harmful effects of excessive radiation. Laws 1977, Ch. 145 § 1 state that
protection " can in some major measure be accomplished by requiring adequate training and
experience of persons operating x- ray equipment." Thus, the Board was created to " establish
standards of education, training and experience and to require the examination and certification
of operators of x- ray equipment."
The Board is statutorily empowered to determine minimum competency standards
for people who work with radiation. The Board is charged with issuing certificates
to and collecting fees from those who meet these minimum standards. The Board is
also responsible for disciplining or revoking the certificates of those who violate
statutory standards of conduct. The Board is authorized to conduct inspections to
assure that only certified individuals or those exempt from certification requirements
operate ionizing radiation machines, and to assure that certified individuals are not
practicing beyond the scope of their certificate.
2. The effectiveness with which the Board has met its objective and purpose and
the efficiency with which the Board has operated.
According to the Board Chairman, the Board meets its mandate to issue certificates
to qualified individuals. However, we question the need for the Board since other
agencies also ensure competence. In addition, the Board is not effective in identifying
unlicensed practice ( see Finding I, pages 7 through 11).
The Board could improve the efficiency of its renewal process. Currently, mammogra-phy
certificates have different due dates than radiographic technologist certificates.
This causes unnecessary confusion and inefficiency since all mammography certificate
holders also must hold radiologic technologist certificates.
3. The extent to which the Board has operated within the public interest.
The Board's authority to issue licenses to people who work with radiation serves the
public interest by ensuring that those who hold such licenses meet minimum
competency standards. Such competency requirements may protect the public from
unnecessary exposure to radiation, and from misdiagnosis due to inaccurate results
from diagnostic tests, such as x- ray exams. However, competency requirements could
be confirmed without the need for licensure through the Arizona Radiation Regulatory
Agency and its regulation of facilities that operate x- ray machines ( see Finding I, pages
7 through 11).
The Board has difficulty identifying uncertified practitioners. Further, according to
the program manager, it often does not refer those uncertified practitioners that it does
identify to county attorneys for prosecution since they are reluctant to prosecute such
cases ( see Finding I, pages 7 through 11). Therefore, the Board does not protect the
public from the possible harmful effects of unqualified people handling sources of
radiation.
4. The extent to which rules adopted by the Board are consistent with the
legislative mandate.
While a statute requires the Board to adopt rules setting minimum standards of
training and experience for persons to be certified, MRTBE has not done this for all
such users. In particular;
MRTBE has not promulgated rules to regulate nuclear technicians who
administer radioactive sources to patients for therapeutic or diagnostic purposes,
such as cancer treatment. Interviews with representatives from the Arizona
Society of Nuclear Medicine and the Attorney General's Office suggest that while
MRTBE has known about the need for such regulation since a 1988 change in
statute, it has not taken actions to adopt such rules. Nonetheless, nuclear
technicians' qualifications are currently being confirmed by ARRA as part of its
inspection and regulation of facilities that handle radioactive materials.
The Board has not promulgated rules listing the permitted applications of
ionizing radiation by practical technologists in podiatry, even though statute
requires such a rule.
5. The extent to which the Board has encouraged input from the public before
adopting its rules and the extent to which it has informed the public as to its
actions and their expected impact on the public.
MRTBE has not adopted rules in ten years, so there is no evidence as to whether the
Board encourages input from the public.
6. The extent to which the Board has been able to investigate and resolve
complaints that are within its jurisdiction.
From July 1,1992, to June 30,1995, MRTBE reported that it received 55 complaints
concerning unlicensed practice, licensees working outside of the scope of their license,
and unprofessional conduct.
MRTBE is limited in its ability to investigate complaints of uncertified practice or
complaints of licensees working outside the scope of their license. According to the
program manager, the absence of staff devoted solely to investigations, and the
statutory requirement that MRTBE must give 24 hours' notice to a facility before
conducting an investigation, hinders MRTBE investigation efforts. As a result, MRTBE
usually relies on the Arizona Radiation Regulatory Agency ( ARM) to conduct
investigations. In addition, the program manager says that MRTBE is not able to take
strong enforcement action against uncertified practitioners due to county attorneys'
unwillingness to prosecute them ( see Finding I, pages 7 through 11).
7. The extent to which the Attorney General or any other applicable agency of
State government has the authority to prosecute actions under the enabling
legislation.
The Attorney General or county attorney has authority to prosecute actions under
MRTBE's enabling legislation.
8. The extent to which the Board has addressed deficiencies in its enabling
statutes which prevent it from fulfilling its statutory mandate.
According to the Board Chairman, a former Attorney General representative noted
that statutory changes may be necessary for MRTBE to regulate nuclear technicians.
Such regulation appears to be necessary since statute mandates that users of radiation
be licensed practitioners or holders of a certificate. Nonetheless, the public's health
does not appear to be in jeopardy, since the Arizona Radiation Regulatory Agency
( ARM) currently confirms nuclear technician qualifications as part of its inspection
and regulation of facilities that use radioactive materials.
In addition, MRTBE's program manager states that a statutory change is needed to
stagger certificate renewals. By changing the statute and staggering renewal dates,
the Agency could more efficiently collect the fees that it is required to collect.
9. The extent to which changes are necessary in the laws of the Board to
adequately comply with the factors listed in the subsection.
If MRTBE is not eventually terminated, its sunset review date should be changed to
coincide with the sunset review date of its parent organization, the Arizona Radiation
Regulatory Agency. Currently, the two entities have separate sunset dates even though
MRTBE is located within ARRA.
10. The extent to which the termination of the Board would significantly harm the
public health, safety, or welfare.
While ensuring the competency of radiation technologists is important to protecting
the public from unnecessary radiation exposure and its subsequent harmful health
effects, the Arizona Radiation Regulatory Agency is already statutorily empowered
to perform this task. In addition, others such as the FDA, the Joint Commission on
Accreditation of Health Care Organizations ( JCAHO), and the Arizona Department
of Health Services confirm that technologists are adequately qualified. Thus, MRTBE
could be terminated without any significant harm to the public health, safety, or
welfare.
MRTBE adds little to the protection of the public's health. In the vast majority of cases,
MRTBE merely confirms certification or test scores from a national association as proof
that licensee applicants are adequately qualified. The Board does little to identify
unlicensed practitioners, and it does not bring unlicensed practitioners that it does
identify to county attorneys for prosecution since they are reportedly not eager to
prosecute such cases. The enforcement actions MRTBE does take are either not needed
or are unrelated to protecting the public from unnecessary radiation exposure.
11. The extent to which the level of regulation exercised by the Board is appropriate
and whether less or more stringent levels of regulation would be appropriate.
The level of regulation exercised by the Board could be reduced. Licensure of
radiation technicians is not necessary to protect the public health. Statute authorizes
ARRA to adopt standards and confirm qualifications for radiation technicians as part
of its regulation of facilities that use radiation sources ( see Finding I, pages 7 through
11).
12. The extent to which the Board has used private contractors in the performance
of its duties and how effective use of private contractors could be accom-plished.
MRTBE has made limited use of private contractors. MRTBE contracts with the
American Registry of Radiologic Technologists ( ARRT) to furnish exams to people
applying for practical technologist certificates. In addition, MRTBE hires a court
reporter to record hearings and prepare transcripts.
( This Page Intentionally Left Blank)
Agency Response
& Z@ W RADlATlON REGULATORY AGENCY
4814 South 40th Street Phoenix, Arizona 85040
Fife Symington
Governor
Aubrey V. Godwin
( 602) 255- 4845
Fax ( 602) 437- 0705
May 14, 1996
Douglas R. Norton
Auditor General
2910 North 44th Street, Suite 410
Phoenix, AZ 85018
Dear Mr. Norton;
Thank you for this opportunity to comment on the draft report on the Medical Radiologic
Technology Board of Examiners. First I would like to thank you and your staff for their efforts in
evaluating this difficult subject for the protection of the public health and safety. While we do not
agree with the finding, we appreciate your efforts. Our comments are attached and we believe they
support a different conclusion than the one provided in the draft.
Again thank you for the review.
Sincerely
@ 44$ K'
Aubrey V. bodwin
Director
Attachment
DRAFT SUNSET REPORT COMMENTS
PAGE, LOCAL. COMMENT
I, Para. 2 The following statement should be added; " Data available from 1979, indicate
that before the passage of the MRTBE Statute and while being regulated by
ARRA, at least 67% of the x- ray equipment operators, outside of hospitals
and radiology clinics, had no formal training, and patients were needlessly
overexposed. This initially occurred while training was regulated by ARRA
and before the establishment of MRTBE. Currently 10% have little or no
formal training, but all have received sufficient on the job instruction to
reduce or prevent overexposures to patients."
ii, Para. 1
7, Finding
The listed states
A. Do not have the same statutory authority as provided for ARRA, particularly
as limited by $ 30- 654 B. 9. and,
B. Are not checking the qualifications of x- ray equipment operators equal to that
of MRTBE as implied by this paragraph. In fact, according to the programs
listed, they are coming close to this only for mammography. Even for
mammography, several important items are not being determined. 1. The
criminal record of the technologist is not requested nor reviewed even for sex
crimes, 2. drug users are not detected, and 3. malpractice in the taking of the
x- rays is not addressed by any of these listed programs. South Carolina comes
closest, in that they request each facility to have a training program which must
cover certain subjects. This is in the form of a guide and may not be enforceable.
See also page 10, the first h l l sentence on that page.
The term " technicians" appears several times on this page and elsewhere in the
report and is not proper for the members of this profession. The proper term is
" technologist." This is a specialist in a technology as opposed to a technician who
is an expert in the technical details of a subject.
This whole finding omits several important points:
A. The MRTBE performs the determination of the qualifications of the
technologists. All of the other Agencies are saying " obey the State Law
( MRTBE)," which requires the certification for radiologic technologists. These
Agencies are not determining the qualifications of the technologists but are
merely confirming compliance with that Law. Contrary to the statements on page
8, JCAHO only confirms that the employees comply with state law. Without a
law requiring the certification ( or licensing) of the technologists, JCAHO will
accept anyone as adequate so long as they comply with state law. The Auditor
General's report does not address the private offices which are not reviewed by
the JCAHO and are not reviewed by the insurance carriers. Data from 1979
indicates that at least 67% of these offices had inadequately trained personnel
operating x- ray equipment when MRTBE was created. In short, the headings are
at best misleading since they are based on a false premise, i. e., that the cited
Agencies actually determine the qualifications of the operators, when, in fact,
all they are doing is determining compliance with State Law.
B. Unless the legislature specifically authorizes ARRA to utilize the American
Registry of Radiologic Technologists or equivalent training, the authorities
contained in the MRTBE statutes would not exist. Currently, for the ARRA to
adopt rules relating to technologists, the rules would be limited to radiation
safety training and the hazards of excessive radiation exposure ($ 30- 654 B. 9.
A. R. S.) and not how well a technologist knows such subjects as anatomy,
positioning of patients ( except when it may affect radiation safety), any criminal
behavior, or other unprofessional conduct.
C. What is more important, the rule adoption process will cost $ 48,000 or more
to complete. Further, since Arizona has had the MRTBE program for years, we
will have to go to other states to get data to justify the need for such rules.
Arizona has no current data on the violation or overexposure rates for non-certified
practice. We will have to find a state who is keeping such data and hope
it will fit Arizona.
D. Even more to the point, this report is asking an Agency which according to
national standards needs 14 additional personnel, to take on at least 2 FTE
additional work without the additional resources. The review by individuals with
60 years experiences in managing radiation programs indicates an increased
staffing need, yet this report proposes to remove two FTE from MRTBE and not
provide the needed resources to ARRA. The Auditor General's own report at
page 8, paragraph 5, indicates a staffing need for MRTBE in the form of an
investigator, and the prior report on ARRA indicated that ARRA could catch up
in three years on their inspection only by achieving at least 450 inspections per
year per x- ray inspector, not having to replace any x- ray inspectors, and if the
rate of increase in x- ray units in Arizona does not maintain it historical rate. The
Auditor General apparently is unaware that the ARRA has had to replace two
inspectors since their report in 1995 on ARRA, Again, this report is
recommending that a workload equal to two FTE be added to ARRA without
corresponding resources. Although this is passingly acknowledged in the report,
as phrased, it minimizes the impact on ARRA inspections. ARRA believes that
the proposed finding if adopted, is only shifting the personnel qualification
review from the in house staff to the field staff where it is more difficult and
man power intensive to accomplish, particularly for non ARRT Technologists.
In addition, as provided in the finding, no provision is made for the approval of
schools which do not meet the ARRT requirements, yet are training limited
technologists. The concept of having these schools give the ARRT examination
will not work because the ARRT will not allow the schools to give their
examination. Further, for the last two years, only an average of 40 % of these
schools are passing the ARRT examination. We see no way for the ARRA not
to be in the testing of potential users replacing MRTBE as the unbiased processor
of the test, but only if authorized by the legislature with adequate resources.
E. Unless the MRTBE Board is made a part of ARRA, ARRA does not have
the expertise that is available through the MRTBE to approve x- ray schools or
tests for those technologists who are not able to take the ARRT exam. Such
technologists represent about 10% of the practicing technologists. This would be
of particular concern in the rural areas of the state.
10, Para. 1 The attached letters from Kansas, Michigan, and Missouri do not support these
statements. Further, unless an analysis was made of the statutory authority of
each state, the conclusion is not valid.
10, Para. 2 The licensing requirements of the Nuclear Regulatory Commission are followed
for this particular class of technologists. This practice is specifically authorized
by 830- 654 B. 6 and 830- 672 A. For x- ray usage, 830- 654 B. 9 and 830- 671
appear to limit the training the ARRA may require since all x- rays would be
given at the direction of a licensed practioner of the healing arts.
10, Ftn 2 The attached letters from Michigan and Missouri appear to contradict the
statements in this footnote, further, there appears to have been no attempt to
confirm that Arizona's legislative authority to ARRA is the same or stronger
than South Carolina or the other states. Without a comparison of the legislative
authority of each state, as well as the rules of each state, the footnote is
unsupported as to the conclusion reached.
MDPH BEOH DRH I& C I. TEL: 517- 335- 9526 Apr 15 96 13: 22 No. 006 P. 02
STATE OF MICHIGAN
h r e a ~ ot Health B ~ t w t ~
3423 M. L. Klng Jr., Blvd.
P. O. Box 30186
Lancing. Miohigan WB09
Job Englu, Gowrnor
DEPARTMENT OF COMMERCE
Kathlemn M. Wilbur. Dlnotor'
Aubrey V. Godwin, Director
Arizona Radiation Regulatory Agency
48 14 South 40th Street
Phoenix, Arizona 85040
Dear Mr. Godwin:
As requested during our telephone conversation on April 15, 1996 concerning x- ray technologist
certification and training, the letter is to clarify the current requirements in the state of Michigan.
Under Part 14 of the Ionizing Radiation Rules of the state of Michigan, an individual, other than a
physician, who operates a mammography machine ehstl meet qualification requirements. These
include training and certification requirements along with a requirement for continuing education.
For individuals that operate x- ray machines other than mammography, Michigan currently has no
artification or training ~ quiremenot ther than requirements that the licensee or registrant instruct
workers in radiation safety,
Should there be any fiarther questions reaardin~ th is, please contact us at ( 517) 335- 8220.
Sincerely, n
Donald E. Parry, Health Physicist
Radiation Safety Section fl
DIVISION OF HEAlLTH FACILITIES
AND SERVICES
GPR- 16- 1336 11: 45 MEDICRL RRBIRTION
.:;:. . . . . ..-. MISSOURI DEPARTMENT OF Mel Camahan
Governor
Colgen Kivlahan, M. D., M. S. P. H.
Director
P. O. Box 570, Jefferson Clh/. MO 1% 1Ci2- 0570 w 31 4- 751 4400 - FAX 3 14- 75 1- 601 0
April 16, 1996
Aubrey Godwin
Arizona Radiation Regulatory Agency
Phoenix, Arizona
( 602) 437- 0705
Dear Mr. Godwin:
I do vaguely recall speaking with some one with the Arizona Auditors ofice about a
month or so ago.
To clarify our state's general actions insofar as radiological technologists go:
( 1) A Technologist licensing bill has been brought up and defeated before our legislature
for the past several years.
( 2) ln lieu of licensing, as we currently have no requirements for either education or
experience, ( except in mammography), there has been discussion of requiring minimum
standards for training of technologists; which, without a licensing board in place, these
standards would presumably be enforced and confirmed by the Medical Radiation
Control Pmgram at the time of inspection. However, let me stress that this proposal is
extremely preliminary in nature. It is neither regulation or pragrarn policy at this time.
( 3) As sf June 1st of 1996, during our inspections, we will begin surveying amounts of
training obtained by personnel taking x- rays, if they are not registered- However, this will
be for information gathering purposes only, for future application of data under the
proposed number ( 2) above. There is not nbw and will not be for the foreseeable future
any regulatory adverse impact on the facilities as a result of the survey.
( 4) Until June 1, 1996, in the past 30 years of our program, again, except b r
mammography, we have never checked, surveyed, confirmed, or athewise inquired as
to the qualitications of radiation machirte operators. ( As we have no qualifications to
meet, except fbr those technoiogists perfsming mammagraphy.)
' Medicaf Radiation Controf Program
Missouri Department of Health
AN EQUAL OPPOmUNIN/ AFRRMATNE ACilON EMPLOYER - SecvceJ D~ Von Io nMond iatrninatow MSI3
TOTRL P. 01
KBHE Radiation Control Fax: 913- 296- 0984 Hpr 17 ' 96 11: 46 P. 02/ 05
S t a t e o f K a n s a s
Bill Ornves
Department of Health and Environment
James J. O'Connell, Secrtcary
April 17, 1996
AUBREY GODWIN DIRECTOR
ARIZONA RADIATION REGULATORY AGENCY
4814 SOUTH 40TH STREET
PHOENIX A2 85040
Dear Mr. Godwin:
This is in reference to your call of April 15, 1996 relating to the
" certif icationfl of x- ray operators, You had indicated that we were
one of several states who were questioned concerning the
certification of X- ray unit operators by the state. I or my staff
would have answered that we have no regulation or statutory
authority to certify any para- professional. That has been reserved
for a board established some years ago including as permanent
members the secretaries of various state agencies including the
Department of Health and Environment. This group has not chosen to
establish a certification program for x- ray users.
We have used K. A. R. 28- 35- 242 ( d) ( 3) and ( 4) which require the
registrant or the registrant's agent to assure... NIndi~ idua19 who
will be operating the x- ray system6 shall be adequately instructed
in the safe operatiqj procedures and be competent in safe use of
the equipment fvz... and .... be provided with written safety
procedures.,,.
We have, where questions of adequate training are identified during
an inspection, asked to see the documentation of training and the
certification by the facility that the operators are trained.
These inquiries have resulted in some very poorly trained persons
being sent for training at a facility with such a program. The
number of cases where actual citations for non- compliance have been
issued are very few, one or two in 32 years. The problem is that
the ability of the inspector to see the more subtle problems that
may result from poor training is limited, The ability to prove
such is even more difficult.
We cannot, of ceurse, judge whether a state certification program
is more effective in this regard since we have never had one with
which to compare our r e s u l t s . It is perhaps one of those self
evident truths that if someone has developed a statewide standard
it should become after time and enforcement at least the minimum
Division of Environment, Burau of Air and Radiation
Forbes RclJ, Building 283, Topeks, KS 66620- 0001
Pnrrftw on RscyeMd Pcircr
Telephone: ( 913) 296- 1560
PAX: ( 91q) 296- 0984
K B E Radiation Control Fax: 913- 296- 0984 Rpr 17 ' 36 11347 P. 03/ 03 I
level of training for uEere and in turn impact the level of safety
in a positive way. We have no way to judge that objectively at
this ag YCY
Bureau of ~ iarnd Radiation
~ adiation Control Program