Radiología.

2019;61(1):35---41

www.elsevier.es/rx

ORIGINAL REPORT

SERAM guide for the renewal and technological update

in radiology夽
M.A. Trapero García a,∗ , I. López Parrilla b

a
Responsable estratégico de la SERAM y Jefe de Área de Diagnóstico por Imagen, Hospital Universitario Fundación Alcorcón,
Alcorcón, Madrid, Spain
b
Fundación Signo, Madrid, Spain

Received 13 April 2018; accepted 18 September 2018

KEYWORDS Abstract The recent financial crisis has led to a substantial reduction in public investment and
Equipment; technological renovation in Spain, resulting in a significant increase in the rate of obsolescence
Technology; of diagnostic imaging equipment.
Obsolescence; The Spanish Society of Medical Radiology, aware of the importance of maintaining appropriate
Renovation; technological measures to ensure the quality of health care, has elaborated a document with
Life cycle; the aim of analyzing and promulgating the state of diagnostic imaging technology in Spain
Guidelines (depending on the imaging modality, between 32% and 59% of the equipment is more than 10
years old) as well as of establishing criteria and recommendations to guide the management of
technology in medical imaging.
© 2018 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Guía de la SERAM para la renovación y actualización tecnológica en radiología

Equipos;
Tecnología; Resumen La reciente crisis económica ha provocado una sustancial disminución de la inversión
Obsolescencia; pública y de la renovación tecnológica en España, que ha causado un incremento relevante del
Renovación; índice de obsolescencia de los equipos de diagnóstico por la imagen.
Ciclo de vida; La Sociedad Española de Radiología Médica, consciente de la importancia de mantener unos
Guía medios tecnológicos apropiados para asegurar la calidad asistencial, ha elaborado un documento
con el objetivo de analizar y difundir la situación de la tecnología de diagnóstico por la imagen

夽 Please cite this article as: Trapero García MA, López Parrilla I. Guía de la SERAM para la renovación y actualización tecnológica en

radiología. Radiología. 2019;61:35---41.

∗ Corresponding author.

E-mail address: matrapero@fhalcorcon.es (M.A. Trapero García).

2173-5107/© 2018 SERAM. Published by Elsevier España, S.L.U. All rights reserved.
36
en España (entre el 32% y el 59% de los equipos, según el tipo de modalidad, tienen más de
10 años) y para formular criterios y recomendaciones que sirvan de guía en la gestión de la
tecnología de imagen médica.
© 2018 SERAM. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.
Introduction
Medical technology is an essential part of the healthcare pro-
cess; it has been and continues to be a fundamental factor
in achieving current levels of quality in healthcare.
Health technologies contribute to improving the effi-
ciency of clinical processes, increasing their quality and
increasing the safety of patients and professionals.
Specifically, diagnostic imaging (DI) technologies have
improved their diagnostic accuracy, which makes it possible
to detect many diseases at earlier stages and, therefore,
treat them more quickly and effectively. The impact of
the implementation of faster computerised tomography (CT)
equipment and with less radiation doses represents only
an example of efficiency and quality improvement in the
healthcare process.
The constant development of physics, electronics and
computing subjects DI technologies to permanent innova-
tion cycles that provide new tools and resources, offering
tangible benefits to healthcare processes. However, the rate
of incorporation of these technological improvements to
the public health centres of the Spanish National Health
System (SNS) depends on the availability of resources of
the autonomous communities (AC) and, specifically, of the
investment plans of the centres, which determine the acqui-
sition of new DI technology, as well as the renovation of the
obsolete technology.
Several publications highlight a substantial decrease in
public investment during the recent economic crisis,1 and
a slowdown in technological renewal in Spain, which is
significantly increasing the obsolescence, operational and
technological index of DI equipment installed in health cen-
tres in Spain. This situation is much more evident if we
compare Spain with the data from neighbouring countries
such as those published by The European Coordination Com-
mittee of the Radiological, Electromedical and Healthcare
IT Industry (COCIR), in which Spain appears among the last
places in Europe because of the age of the DI equipment in
use.2
This situation can be attributed to the current economic
situation, but the lack of documentation on the life cycles
of the technology, its costs of use, updating criteria, as well
as the direct and indirect benefits that can be provided by
renewing it with new more capable equipment, with lower
consumption and greater diagnostic capacity also have an
impact.
Given the evidence of a marked reduction in tech-
nological renewal and an increase in obsolescence and
the comparative data with other European countries, the
M.A. Trapero García, I. López Parrilla
Sociedad Española de Radiología [Spanish Society of Radiol-
ogy] (SERAM) considered it necessary to make a diagnosis as
accurate as possible of the current situation.
Material and methods
The situation in Spain was evaluated based on surveys car-
ried out with the heads of the radiology department of public
hospitals with more than 250 beds, using a form, sent and
received by telematic means. The surveys were conducted
from May to October 2017 and included a quantitative part,
referring to the specific data of the equipment in their cen-
tre, and a second qualitative part that included the point
of view of the heads of the department on the process of
technological renewal in their setting.
In order to ensure greater objectivity, for the devel-
opment of the surveys and their statistical analysis, the
collaboration of the Fundación Signo was requested, which
through its ‘‘Innovation and Technology’’ line of action has
involved experienced professionals in this area to analyse
the data.
During the summer of 2017, an analysis of the interna-
tional literature that addresses the management criteria of
the life cycle of the technology was carried out, mainly
focused on official sources, from developed countries and
with a similar health organisation. No exhaustive analysis has
been attempted, instead just to find the basic indicators that
define the renewal criteria of each country studied, knowing
that they are indicators of recommendation and that, in no
case, are they the norm or law.
At the same time, contributions and suggestions from
different agents related to the technological acquisition
and renewal process (managers, regional health services,
medical physics departments, etc.) were collected through
interviews.
The guide was published in October 2017.
Results
In the analysis of the situation, 59 public hospitals of the
SNS, which represent 48% of those consulted, have con-
tributed their data by responding to the survey. 55% are
hospitals with 250---500 beds; 21%, 500---1000 beds, and 24%
have more than 1000 beds.
The ACs where the highest number of hospitals responded
were Madrid and Catalonia (Table 1).
From the statistical point of view, the sample obtained is
sufficiently representative and with a distribution that cov-
ers practically the entire country; the biases and limitations
SERAM guide for the renewal and technological update in radiology 37

Table 1 Distribution by autonomous community of hospi-

including public and private.2 It should be clarified that
tals that participated in the survey.
the data requested in the survey is the date of installation
of the equipment; however, there is a growing number of
Andalusia 4 MRI equipment and, to a lesser extent, CT equipment,
Aragon 3 which have been completely renewed in their hardware,
Principality of Asturias 2 firmware and software components, which can generate a
Balearic Islands 2 distortion in their chronological classification. Therefore,
Canary Islands 2 it is probable that part of the documented equipment has
Cantabria 2 been partially updated, which would allow reclassification
Castilla-La Mancha 3 of some of them.
Castile and León 4 • In conventional radiology, 59% of the equipment has
Catalonia 8 been installed for more than 10 years; more than half
Extremadura 3 is based on analogue technology to obtain the image,
Galicia 2 which greatly limits the implementation and use of new
Community of Madrid 14 image management and distribution technologies. This is
Region of Murcia 2 an aspect that should be taken into account for the tech-
Autonomous Community of Navarre 1 nological update of conventional radiology systems.
Basque Country 2 • 40% of the ultrasound equipment located in the radiol-
Autonomous Community of Valencia 5 ogy departments have been installed for more than 10
years and are older than the global average of ultrasound
machines available in the centre, which is especially para-
are that the hospitals which are more aware of the problem doxical, when the ultrasound scans located in radiology
may be oversized as the response was voluntary, that the sur- should have the greatest diagnostic capacity.
vey focuses on a partial segment of the set of public health • 19% of the plain radiology rooms, 15% of the radiosurgical
centres of the SNS (hospitals with more than 250 beds), equipment, 29% of the laptops and 36% of the ultrasound
although some include the teams of the speciality centres scanners do not have a maintenance contract, so they
and health centres that depend on them, and that data are do not receive preventive checks and maintenance of the
not collected from autonomous organisations that in some original characteristics with which they were acquired. In
communities perform part of the activity, especially mag- our opinion, this is an important factor in the life cycle
netic resonance imaging (MRI) and computed tomography of the technology, given that a regulated maintenance
(CT) scans, nor from those specifically dedicated to breast that covers the manufacturer’s recommendations has a
cancer screening. Also, the different degree of response per relevant influence on the maintenance of the equipment’s
C could represent an additional bias. useful life, especially when the basic functions are linked
However, in general, a good correlation is observed with to rapidly evolving technologies such as information and
the data elaborated by other agencies. communication technologies.
The results obtained related to the age profile are shown
in Table 2.
The most relevant information is that a significant num- The survey also included aspects related to the manage-
ber of equipment of all types, between 32% and 59%, are ment of DI technology. The most significant data were:
more than 10 years old; data that agree enough with what
was elaborated by the Federación Española de Empresas
de Tecnología Sanitaria [Spanish Federation of Health Tech- • Hospitals that have a complete inventory database
nology Companies] (FENIN), with values between 23% and that incorporates the information related to the acqui-
60%. sition, installation, maintenance, healthcare activity,
Other significant data are: technological update and use costs that would allow a
comprehensive management of the DI technology are
• 49% of the MRI equipment, 32% of the CT and 48% of the exceptional.
angiographs installed in the radiology departments are • Only 8% of the hospitals surveyed had a structured process
more than 10 years old, which corresponds to an age level (formal document) for planning the renewal of their DI
higher than the average of equipment installed in Spain, technology.

Table 2 Age of the equipment according to the survey data.

Spanish public hospitals of the Spanish National Health System

Year of installation CT MRI Angiography X-ray MX Echo-Rad

<5 years 25% 26% 26% 14% 22% 25%
5---10 years 43% 24% 26% 27% 34% 35%
>10 years 32% 49% 48% 59% 44% 40%
CT: computed tomography; MR: magnetic resonance; MX: mammography; X-ray: conventional radiology.
38
• Satisfaction with the current process of technology
renewal was 3.62 out of 10 points, which indicates a high
level of dissatisfaction.
• Only 12% of hospitals or health ministries have a guide or
protocols for managing the life cycle of their DI equip-
ment.
• The degree of importance of having a guide for the man-
agement of technology has reached in the survey to the
heads of department an average rating of 9.30 points out
of 10, which indicates the high interest in developing this
documentation.
A wider discussion and analysis of the data obtained
in the survey and its comparison with the European data
are available in Annex 1 of the SERAM guide for the
renewal and technological update in radiology,3 avail-
able at: http://seram.es/modules.php?name=webstructure
&idwebstructure=207.
After the SERAM guide, in December 2017, FENIN pub-
lished a document on the technological profile of hospitals,
obtained by adding data from their associated companies,
with results that matched considerably with ours: between
23% and 60% of DI equipment in public hospitals, according
to modalities, were more than 10 years old.4
Discussion
In addition to the analysis of the situation, the SERAM guide
aims to help health organisations determine when and how
to update or replace DI medical technology equipment or
add new emerging technologies through the analysis of the
useful life cycles of these technologies.
There are different ways of approaching the manage-
ment of DI technology, which depend mainly on the health
system model (financing and provision) where the services
are developed, the purpose of the institution providing
the service and the macroeconomic and social environment
where the activity is developed.
In private insurance systems, in which the incorpora-
tion of technological innovation represents a competitive
advantage to attract more patients and increase health-
care activity, a business model is developed that adjusts
the renewal criteria to the expectations of the return on
investment (ROI) made.
The concept of life cycle changes in public insurance sys-
tems, where benefits are defined a priori and there are no
economic incentives that justify the concept of ROI. In them,
investment in technology is interpreted more as a necessary
cost than as an investment in itself, and the renewal of the
equipment is based above all on the life cycles of DI tech-
nology, although in the private provision systems the return
differences that are established depending on the age of the
equipment are important. Therefore, it is in the public pro-
vision systems where the best references for our case are
found.
The most complete reference is Lifecycle Guidance for
Medical Imaging Equipment in Canada 2013,5,6 published
by the Canadian Association of Radiologists and which has
served as a reference for the preparation of this guide for
its extensive documentary review and selection of the most
M.A. Trapero García, I. López Parrilla
relevant data to document the criteria used in the United
States, Canada and Australia.
Canada has an excellent bibliographic base based on the
complete monitoring of usage indicators and renewal guides
in the different provinces. It has established some recom-
mendations for the planning of the equipment that include
the definition of the criteria for the prioritisation of the
replacement or life cycle management, defined as a formal
process of planning the renewal of the DI equipment, and
monitors the degree of application and compliance. In 2016,
the conclusions document on the practice in the renewal of
DI equipment, developed by the Canadian Agency for Drugs
and Technologies in Health (CADTH), was published.7
The recommendation on life expectancy of the equip-
ment of the Canadian guide introduces a relevant element,
such as incorporating the degree of use to the life cycle
criterion, which is assessed according to the number of
exams or the daily time of use (8 h/16 h/24 h), defining
three bands according to the level of use: high, medium or
low.5
In the United States, there are multiple publications that
address the criteria of renewal or useful life of equipment.8,9
The American Hospital Association has published several
reviews of its guide ‘Estimated Useful Lives of Deprecia-
ble Hospital Assets’.10 This guide is used as a reference for
the assessment of the state of the technological resources
from the healthcare providers Medicare and Medicaid. The
U.S. Department of Veterans Affairs published a guide in
2012 with an exhaustive list of life expectancy times of
health technology equipment in which it states that ‘‘the
life expectancy (cycle) must not be the only criterion for
replacing equipment, but it must be used together with
other factors such as technological obsolescence, failure
rate, usage costs, maintenance problems, suspicions of lack
of safety, etc.’’.
Australia has a universal health system financed by the
federal government, although the responsibility for man-
agement lies with the six states of the nation. In 2003, the
state of Victoria published the document ‘Managing medical
equipment in public hospitals’,11 prepared by the Office of
the Auditor General of Victoria, which has been an important
documentary reference on the management of healthcare
technology. Some of the conclusions of the audit are to have
a record of the technology with its classification and essen-
tial documentation and the need for hospitals to plan their
needs for medical equipment on a long-term basis (indicates
5 years), including regular monitoring of their life cycle and
the conditions of maintenance and use.
A more recent publication12 focuses the audit report on
the analysis of high-value equipment, specifically MRI and
CT. This document once again emphasises the importance
of planning, in the medium-to-long term, the needs for the
renewal of technology in such a way as to avoid improvisa-
tion.
The comprehensive management of the life cycle of
medical technology has been addressed in a very detailed
way by the Department of Health of the State of Victoria, to
the point of developing a comprehensive protocol of medical
technology management that addresses from the planning of
the replacement, the increase of resources, the acquisition
process, the usage with its maintenance and control, until
the uninstallation and discarding, which also includes the
SERAM guide for the renewal and technological update in radiology
specific programme of technological renewal for the period
2018---2019.13
The United Kingdom has generated multiple documents
related to the management of health technology and,
specifically, of DI. Thus, in 2015, the Medicines and Health-
care products Regulatory Agency published a guide for
the management of medical technology: ‘Managing Medical
Devices’,14 which addresses the comprehensive concept of
the life cycle, from procurement planning to uninstallation,
and which reinforces the concept of maintaining a single
documentary record with the complete information of each
team, both economic and technical as well as regulatory.
The Auditor General for Scotland has published a more
comprehensive study on the management model of medi-
cal technology, ‘Equipped to care’,15 in which it describes
and recommends the model of management and activity of
health technology in the centres of the UK National Health
Service (NHS). In its subsequent review, in 2004, ‘Better
Equipped to Care?’,16 it evaluates the profile of the tech-
nology in Scottish hospitals, indicating, in annex 9 of the
document, the replacement periods of certain technologies.
In Spain, in 2013, the Ministry of Health, Consumption
and Social Welfare published a document on quality stan-
dards and recommendations in the diagnostic and image
processing healthcare units in which the management of
equipment, planning, hiring, commissioning and mainte-
nance is analysed, and in which several estimates of the
useful life of different imaging modalities are included.17
COCIR, which integrates the main European manufactur-
ers and suppliers of DI technology, launched the ‘Golden
Rules’ a few years ago, in which the age of the equipment is
related to its ability to incorporate current and innovative
technology; three rules are proposed:
• At least 60% of the equipment installed in a centre must
be less than 5 years old.
• At most, 30% of the equipment must be between 6 and 10
years old.
• The available technology older than 10 years old will be
limited to a maximum of 10%.
Conclusions and recommendations
From the international literature that gathers the expe-
riences, criteria and indicators of the most developed
countries and the suggestions and recommendations
received from the different agents related to the techno-
logical acquisition and renewal process, SERAM considers it
necessary to make the following recommendations:
• It is necessary to develop and maintain a complete record
of all DI equipment. The collection of data from the sur-
vey of the guide illustrates the difficulties in documenting
the inventory of the equipment of each hospital, and high-
lights the dispersion of the information of each of them,
date of acquisition, number of work shifts, annual activ-
ity, types of maintenance performed, quality controls and
corrective measures in equipment that uses ionising radi-
ation, inventory of breakdowns, etc., data that in many
cases are available, but in different spread out records.
It seems evident that to carry out an active management
39
Table 3 Years of life expectancy of the equipment based
on their use.
Years of life expectancy
Degree of usage High Medium Low
Plain radiation room 10 12 14
Remote control 8 10 12
Radio-surgical arch 8 10 12
Mammogram 8 9 10
Ultrasound machine 7 8 9
Computed Tomography 8 10 12
Magnetic resonance device 8 10 12
Angiograph 8 10 12
of these resources, it is essential to begin by having a
documentary record that is as complete as possible.
• The basic part of these records must be publicly acces-
sible. The current demands for greater transparency and
patient access to all the information that affects them
make it advisable that at least the basic information of
this record be of a public nature; essential, on the other
hand, as a tool to control resources and their status, as
well as when preparing status reports and reliable statis-
tics.
• It is necessary to establish objective criteria for the
renewal of equipment. There are multiple factors that
influence the life expectancy of equipment, but, from the
practical point of view, in most institutions the parame-
ter ‘‘time of use’’ is used as a renewal criterion. Although
the life cycle is different for each type of image modality,
there is an important coincidence between the different
publications, which establish periods of obsolescence that
range between 7 and 10 years.
Among the criteria analysed, we recommend using those
developed by the Canadian Association of Radiologists,
which are the most widespread and that add another rele-
vant element to the temporary parameters of renewal, such
as the degree of use.
To determine the degrees of use, it is possible to use the
number of studies that appear in the Canadian guide or the
number of daily working shifts, which is low when they work
in a single shift, medium when they work in two, and high
in the cases of emergency equipment or that work in three
daily shifts (Table 3).
Although life expectancies are essential when planning
the needs for the renewal of technology, this should not
be the only criterion for replacing a piece of equipment,
but should be used in conjunction with other factors that
may advise moving forward with the renewal, such as
technological obsolescence, lack of safety, improvement of
productivity, cost of use, failure rate, maintenance prob-
lems, availability of spare parts, etc. An example is the
tomographs for paediatric patients, in which the lower radi-
ation dose of the new equipment advises to move forward
their renewal.
• The equipment must have adequate maintenance. The
maintenance of the equipment has a decisive influence on
40
its life expectancy. Non-existent or incorrect maintenance
reduces the useful life, but can also affect the reliability
and safe use. It is essential to ensure, throughout the life
cycle, a complete maintenance that preserves the func-
tionality of the equipment in its original specifications.
• Assessing the need to perform updates during the life of
the equipment. Inside a piece of equipment, the com-
puter components (hardware and software) have a shorter
life cycle than the rest of the equipment (around 5 years).
Updates are often recommended by replacing these com-
ponents or incorporating new ones that can add value by
improving patient safety or examination quality.
• It is necessary to plan the renewal needs in the medium
term. Once the replacement criteria have been defined,
it is convenient to establish a formal process for plan-
ning the renewal of the DI equipment, which defines
the equipment, technological band and necessary finan-
cial resources. In order to avoid improvisation, prioritise
objectively the most necessary investments and improve
efficiency in the use of resources, in all the references,
special emphasis is placed on the necessary medium-term
planning; the most common is to plan for 5 years.
• At present, for the replacement of some types of equip-
ment, it is necessary to consider whether it is more
appropriate to acquire a new one as opposed to the major
update (which replaces a relevant part of the equip-
ment), which can be perfectly technically valid and more
economical (e.g. update of the hardware, software and
firmware of an MRI device maintaining the magnet).
• Maintaining the diagnostic reliability and safe use are
essential premises. Pieces of equipment that have
exceeded their life cycle should follow, until their
renewal, an exhaustive control process that more fre-
quently monitors and regulates compliance with their
functionality and calibration through appropriate pre-
ventive maintenance and certification of functionality
and safety by a qualified and accredited technical
service.
Although some of the recommendations make it nec-
essary to recover at least the level of investment and
replacement prior to the economic crisis, many of them
are organisational and refer to the need to develop a
comprehensive, objective and transparent DI equipment
management process.
Authorship
1.
Responsible for the integrity of the study: MATG and ILP.
2.
Study conception: MATG and ILP.
3.
Study design: MATG and ILP.
4.
Data collection: MATG and ILP.
5.
Analysis and interpretation of data: MATG and ILP.
6.
Statistical processing: N/A
7.
Literature search: MATG and ILP.
8.
Drafting of the paper: MATG and ILP.
9.
Critical review of the manuscript with intellectually rel-
evant contributions: MATG and ILP.
10. Approval of the final version: MATG and ILP.
M.A. Trapero García, I. López Parrilla
Conflicts of interest
The authors declare that they have no conflicts of interest.
I. López Parrilla is currently the director of institutional
relations at Philips Ibérica.
References
1. Bandrés E, González R. La reducción del gasto sanitario en
España durante la crisis. Cuadernos información económica.
2015;248:165---94.
2. Medical imaging equipment age profile & density --- cocir
2016. Available at: http://www.cocir.org/uploads/media/
16052 COC AGE PROFILE web 01.pdf [accessed 01.07.18].
3. Guía de la SERAM para la renovación y actualización tecnológ-
ica en radiología. Available at: http://seram.es/modules.
php?name=webstructure&idwebstructure=207 [accessed
01.07.18].
4. Perfil tecnológico sanitario. FENIN; 2017. Available at:
http://panelfenin.es/uploads/fenin/documento estudios/pdf
documento 34.pdf [accessed 01.07.18].
5. Lifecycle guidance for medical imaging equipment in Canada.
Canadian Association of Radiologists; 2013. Available at:
https://car.ca/wp-content/uploads/car-lifecycleguidance-
mainreport.pdf [accessed 01.07.18].
6. Nuclear medicine; equipment life expentancy study. Cana-
dian Association of Nuclear Medicine; 2014. Available at:
https://canm-acmn.ca/Resources/Documents/Report CANM
%20modified%20Cancun ENG August%2010.pdf [accessed
01.07.18].
7. Diagnostic imaging equipment replacement and upgrade
in Canada. CADTH Environmental Scans; 2016. Available
at: https://www.cadth.ca/sites/default/files/pdf/ES0303 DI
Equipment Replacement es e.pdf [accessed 01.07.18].
8. Dondelinger RM. A complex method of equipment replacement
planning An advanced plan for the replacement of medical
equipment. Biomed Instrum Technol. 2004;38:26---31.
9. Evanoo J, Cameron D. Healthc Financ Manage. 2010;64:84---8,
90.
10. A.H. Association. Estimated useful lives of depreciable hospital
assets, revised 2013 edition. Chicago: AHA Press; 2013.
11. Managing medical equipment in public hospitals. Victo-
ria. Auditor General Victoria. Available at: https://www.
parliament.vic.gov.au/papers/govpub/VPARL2003-06No9.pdf
[accessed 01.07.18].
12. Efficiency and effectiveness of hospital services: high-
value equipment. Victorian Auditor --- General’s Report;
2014---2015. p. 19. Available at: https://www.audit.vic.
gov.au/sites/default/files/20150225-Hospital-Equipment.pdf
[accessed 01.07.18].
13. Medical equipment and engineering infrastructure replace-
ment programs guidelines. Victoria; 2018---2019. Available at:
https://www2.health.vic.gov.au/hospitals-and-health-services/
planning-infrastructure/medical-equipment [accessed
01.07.18].
14. Managing medical devices. Guidance for healthcare and
social services organisations. UK: Healthcare products
Regulatory Agency; 2015. Available at: https://assets.
publishing.service.gov.uk/government/uploads/system/
uploads/attachment data/file/421028/Managing medical
devices - Apr 2015.pdf [accessed 01.07.18].
15. Equipped to care. Managing medical equipment in the
NHS in Scotland. A report to the Scottish Parliament by
the Auditor General for Scotland. Available at: http://
SERAM guide for the renewal and technological update in radiology 41

www.audit-scotland.gov.uk/docs/health/2000/nr 010309 17. Unidad asistencial de diagnóstico y tratamiento por la

medical equipment nhs.pdf [accessed 01.07.18].
16. Better equipped to care? Follow-up report on manag-
ing medical equipment. Audit Scotland; 2004. Available at:
http://www.audit-scotland.gov.uk/uploads/docs/report/2004/
nr 040226 medical equipment km.pdf [accessed 01.07.18].
imagen. Estándares y recomendaciones de calidad. Mini-
sterio de Sanidad, Consumo y Bienestar Social; 2013.
Available at: https://www.msssi.gob.es/organizacion/sns/
planCalidadSNS/docs/Diagnostico Imagen EyR.pdf [accessed
01.07.18].