A Sequential Governance Framework for Clinical Physiologist EEG Reporting in a District General Hospital: From Agreement Study to Autonomous Practice

Abstract Background: Definitive electroencephalography (EEG) reporting by clinical physiologists remains uncommon in United Kingdom (UK) district general hospitals, despite a documented national shortage of consultant medical neurophysiologists and growing demand. No formal UK governance framework for safe autonomous reporting has been published. Approach: A pragmatic three-phase governance model was implemented in a single-practitioner neurophysiology service: a formal agreement study, an active triage phase of graduated withdrawal from oversight, and fully autonomous practice. Fifty consecutive adult EEGs were prospectively categorised into Green (lowest), White (intermediate), and Blue (highest disagreement potential) tiers, with clinical opinions generated by a clinical physiologist (CPN) and reviewed by a consultant neurophysiologist (CN) prior to report release. Results: Twenty-one EEGs (42%) were Green, fourteen (28%) White, and fifteen (30%) Blue. Clinical concordance (no difference in overall classification, clinical liability, or management implication) was 100% across all fifty studies and all three triage categories, (κ = 1.00 complete agreement). On ultra-conservative secondary analysis, percentage agreement was 88% and κ = 0.43 (moderate); on conservative weighting, 98% and κ = 0.49 (moderate). The agreement study validated entry into a six-month active triage phase (October 2023 to April 2024), during which referral rates declined from approximately 30% to zero. Fully autonomous practice followed (April 2024 to April 2026), generating 677 reports with one escalation. Conclusions: A governance framework anchored to anticipated disagreement potential, rather than a normal/abnormal binary, supported safe staged extension to autonomous adult EEG reporting in a district general hospital. The framework is self-limiting by design and provides a replicable career development pathway for clinical physiologists seeking to extend reporting scope. Keywords: EEG reporting; non-medical reporting; clinical physiologist; inter-rater agreement; triage; clinical governance; autonomous reporting; scope of practice