The concept of diagnostic reference levels (DRLs) has been introduced to provide standard doses against which hospital patient dose measurements can be compared to evaluate practices. DRLs are defined in terms of measured dose quantities. National DRLs can be derived from surveys of patient doses for common types of examinations in 20–30 large hospitals. The International Commission on Radiological Protection proposes that median doses for each type of examination at every hospital be collated and DRLs based on the third quartile value of the distribution. Once DRLs have been set, periodic audits of patient dose should be undertaken for examinations that reﬂect the clinical workload. Median doses from these distributions should be compared with relevant DRLs to identify procedures for which further optimisation is required and appropriate corrective action taken. This paper discusses factors that should be considered in the optimisation process and gives examples of experiences in application of DRLs in Scotland.