23 December 2017

Checklist of Radiology and Imaging department and its quality indicators for NABH accreditation preparation

Imaging department is one of the pivotal department for diagnosis of diseases. It includes both radiation based and non-radiation based imaging modalities. The key result areas (KRAs) for imaging departments are availability of required tests, accuracy of diagnosis, safety of patients and staff, maintenance of turn-around time and optimal utilization of equipment. NABH standards for imaging revolves around these KRAs. 

Below is the compilation of all requirements that is applicable to an imaging department for NABH accreditation fulfillment

  1. Imaging must be able to provide those tests that are required by various clinical specialities offered by the hospital. For this hospital must identify various imaging tests required by different specialities and same should be made available.
  2. A list of all imaging tests that can be done in the department should be maintained and updated from time to time. This list will be the scope of imaging services
  3. In case some tests cannot be offered or is not available, an arrangement should be there to outsource such tests. In this case following things are required to be ensured
    1. A list of all tests that can be outsourced in available in the imaging department, specifying which lab (or labs) the specific test can be outsourced to
    2. In each of the imaging lab where the test is being outsourced, identity of the personnel from that lab has to be written, so that accountability can be fixed
    3. A standard process should be there on how to outsource the test. The standard process must describe, the method of patient identification, test requisition details, communication with outsourced lab and other relevant details
    4. The selection of labs where the tests will be outsourced should be based upon criteria of quality and safety. The criteria should be documented.
    5. A written MoU should be signed with the outsourced lab, specifying the terms and conditions related to quality assurance requirements
  4. Imaging department must comply with following legal requirements
    1. Layout approval from AERB of each rooms that houses radiation emitting equipment such as X-ray and CT-scan
    2. Type approval certificate of all radiation emitting equipment from AERB
    3. TLD badges for all staff working in radiation areas and 3 monthly report of TLD monitoring results. This is applicable to other areas, which are not within imaging department but has radiation emitting equipment, like Cath lab, C-arm machine in OT etc. 
    4. Designation of a BARC certified radiation safety officer (level 1, 2 or 3) depending upon amount of radiation
    5. Registration of all ultrasonography machines under PNDT act. (Check this post on 'all legal documents required by a hospital')
  5. Standard operating process for carrying out each test procedure should be available
  6. Defined turn-around time for each test 
  7. Informed consent should be taken from patient before any imaging test
  8. A documented process on ‘handling of critical finding’ should be available. The document should list out findings that should be considered as critical and step by step process on what should be done, once a critical finding is found.
  9. A declaration to be taken from pregnant lady undergoing USG, for non-declaration of sex
  10. A documented plan of peer review should be available and records related to peer review is available. In peer review, randomly selected samples of the test results should be interpreted by peers and findings should be correlated.
  11. A randomly selected samples of test results should also be correlated with the clinical findings and recorded. 
  12. Minutes of meeting (or any other similar records) should be available to show that peer review findings and surveillance findings has been communicated, discussed, analysed and actions has been taken
  13. Each equipment in imaging should have a calibration scheduled. This can be documented in the equipment log. A calibration report / label on equipment should be there as an evidence that calibration has been done, as per schedule
  14. Each equipment in imaging should have a preventive maintenance schedule. This can be documented in the equipment log. A record of preventive maintenance check carried out should be available.
  15. A register documenting all corrective and preventive action taken should be available
  16. Following radiation safety measures should be in place
    1. Radiation protection gears such as lead apron, lead shields etc. should be available in adequate quantity. All these lead shields should be stored properly (they must not be folded).
    2. The lead aprons should have been checked at-least once in six months to ensure that they have not formed crevices. This can be done by taking an X-ray image of lead apron and examining it. These images and the findings should be maintained as a record
    3. Each staff working within radiation areas must have his/her own TLD badges, which they are wearing when on duty. The TLD badged should be worn under lead apron and not over it
    4. Records of TLD badges been checked on a periodic basis
    5. Each staff should have been trained and are aware of radiation safety practices. Records of training and evaluation to be maintained
  17. For MRI, the safety practices to prevent any hazard from strong magnetic field should be available and in use. This include measure to prevent any metal item to be taken inside MRI room.
  18. A representative of radiology department should be a part of hospital’s safety committee (Refer safety committee under 'list of hospital committees and teams')
  19. Display and signage should be in place, as per regulatory requirements. These include
    1. Display of ‘No sex determination’
    2. Warning for pregnant ladies and small kids
    3. Warning/hazard lights when radiation equipment is on
    4. Restricted entry signs at appropriate places
    5. Warning signs related to MRI
  20. MSDS sheet for radio-active materials should be available
  21. Radio-active waste disposal, if applicable, in a lead container and as per AERB regulations
  22. The staff should be aware of other topics which includes
    1. Patients’ rights and responsibilities
    2. Employee rights and responsibilities
    3. Scope of services of hospital and of imaging departmentCritical findings and what to do in those situation
    4. Identification and care of vulnerable patients
    5. Occupational health hazard that they are exposed to and how to prevent
    6. Basic life support and code blue procedure
    7. Other emergency codes used in hospital, such as code red, code pink etc.
    8. Standard precaution for infection prevention
    9. Emergency evacuation plan
    10. Their role during disaster situation. (Suggested read - Disaster handling checklist for hospitals)
    11. Dealing with HIV +ve patients and maintaining confidentiality
    12. Turn-around time and other quality indicators being used in imaging

Quality Indicators: 

Following quality indicators must be used in imaging as a part of quality assurance programme. Each doctor and staff should be aware of these indicator

  1. % of test result delayed from standard turn-around time 
  2. % compliance to radiation safety practices (done through sample monitoring)
  3. % of critical results reported to concerned consultant within the given timeframe
  4. % of variation in peer review findings
  5. % of variation of test results from clinical findings
  6. % of re-testing required
  7. Average waiting time for each modalities

Other checklists available: 

















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