Summer Training in Sterling Hospital, Ahmedabad

(14st April - 26th May2012)

A Report on Quality Management in Radiology Department In Sterling Hospital, Ahmedabad

Kartika Singh Naruka

Post Graduate Diploma in Hospital and Health Management

2011-2013/25

Institute of Health Management Research Bangalore.

DECLARATION BY THE STUDENT

This is to declare that the Report is made for the Partial fulfillment of completion of the Course: Summer Training in Term-II of PGP (PGDHM 2011-13 Batch) by me in STERLING HOSPITAL, AHMEDABAD under the supervision of Dr. / Ms. SHRUTI THAKKAR and my Mentor was Dr. /Mr. RAVI PRAKASH. I confirm that this report truly represents my work and accomplishment undertaken as a part of my Dissertation work. This work is not a replication of work done previously by any other person. I also confirm that the contents of the report and the views contained therein have been discussed and deliberated with the (Supervisor) as well as the Mentor.

Name of the Student: KARTIKA SINGH NARUKA Register No: IHMRB/PGDHM/2011-13/25

Abstract
Background
The aim of the Radiology Department at Sterling Hospital is to forge links between medicine and science to improve the diagnostics and treatment of diseases. The department offers a wide range of clinical diagnostic and high quality therapeutic imaging and efficient services to the patients and their physicians. This is very effective in evaluation of Polytrauma patients and critical patients.

METHODS
1) Turnaround time 2) Flow chart 3) Data recording 4) Observation method 5) Feedback Form (with Graphs)

RESULTS
Quality in radiology may be defined in many ways and from different angles. One of these is: A timely access to and delivery of integrated and appropriate radiological services and interventions in a safe and responsive facility and prompt delivery of accurately interpreted reports by capable personnel in an efficient, effective and sustainable manner. TQM is used in the hospitals due to concerns about the quality of care. Which differentiates it from other hospitals and the best class services because this is what which makes sterling one of the best multispecialty hospital in Gujarat, with the applying of Total quality management the OPD Patient will come as well as the departments in which patients visit more (IPD ,OPD ,Health -Check -UP, and ER) will be there and more and more no. of increase in the patients as well as profit maximization with proper utilization of human resources that too with minimum cost. The purpose of my project is to find out how quality is maintained in radiology department. CONCLUSION In my project I have used various methods to look for that, proper quality. I have used different methods to assess main areas where quality needs to be addressed for a complete quality and safety program in radiology. Safety, assessment, and satisfaction. These areas need to be coordinated by individuals who belong to a quality oversight committee. The ultimate goal is a cultural shift in which all departmental workers assume responsibility for quality and safety improvements and behave consistently with the core values of the organization. A road map for thinking about quality and safety issues in radiology allows all of these areas to be tied together.

ACKNOWLEDGEMENT
It is with great pleasure that I express my deep sense of gratitude & heartfelt thanks to Dr. K.S RAO & all the faculty members for providing the opportunity to exercise the practical aspect of studies. I extend my gratitude to our course coordinator & my mentor Dr. RAVI PRAKASH for her suggestions & immense help in accomplishing the summer training program. I would like to thank our supervisors. I am highly fortunate to express my deep sense of gratitude & indebtedness to Ms. Gayatri Singh & Ms. Shruti Thakkar for permitting me to carry out the project work in STERLING HOSPITAL, AHMEDABAD .Finally my special thanks to all staff members of Sterling Hospital for their cooperation.

INDEX S.NO. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. a) b) c) d) e) f) g) CONTENTS

Title of Project Declaration by the student Certificate Acknowledgement Abstract Abbreviations

Executive Summary Methods Flow Charts(IPD & OPD) Organization Profile Organogram Radiology Department Familiar with the department Location Related Department Time Duration Staffing Rooms General Overview Of Sonography

h) i) j) k) l) m) n) o)

Types of Limb Doppler Types of CT Scan Radiology Services Services not available Types of X-Ray Machines in X-Ray Room Facility in radiology department Equipments in radiology department Various process in radiology department 1)Reporting

p)

2)x-ray procedures in in-patients 3)Patients recall for out-patient 4)Dispatch Total Quality management 1)Quality Assurance 2)The components of the quality assurance for radiology &

13.

imaging 3)Quality Assurance program for medical exposure include 4)Radiation Safety-Regulatory Requirement

14.

Radiation Safety(Procedure)

1)x-ray room 2)Equipments 3)Patient 4)Radiology staff 5)Policy 6)Precautions

15. 16.

Patient information Scope of Services Chart illustrating a process of engaging radiologist in quality & safety programs

17.

ABBREVIATIONS:

TAT- TURN AROUND TIME BP BLOOD PRESSURE IPD INPATIENT DEPARTMENT HR HUMAN RESOURCE HOD HEAD OF DEPATMENT

EXECUTIVE SUMMARY

TQM is used in the hospitals due to concerns about the quality of care. which differentiates it from other hospitals and the best class services because this is what which makes sterling one of the best multispecialty hospital in Gujarat, with the applying of total quality management the OPD patient turnaround time will come as well as the departments which patients visit more (IPD, OPD, Health Check UP, and ER) will be there and more and more no. of increase in the patients as well as profit maximization with proper utilization of human resources that too with minimum cost. The purpose of my project is to find the flaws in the current working procedures and maintenance of quality in radiology department. Quality in medical imaging and interventional radiology may be defined in many ways and from different angles. One of these is: A timely access to and delivery of integrated and appropriate radiological studies and interventions in a safe and responsive facility and prompt delivery of accurately interpreted reports by capable personnel in an efficient, effective and sustainable manner. Some factors which all together add up to quality of a department are mentioned below: 1.) Access: the ability of a patient to obtain medical imaging and interventional radiology at the right place and right time irrespective of income, physical location and cultural background 2.) Integrated: the ability to provide uninterrupted and coordinated care across facilities and practitioners. In medical imaging and interventional radiology, the availability of and access to relevant clinical history, indications and findings of previous radiological studies of interventions, and the opportunity to discuss with the referring physician or patient are essential components, which can significantly influence the diagnostic study, intervention selection, interpretation and follow-up management options 3.) Appropriate: the care, intervention or action provided is relevant to a patients need and is based on established standards. The radiologist is the consultant assisting the referring physician and patient in selecting the most appropriate radiological study or intervention for the clinical condition, based on evidence based practice guidelines 4.) Safe: the avoidance or minimization of actual or potential harm from medical imaging or interventional radiology, including radiation exposure, magnetic fields, contrast media etc 5.) Responsive: the primacy of a patient is recognized and respected. The facility is patient-oriented and practices these aspects: respect for patients dignity and confidentiality, participation in choices or decision-making, prompt, and good quality of amenities and choice of provider 6.) Timely report and accurate interpretation: the medical imaging report should be accurately interpreted and the interventional procedure precisely documented and delivered to the referring

physician in a timely manner for optimal patient management. Reliable means of report delivery and confirmatory mechanisms are essential especially in the case of urgent or unexpected findings 7.) Capable: the facilitys and individuals capacity to provide medical imaging and interventional radiology based on skill and knowledge 8.) Efficient: achievement of the desired results with the most cost-effective use of resources 9.) Effective: the care, intervention or action should be effective in achieving the desired outcome 10.) Sustainable: the system must be capable in providing infrastructure such as workforce, facilities and equipment, and be innovative and responsive to emerging needs.

METHODS
Data collected using excel sheet template for, Operation theatre utilization was studied with respect to the starting and closing of the operation theatre, interval between surgical procedures, cancellation of surgical procedures and reasons thereof. METHODS FOR DATA COLLECTION: With the help of the template framed by the researcher which comprised of following indicators: TAT (TURN AROUND TIME) Date Investigation and procedure name OP NO. ( Outpatient no.) Name of the patient Arrival time Waiting time for the investigation and procedure Investigation and procedure time(Starting time and Completing time) Film time Waiting time to collect the report(Authenticate and Dispatch) Report collection time Remarks Sign TAT is the continuous improvement monitoring sheet. Monitoring of turnaround time for radiological procedures and investigations. After every 3 months the collected TAT Form in the radiology reception goes in the MRD.

DATA ANALYSIS : RADIOLOGY

S. NO. 1

WAITING TIME (hrs) 0.1

PROCEDURE TIME (hrs) 0.07 0.05 0.08 0.46 1 0.09 0.13 0.07 0.06 0.06 0.07 0.07 0.04 0.09 0.57 0.07 0.15 0.09 0.59 0.07 0.15

DISPATCH TIME (hrs) 0.43 0.46 3.18 3.3 2.15 2.01 2.14 2.53 1.59 1.24 1.41 1.33 1.02 1.25 2.33 0.46 0.14 3.41 2.18 3.33 2.45

2 0.07 3 0.27 4 0.14 5 0.22 6 0.5 7 0.33 8 1.02 9 0.37 10 0.3 11 0.19 12 0.27 13 0.05 14 0.06 15 0.45 16 1.24 17 0.06 18 0.4 19 0.59 20 0.45 21 0.55

22 1.27 23 0.4 24 0.38 25 0.53 26 1.47 27 1.52 28 1.2 29 0.5 30 1.56 31 1.33 32 0.55 33 1.43 34 0.09 35 1.5 36 1.08 37 1.03 38 0.44 39 0.43 40 1.08 41 1.46 42 1.01 43 0.11 44 0.09 45 1.12 0.25 4.4 0.27 5.55 0.49 1.56 0.13 2.54 0.37 2.25 0.05 3.35 0.04 5.17 0.53 5.22 0.15 5.5 0.02 5.11 0.54 4.26 0.08 1.05 0.05 3.41 0.11 1.36 0.09 3.53 0.08 3.45 0.1 5.41 0.08 0.28 0.06 1.14 0.4 1.23 0.07 3.2 0.15 3.27 0.07 3.33 0.23 2.05

46 1.15 47 3.04 48 2.06 49 1.52 50 0.3 51 0.04 52 0.36 53 0.18 54 0.1 55 0.15 56 0.55 57 0.2 58 0.26 59 1.41 60 0.16 61 0.58 61 0.18 63 0.57 64 0.1 65 0.25 66 0.25 67 1.08 78 1.02 69 1.21 0.08 3.59 0.1 3.36 0.04 3.47 0.06 1.01 0.06 1.01 0.05 1.45 0.08 1.15 0.19 1.34 0.25 3.02 0.08 2.3 0.55 2.08 0.06 3.37 0.29 0.33 0.1 1.02 0.21 1.12 0.12 1.14 0.49 1.41 1.1 0.1 0.11 2.17 0.23 3.07 0.06 3.29 0.05 3.4 0.2 2.45 0.55 4.45

70 0.46 71 0.47 72 0.2 73 0.22 74 0.03 75 0.04 76 1 77 0.24 78 1.12 79 0.19 80 1.31 TOTAL 51.21 TOTAL MINS 3081 AVERAGE MINS 38.5125 11 151.025 880 12082 14.8 201.62 0.51 1.16 0.06 1.16 0.05 3.46 0.05 4.38 0.08 0.47 0.06 1.5 0.09 4.03 0.1 5.55 0.11 6.06 0.07 3.51 0.07 3.28

 INTERPRETATION:

1) As shown in the graph total turnaround time for radiology is 200.53 minutes. 2) It comprises of waiting time, procedure time & dispatch time. 3) Waiting time is the time duration between registering patient & patient coming in for procedure . It Is Around 38.51 Minutes For A Patient Coming For Radiology. 4) Procedure time is the time duration Between patients entry in the depatment for procedure to patints Exit after completion of it. It is around 11 minutes for Radiology. 5) Dispatch time is the time taken after completion of procedure to dispatching of report. It is around151minutes which is nearly about2.5 hrs for Radiology. It is a large duration taking patients valuable time. 6) The above mentioned facts can also be understood from the table given above.

Turn Around Time-RADIOLOGY

250

200.5375 200

151.025 150 Series1

100

50

38.5125

11 0 Waiting Time Procedure Time Dispatch Time Total Time

Waiting Time Procedure Time Dispatch Time Total Time

38.513 11 151.03 200.54

 FEEDBACK FORMS
Q1. Friendliness & helpfulness of front desk staff: EXCELLENT GOOD FAIR POOR

12 34 4 0

Friendliness & helpfulness of front desk staff

35 30 25 20 15 10 5 0 EXCELLENT GOOD 12 34 Series1

4 0 FAIR POOR

Q2. Waiting time in reception area EXCELLENT GOOD FAIR POOR

12 22 10 6

Waiting Time in Reception Area

6 10

12

EXCELLENT 22 GOOD FAIR POOR

Q3. clean &tidy : EXCELLENT GOOD FAIR POOR

21 20 3 6

Clean and Tidy

6 3 21 EXCELLENT GOOD FAIR POOR

20

Q4. well signposted : EXCELLENT GOOD FAIR POOR

10 10 21 9

Well signposted

25 21 20

15 10 10

10 9

Series1

0 EXCELLENT GOOD

FAIR POOR

Q5. convenient to get to: EXCELLENT GOOD FAIR POOR

9 18 10 13

Convenient to get to

20 15 10 5 0 EXCELLENT 9

18

10

13 Series1

GOOD

Series1 FAIR POOR

Q6. waiting area EXCELLENT GOOD FAIR POOR

24 17 4 5

Waiting Area

25 20 15 10 5 0

24 17

4 EXCELLENT

5 Series1

Series1

GOOD

FAIR POOR

Q7. Sinologists/Radiographer's explanation of your procedure: EXCELLENT GOOD FAIR POOR

11 8 12 19

Sonologist's/Radiologist's explanation of your procedure

20 18 16 14 12 10 8 6 4 2 0 EXCELLENT GOOD FAIR POOR Series1

Q8. Respect of your privacy & confidentiality : EXCELLENT GOOD FAIR POOR

14 13 13 10

Respect of your privacy & Confidentiality

14 12 10 8 6 4 2 0 EXCELLENT GOOD FAIR 14 13 13 10 Series1

POOR

Q9. Reason for using SDMH radiology Services Recommendation Doctor's Choice Personal Experience Other 13 9 14 10

Reason for using SDMH radiology services

14 12 10 8 6 4 2 0 Series1

 FLOW CHART

X-ray for Outdoor patient:

X-ray Reception- Patient comes with the requisition form for investigation.

No

Does investigation preparation?

the need Yes No

Yes

Is the Pt. with necessary preparation? No Pt. is told about the requirement of appointment and given for the earliest available time Pt. will come on that date and time of appointment with preparation

Can the pt. be allocated for investigation? Yes After investigation entry is done in Radiology Room

Patient is asked to wait for stated hrs. for collecting report. Only In case of request by consultants for unreported film are given in 1 hrs. unreported film are given

 FLOW CHART X-ray for Indoor patient

During working hours

Nurse will inform about the investigation and the pt. details to the Radiology department on requisition form. The Reception will check the type of test and the need for pt. preparation

Time of investigation informed to nurse

Is pt. Preparation needed? Inform the nurse about the preparation

Patients are taken for Investigation

The appointment is given according to the preparation

If Pt. is prepared?

The nurse is told to send the pt. to the department.

Investigation is done and entry is made in Digital Room.

Patient is transferred back to the wing accompanied with Ward Boy/Lady

ORGANIZATION PROFILE:

About the organization History

Sterling Hospitals is one of the largest hospital chains in Gujarat, considered to be the leading one by the levels of independent certification, facilities and equipment, as well as size and capacities. It is owned and managed by Sterling Add Life India Ltd. The specialties in which it provides medical care include: Cardiology, Neurology, GI Medicine, Hematology, Oncology, Reproductive Medicine, Critical and Emergency treatment, Trauma and Orthopedic, Neonatology and General Medicine. Surgery treatments include CVTS-, Neuro- and Onco-surgeries, Nephrology (with Kidney Transplant), GI surgeries and General Surgeries.

Infrastructure
Sterling's multi-specialty hospitals have presence in six major cities of Gujarat. 1) Ahmadabad (310 beds)- NABH & NABL Accredited 2) Vadodara (196 beds)- NABH Accredited 3) Rajkot (190 beds) 4) Mundra (100 beds) 5) Bhavnagar (180 beds) 6) Gandhidham It also has three satellite centers at Kalol, Mehsana and Himmatnagar. STERLING HOSPITAL, the company's largest hospital complex in Ahmedabad has 310 beds, 7 major operation theatres and 84 ICU beds. Multiple facilities are also available at Vadodara complex. Patients treated by Sterling Hospitals come from Gujarat, Madhya Pradesh, Maharashtra, Rajasthan, as well as from abroad.

Recognitions
In 2009 Sterling became the first hospital in Gujarat to be fully accredited by NABH. Its laboratories were also the first in Gujarat to be accredited by NABL. In 2010, for the second consecutive year, Sterling Hospital had been named the No. 1 hospital in Ahmadabad based on the latest THE WEEK - IMRB surveys.

Other specialty care unit

We at Sterling Hospitals are committed to your health. Conforming to the best practices worldwide, Sterling Hospitals offer you more options, better choices and greater flexibility of treatment Services are the backbone & core part of our healthcare deliveries. Patient comfort & satisfaction are the areas of our focus & Concern and to deliver the highest standard of health care services.

Key Services

33 Specialties all under one roof 24 hrs Emergency Stroke and Cardiac Helpline Services Continuous Renal Replacement Therapy (CRRT) to treat multi-organ dysfunction Special programmes include Bone Marrow Transplant, Liver Transplant & Renal Transplant Specialized services include Diabetes Clinic, Pain Clinic, Stroke Clinic, Wellness Clinic and Sleep Lab Ancillary services include Blood Bank, Dietetics, Dialysis Unit, Molecular Lab, Pathology, Pharmacy, Physiotherapy and Radiology Special Services for Corporate including medical holidays, health check-ups and health seminars Specialty
Bone Marrow Transplant Cardiology Critical Care and Pulmonary Division Dentistry Department of Diabetology & Endocrinology Department of Neuro Sciences Department of Psychiatry & Behavioral Psychology Ear, Nose and Throat (ENT) Gastroenterology Gynecology & High Risk Pregnancy Hematology- Oncology Infectious Diseases Joint Replacement Unit Neonatology Nephrology Neurosurgery Pediatric Surgery Plastic reconstructive and cosmetic surgery Polytrauma / Multiple Injury Renal Transplantation Unit Rheumatology Department Skin Diseases Spine Surgery Surgical Gastroenterology & Minimally Invasive Surgery

 ORGANOGRAM OF HOSPITAL

CEO COO CMA

HOD+ Medical Supritendent 4 Radiologist(full time) 1 Radiologist(Part time) Technicians+ Nsursing Staff

 RADIOLOGY DEPARTMENT Familiar with the department: Location: The radiology department is located at ground floor Related department: Emergency(ER),Health check up department Time duration:24 hrs Staffing: STAFF RADIOLOGIST TECHNICIAN NURSING STAFF ATTENDANT MAMMOGRAPHER RECEPTIONIST MT NO. 5 10 5 2 1 2 3

In sterling hospital radiology department has total 19 staff members ROOMS 1)USG-1(Ultra sonography) 2)USG-2 3)Preparation room 4)CT Scan 5)CT Scan console room 6)X-Ray -1 7)X-Ray-2

General overview of Types of sonography USG Abdomen USG Neck USG Breast USG Chest or Thorax Local part (Particular part of soft tissue)

General overview of Types of limb Doppler

ARTAL DOPPLER(Left and right upper limb),(Both lower limb arteal Doppler) VENUS DOPPLER

 General overview of Types of CT Scan(Over body)

1 Brain 2 Abdomen 3 Chest 4 Neck 5 PNS(related to nasal sinus)

Radiology Services
1 Digital X-Ray and fluoroscopy 2 Mammography 3 Sonography 4 Color Doppler study 5 Multi slice CT-Scan(MSCT) 6 MSCT Angiography 7 Interventional Radiology

Services not available

1 PET SCAN 2 NUCLEAR MEDICINE 3 MRI

Machines in X-Ray room

1 Phillips 2 Siemens

Types of x-ray
1 Conventional x-ray 2 Non- conventional x-ray (not done here)

 Facility in Radiology Department:

1)Digital X-Ray like chest ,abdomen, limbs 2) Special procedures like barium studies etc. 3)Ultrasonography 4)Angiographies 5)CT Scan 6)Breast Imaging

Equipments in the department

1)X-Ray Machines 2)Color Doppler 3)CT Scan 4)USG Machine 5)Mammography Machine

Various process in the Radiology Department

Reporting X-Ray and Procedures:

The x-ray technician performs the x-rays, other process and put them in a labeled folder. These are then given to the radiologist for reporting. The radiologist writes the report. Thereafter, the unit (radiology) enters the report in the HIS Radiology Module. The normal report templates are saved into the system, which can be modified for the reports.MT prepares computer typed report. The typed report is verified and signed by the

radiologist and sent for dispatch. The PRO (Radiology) the prepares, verifies the folders before dispatch. In case of In-Patients: In some special cases (emergency hours or physician request the films are dispatched without reports. These are recorded in the x-ray dispatch register. The films are then sent back by the ward boy/staff for reporting

Patients recall for Out-Patient If the radiologist needs to repeat the x-ray or perform other additional views or requires any other additional history of a patient to aid in reporting, the patient needs to be recalled, the customer care officer (radiology) or the technician on duty will call the patient on the available contact no. and recall the patient with proper examination for the need of the same. The extra films are not charged. A) Sonography The radiologist while performing the ultrasound dictates the report to the sonography technician. Who then types the report in the HIS radiology module.The normal report templates are saved in the system, which can be modified for reporting. The typed report is verified and signed by the radiologist and sent for dispatch. The technician or customer care officer (radiology) then prepares the folders and sent to dispatch. B) Dispatch: X-Ray and Procedures:

All out-patients x-ray reports are dispatched by 5pm on the same day. The technician will dispatch the x-rays to the main reception desk for dispatch. The in-patient reports are dispatched to the respective wards/icu by the staff. If the films are taken without reports for any reason, the films should be sent back for reporting. The dispatched x-rays are recorded in the registers and maintained for out patients and in patients .All emergency cases will be reported and dispatched of reports within 24hrs. Sonography:

The outpatient sonography reports are dispatched by 5pm.The sonography technician dispatches the reports to the main reception desk. The inpatient reports dispatched to the respective ward/icu By the staff. The dispatched reports are recorded in registers maintained for outpatients and inpatients. All emergency cases will be reported and reports will be dispatched with (1) hour. If any emergency report is required its given within 15 min.

 TOTAL QUALITY MANAGEMENT Quality is never ending cycle of continuous improvement. Quality is not a static goal but a progressively improving state, and interventional radiology is a rapidly moving, technology-driven subspecialty in which high-quality patient care should be the norm. The health care which is delivered after must be better than the health care which is delivered today. In order to attain such essential goals, radiology department must initiate specialty wise continuous quality improvement Quality Assurance A quality assurance program in diagnostic radiology as defined by the WHO is an organized effort by the staff operating a facility to ensure that the diagnostic images produced are of sufficiently high quality so that they consistently provide adequate diagnostic information at the lowest possible cost and with the least possible exposure of the patient to radiation Registrants and licensees shall establish a comprehensive Quality Assurance program for medical exposures with the participation of appropriate qualified experts in radiation physics taking into account the principles established by the WHO The components of the Quality Assurance for Radiology & Imaging 1. A list of the individuals responsible for monitoring and maintenance techniques. 1. 2. 3. 4. 2. Policy statement Organization and responsibilities Quality Assurance (and Radiation Protection) Committee Radiation Protection Officer (these duties could be assumed by the medical physics expert, the radiologist or the radiographer) A list of the parameters to be monitored and the frequency of monitoring. Medical Practitioner (Radiologist, other Physicians)

 Qualified Expert in Diagnostic radiology Physics (Medical Physicist, Hospital Physicist) Justification and optimization of radiological procedures

3.

A description of the standards, criteria of quality, or limits of acceptability, which have been

established for each of the parameters monitored. Patient dosimetry and image quality evaluation Reject analysis Quality control procedures Acceptance test and commissioning Constancy tests Status tests Verification of RP and QC equipment and material Follow up of the corrective actions proposed Staffing levels and responsibilities

4.

A brief description of the procedures to be used for monitoring each parameter.

The acceptance test of the equipment after installation should be performed by the supplier in presence of the local medical physicist to confirm that the equipment actually performs at the level described in the technical specifications agreed upon by the manufacturer and the purchaser Commissioning is the process of acquiring all the data from equipment that is required to make it clinically useable in a specific department. This commissioning test will give the baseline values for the QC procedures

5.

A description of procedures to be followed when difficulties are detected to call these

difficulties to the attention of those responsible for correcting them.

6.

A list of the publications in which detailed instructions for monitoring and maintenance

procedures can be found. Copies of these publications should also be readily available to the entire staff, but they should be separate from the manual.

7.

A list of the records (including sample forms) that should be kept. The facility staff should

also determine and note in the manual the length of time each type of record should be kept before discarding.

8.

A copy of each set of purchase specifications developed for new equipment and the results

of the acceptance testing for that equipment. Patient dosimetry and image quality evaluation Education and training

9.

A list of who to call for answers to quality control questions. QA programs for medical exposures shall include: Measurements of the physical parameters of the radiation generators and imaging devices at the time of commissioning and periodically thereafter Verification of the appropriate physical and clinical factors used in patient diagnosis (or treatment). Measurements of the physical parameters of the radiation generators and imaging devices at the time of commissioning and periodically thereafter Verification of the appropriate physical and clinical factors used in patient diagnosis (or treatment) Written records of relevant procedures and results the assignment of responsibility for quality assurance actions the establishment of standards of quality for equipment in the facility The provision of adequate training The selection of the appropriate equipment for each examination

 Verification of the appropriate calibration and conditions of operation of dosimetry and monitoring equipment Regular and independent quality audit reviews of the QA program QA programs are designed to ensure that the radiology equipment can yield the desired information. They include: Quality control techniques used to test the components of the radiological system and verify that the equipment is operating satisfactorily Administrative procedures or management actions designed to verify that: The quality control techniques are performed properly and according to a planned timetable, The results of these techniques are evaluated promptly and accurately, The necessary corrective measures are taken in response to these results.

Radiation Safety - Regulatory Requirements No person other than those specifically concerned with a particular X-Ray examination shall stay in the X-Ray / CT gantry room during radiological examinations. The room shall be kept closed during the radiation exposure. Holding of children or infirm patients for X-Ray examination shall be done only by an adult relative or escort of the patient and not by a staff member. Such a person shall be provided with protective aprons. No pregnant women shall hold the patient during X-Ray examination. Immobilization devices shall be used to prevent movement of children during exposure. In no case shall the film or X-Ray tube be held by hand. Notice in local language shall be displayed in the X-Ray department at a conspicuous place asking every female patient to inform the radiographer or radiologist whether she is pregnant. Examination of women know to be pregnant shall be given special consideration, such as avoiding fetus dose by using protective devices. Gonad shield shall be employed to shield the reproductive organs of the patient unless it would interfere with the information desired. Eye shield shall be provided to protect eyes of the patient undergoing such special examinations as carotid angiography. Thyroid shield shall be used where necessary.

A Mobile X-Ray equipment shall be used with appropriate safety measures to distance from occupied areas and temporary shields shall be employed for the purpose. . All radiation workers shall use appropriate personnel monitoring devices. Do not leave personnel monitoring badges in side the drawer of the table in the X-Ray room or do not leave the apron with badge inside the X-Ray room after the working hours. To ensure minimum possible dose to the patient, the field size shall be restricted to the minimum that is consistent with the diagnostic requirement. Particular attention should be paid to restricting field size in pediatrics radiology. Gonads, unless required, should not be exposed to primary beam.

Radiation safety:

Procedure: The department has taken to the radiation hazards to the staff and patients. A) X-Ray room design: 1) The room housing of the x-ray is designed under the guidelines of the bhabha atomic research centre, which is the local governing body for radiation protection and monitoring. 2) There is incorporation of lead within the walls and the doors to prevent radiation leakage 3) Room size is big enough to house the machine 4) There is warning light outside the room to indicate that the procedure is on 5) The patient waiting area is away from the x-ray room

B) Equipment: The equipment is checked regularly to look for any mal functioning, to prevent radiation leakage (Bio-medical engineering SOP)

C) Patients

1) The x-ray will be taken using proper collimation when applicable to reduce radiation dose to the patient 2) Gonadal shields are used 3) In case of adult female patients, proper history will be obtained to rule out the possibility of a pregnancy 4) No one is allowed in the x-ray room accept for the patient to be examined 5) In case of a need to hold the patient, the attendant will protection wear a lead apron for

D) Radiology Staff 1) Lead aprons are provided to the radiology technician .These will be worn for any procedures involving the us of fluoroscopy 2) During radiography, a lead shield of glass is provided next to the control panel. The technician stands behind this shield while performing the x-ray.

E) TLD Badges 1) All doctors and staff exposed to radiation will wear the tld badge provided to them, compulsorily 2) These are radiation monitoring badges provided by for personal radiation dose monitoring

3) These are worn on the apron near the chest, at all times on duty. The badges are changed every 3 months. The used badges are sent to bhabha atomic research centre for readings and new ones are provided for the same 4) The readings of all personnel are maintained in a file by the head of the department of radiology 5)In case of an abnormally high reading the matter is discussed with the personnel and if required further steps to prevent radiation is taken -Training of all staff regarding radiation protection is done -While performing portable x-rays, the technician will wear a lead apron F) Pregnant Staff The female will be move doubt of the work involving radiation. She will work in sonography departmental G) Policy 1) For each employee joining the radiology department of the personnel monitoring form supplied by BARC is to be filled 2) The TLD badge is being issued to each employee working in radiology department who are exposed to radiations 3) Each member of the staff is responsible for wearing the TLD batch all the time when at work .They should not be taken home, as there is record of occupational exposure 4) TLD badge are maintained at interval of 3 months. The badges are sent to BARC for measuring radiation dose upon receipt of new badges 5) The readings of all personnel are maintained in a file by head of department 6) In case of an abnormally high reading, the matter is discussed with the personnel and if request further steps to prevent radiation are taken. The concerned technician will be granted leave for 15-30 days or will be given work not involving radiation till 15-30 days

Precautions to be taken
1. Always use the TLD sachet inside the holder. The holder incorporates filters which allow an assessment of radiation quality. 2. Do not damage the badge 3. Do not store TLD badge near radiation sources when not being worn 4. If it is suspected that a person has received a significant radiation dose, return the TLD badge for assessment immediately

5. The radiation worker receiving more than the permitted dose is informed and necessary measures are to be taken 6. Always wear the TLD badge under a lead apron as the badges used to measure radiation exposure to the body. It should not be worn outside of the protective clothing

Patient information:
Dear patients, for you to serve you better, request your attention 1) You are requested to not to have food after 10 pm from previous night of the test which is to be conducted the next day and please come fasting (please do not eat) in procedures like renal, Doppler, barium and ivp

2) Please do not wear dresses with heavy embroidery work at time of x-ray

3) Please communicate your true last mensuration period or inform the technician or nurse in case of pregnancy inclination

4) You are requested to not to take food after 10 pm from previous night and come fasting (please do not eat) for the examination regarding liver and gall bladder

5) For contrast study in CT scan, you are requested to come fasting

6) In case of kidney, uterus or pregnancy sonography, the urinary bladder is requested to be adequately full. Please take 3-4 glasses of water at least four hours before examination

7) You are requested to bring the receipt of the paid amount when you come to collect reports

8) If it is not an emergency, a prior appointment is necessary for all USG, Doppler, x-ray procedures and ct scan

9) You are requested to provide the medical history or any information relevant to your medical history. In case of any allergy or reaction towards any medicine, you are requested to inform the nurse or technician in advance

10) Any query or information regarding tests related to radiology, please feel free to contact the radiology reception

Scope of Services
Process Stations/ counter/ area Process

General Radiology (Conventional Digital) and X-rays are a form of radiation, like light or radio waves that can be focused into a beam. Once it is carefully aimed at the part of the body being examined, an X-ray machine produces a small burst of radiation that passes through the body, recording an image on

photographic film or a special image recording cassette.

Mobile unit used to X-ray bed ridden patients and sometimes used Mobile radiography to X-ray during operative procedures in Operating Room.

Color Ultra sound study which reveals signal of vascular structures Doppler

Ultrasound, or Sonography, uses high frequency sound waves to see inside the body. As the sound waves pass through the body, echoes Ultrasound are produced, and bounce back to the transducer. These echoes can help doctors determine the location of a structure or abnormality, as well as information about its makeup. Ultrasound is a painless way to examine internal organs.

M.R.I.

(Magnetic Out sourced (Samved Hospital)

Resonance Imaging

Pet Scan

Out sourced (Samved Hospital)

NUCLEAR MEDICINE Out sourced (Samved Hospital)

 Chart illustrates a process for engaging radiologists in quality and safety programs

This chart is suggestion from my side for further improvement of quality in radiology departments