Nmhaacqsp7 Quality Assurance Programme For Imaging

NARAYAN MEMORIAL HOSPITAL Document No.
(A UNIT OF NARAYAN HEALTH SERVICES PVT. LTD.) NMH/AAC/QSP/7
QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 1 of 9
QUALITY ASSURANCE PROGRAMME FOR IMAGING
NARAYAN MEMORIAL HOSPITAL

(A UNIT OF NARAYAN HEALTH SERVICES PVT. LTD.)
Behala Manton, 85, (Mail – 601), Diamond Harbour Road, Kolkata- 700034, West Bengal
Issue No: 01 Version No: 1

QUALITY SYSTEM PROCEDURE
Issue Date: 15.11.2023 Revision Date: NA
DOCUMENT SUMMARY
Document Title Quality assurance programme for imaging
Document No. NMH/AAC/QSP/7
Current Version No. 1
Implementation Date 15.11.2023
Department Imaging
Document Storage Location Imaging & Quality Assurance
DOCUMENT DISTRIBUTION
Sl No. Name Designation Department
1 Dr. Sneha Priya Chowdhury Medical Superintendent Medical Administration
DOCUMENT REVISION HISTORY

Sl No. Version No. Date of Amendment Page No. Clause No. Amendment Details
NA NA NA NA NA NA
DOCUMENT AUTHOR(S)
Version No. Name Designation Signature Date
Dr. Sneha Priya
1 Medical Superintendent 15.11.2023
Chowdhury
DOCUMENT REVIEWER(S)
Dr. Sneha Priya
Chowdhury
DOCUMENT APPROVER(S)
Dr. Sneha Priya
Chowdhury
DOCUMENT ISSUE
Issue No. Name Designation Signature Date
1 Ms. Subhasree Ghosh Executive- Quality Assurance 15.11.2023

TABLE OF CONTENT
Sl. No. TITLE Page No.

1 QUALITY ASSURANCE PROGRAMME FOR IMAGING SERVICES 4
2 LIST OF DOCUMENTS 8
3 REFERENCES 9
4 ABBREVIATION 9

1. QUALITY ASSURANCE PROGRAMME FOR IMAGING SERVICES
1. Purpose
 Quality assurance can be defined as a cyclical process involving assessment of imaging

services and leading to improvement .It is designed to objectively and systematically monitor
and evaluate the services offered to patients.
 This has been prepared to assess service quality and enable service provider to provide better
care.
2. Scope
 The Quality Assurance Programme which includes quality control tests helps to ensure high
quality diagnostic images are consistently produced while minimizing radiation exposure.
 This program will help to recognize when the parameters are out of limits resulting in poor
quality images and to take appropriate corrective action wherever needed.
 Implementation of QA program is accomplished through the work of several people. The QA
program is the unifying element bringing together information about personnel, process, and
tests and results, and everybody should participate in QA activities.
3. Quality Assurance Program contains following elements
a. Quality Control Personnel

b. Quality Control Measures
c. Policies and Procedures
d. Radiation Safety Measures
e. Record keeping
f. QA Annual review
a. Quality Control Personnel
 The Departmental In charge is responsible for carrying out the Quality Assurance
Programme, to assess its effectiveness and review the programme annually. The review is
consisted all tests, test results and corrective action taken and any recommendations offered
by staff.
 All the staff is adequately qualified for performing procedures in the imaging department.

 All the consultants regularly update in latest national and international advancement through
CME and on a regular basis.
 All the consultants, technicians take part in quality assurance program.
b. Quality Control Measures
 A list of equipments
 A list of QC tests performed and frequency.
 Critical alerts intimation and maintaining proper record.
 Validation of imaging reports with another hospital/diagnostic center.
 Procedure for surveillance of imaging results.
i. List of equipments
Refer to Asset list (Equipment list) maintained in biomedical engineering department.

Periodic calibration and maintenance of all equipments are performed.
ii. List of QC Tests performed and Activity plan:

 Machine warm up regularly.
 Preventive maintenance service done by the manufacturer as per the defined frequency and
records are kept with biomedical Engineering department. Image systems are calibrated
with Phantom set; all values are monitors with the help of service s/w. These processes are
done in every preventive maintenance services. Corrective & Preventive actions are taken
documented if necessary.
 UPS clean up - As per the defined frequency.
 Fluoroscopy test of all lead aprons every once in a year.
 Monitoring of TLD batch every at 3 months interval.
 Leakage rate test - Once in a year
iii. Critical alerts intimation and maintaining proper record
The critical results of imaging services are identified by the Head Radiologist. Critical results
are intimated to the person concern within 15 mints of the test result and all the details are
maintained in the critical alert reporting register.

iv. Validation of imaging reports with another hospital/diagnostic center
Validation of imaging reports is done on quarterly basis.
v. Procedure for surveillance of imaging results
Surveillance of imaging test report is done on quarterly basis and validated accordingly to
check the test method. The sample size is decided by the radiologist depending upon the
criticality of the report.
c. Policies and Procedures:
Following are the policies of NMH:
i. Policy for holding the patient in the room during radiation exposure:
No person will be employed to hold the patient routinely during radiographic procedure.
The person holding the patient should not be less than 19 years of age and should wear lead
apron.
ii. Policy for presence of individual in the room:

 No person will be permitted or arrange for the intentional exposure of a human being
except
 For the purpose of medical diagnosis /treatment.
 Only individuals required for the medical procedure will be permitted in the
Radiographic during exposure.
 Individuals present in the room will wear lead aprons.
 Individuals whose hands may be in the primary beam will be required to wear
Protective gloves.
iii. Pregnant Patient and Pregnant Worker Policy:
A. Patient
 Special consideration is given to the protection of the embryo or fetus of women
known to be, or potentially pregnant.
 All patients are asked questions as per the patient preparation checklist to ascertain the
likelihood of pregnancy in case of female patient.

 If the patient is found to be pregnant or likely to be pregnant, the physician or

radiologist should be consulted to decide whether this radiation dose to the patient is
justified or not.
B. Personnel
 An employee should contact the departmental in charge when she knows or suspects
that she is pregnant.
 The employee shall be transferred to other department when pregnancy is confirmed.
iv. Policy and responsibility for Personal Radiation Monitoring
 Each personal monitoring device is assigned to and worn by only one individual.
 The TLD badge monitoring records are maintained for each individual badges.
 The TLD badges are sent quarterly for testing to BARC.
 The Intentional exposure of personal monitoring device to deceptively indicate a dose
delivered to an individual is prohibited.
v. Proper Operating Procedures for Radiographic Units
 Limit the x-ray primary beam to the smallest area possible consistent with the
objectives of the clinical examination.
 Align the x-ray beam properly with the patient and the image receptor.
 Remain behind a protective barrier (i.e. a leaded glass wall or a leaded door) during
the entire radiographic exposure and observe the patient during the exposure from this
protected area.
 Do not use expire radiographic films and protect unprocessed film adequately.
 Provide protective garments (lead aprons and shielding) for all individuals whose
presence is necessary during the radiographic exposure.
d. Radiation Safety Measures:
A. Personnel Shielding: Personnel who remain in the room during examinations must be
protected by proper shielding-
 All personnel in the room during an exposure should wear leaded aprons.

 Personnel who are likely to be exposed to high levels of scattered radiation to the thyroid
during any procedure should wear thyroid shields.
 Leaded glasses can greatly reduce the exposure of eye lenses to scattered radiation in
fluoroscopy, especially for physicians.
 Any person who must have his or her hand near the primary beam (as in cases in which
no other means is available to immobilize a patient) should wear leaded gloves to reduce
exposure of the extremities.
B. Structural Shielding: Each radiographic room has been designed with sufficient shielding
in the walls as per statutory requirement to provide protection from radiation .If any personnel
notice structural changes such as holes drilled into walls, doors departmental In-charge should
be notified as soon as possible for taking appropriate action.
e. Record Keeping
All the records should be maintained and updated properly by authorized personnel
f. QA Annual review
The QA programme is reviewed and updated when any changes occur in the department.
Additionally the QA programme will be reviewed annually.
2. LIST OF DOCUMENTS
FORMS
SL NO. FORM NAME FORM ID
NA NA NA
REGISTERS
SL NO. REGISTER NAME REGISTER ID
NA NA NA
FILES
SL NO. FILE NAME FILE ID
NA NA NA

3. REFERENCES
National Accreditation Board For Hospitals & Healthcare Providers (5th edition)
4. ABBREVIATION
1. QA- Quality Assurance

2. CME- Continuing Medical Education
3. QC- Quality Control
4. TLD- Thermoluminescent dosimeter
5. NMH- Narayan Memorial Hospital


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NARAYAN MEMORIAL HOSPITAL Document No.

(A UNIT OF NARAYAN HEALTH SERVICES PVT. LTD.) NMH/AAC/QSP/7

QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 1 of 9

QUALITY ASSURANCE PROGRAMME FOR IMAGING

NARAYAN MEMORIAL HOSPITAL

Issue No: 01 Version No: 1

QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 2 of 9

DOCUMENT REVISION HISTORY

Issue No: 01 Version No: 1

QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 3 of 9

Sl. No. TITLE Page No.

Issue No: 01 Version No: 1

QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 4 of 9

1. QUALITY ASSURANCE PROGRAMME FOR IMAGING SERVICES

 Quality assurance can be defined as a cyclical process involving assessment of imaging

3. Quality Assurance Program contains following elements

a. Quality Control Personnel

a. Quality Control Personnel

Issue No: 01 Version No: 1

QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 5 of 9

b. Quality Control Measures

Refer to Asset list (Equipment list) maintained in biomedical engineering department.

ii. List of QC Tests performed and Activity plan:

iii. Critical alerts intimation and maintaining proper record

Issue No: 01 Version No: 1

QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 6 of 9

iv. Validation of imaging reports with another hospital/diagnostic center

Validation of imaging reports is done on quarterly basis.

v. Procedure for surveillance of imaging results

c. Policies and Procedures:

Following are the policies of NMH:

ii. Policy for presence of individual in the room:

iii. Pregnant Patient and Pregnant Worker Policy:

Issue No: 01 Version No: 1

QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 7 of 9

 If the patient is found to be pregnant or likely to be pregnant, the physician or

iv. Policy and responsibility for Personal Radiation Monitoring

v. Proper Operating Procedures for Radiographic Units

d. Radiation Safety Measures:

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QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 8 of 9

Issue No: 01 Version No: 1

QUALITY ASSURANCE PROGRAMME FOR IMAGING Page 9 of 9

1. QA- Quality Assurance

Issue No: 01 Version No: 1

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