Questionnaire for Accreditation
Diagnostic Imaging - Radiography
Revision: May 2009
Electronic submission of questionnaires & manuals is required via e-mail or CD.
Category 1:
Category 2:
Category 3:
Requirement
Recommendation
For Information
Revision Date:
May 2009
April 2008
July 2005
May 2005
May 2003
February 2003
September 2002
May 2002
September 2001
June 2001
March 2001
June 1998
Approval Date:
February 1996
Originating Committee:
Advisory Committee on Radiology
and Diagnostic Imaging
CPSA: May 2009
Replaces: April 2008
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
i
Diagnostic Imaging – Radiography
Table of Contents
Interpreting Radiologist............................................................................................................ 1
DR.01 Interpreting Radiologist ................................................................................................ 1
Facility Operation ..................................................................................................................... 2
DR.02 Facility Name ............................................................................................................. 2
DR.03 Personnel - Medical .................................................................................................... 2
DR.04 Personnel - Technical .................................................................................................. 2
Medical Records ...................................................................................................................... 3
DR.05 Images ...................................................................................................................... 3
DR.06 Digital Image Review/Storage (PACS) ............................................................................. 3
Quality Assurance .................................................................................................................... 4
DR.07 Quality Control ................................................................................................................................... 4
DR.08 Diagnostic Imaging Equipment ...................................................................................... 4
DR.09 Film/Screens ............................................................................................................. 4
DR.10 Processing Equipment ................................................................................................. 4
DR.11 Accessories ............................................................................................................... 5
Policy and Procedure ............................................................................................................... 6
DR.12 Fluoroscopy .............................................................................................................. 6
DR.13 Injectable Contrast Agents ............................................................................................ 6
Equipment ............................................................................................................................... 7
DR.14 Radiography .............................................................................................................. 7
DR.15 Image Recording ......................................................................................................... 7
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
1
Replaces: April 2008
Diagnostic Imaging – Radiography
Interpreting Radiologist
The following is to be completed by the interpreting radiologist
DR.01
Interpreting Radiologist
DR.01.001
Are unreported images readily available for timely reporting?
DR.01.002
Are reports/images from previous examinations readily
Category
1 Yes
No NA
available for review?
1 Yes
No NA
DR.01.003
Is there an internal process to monitor report turnaround time?
2 Yes
No NA
DR.01.004
Is there an internal process to monitor report content?
2 Yes
No NA
DR.01.005
Is there a process to monitor and provide feedback on the
technical quality of examinations?
1 Yes
No NA
DR.01.006
Are the recommended improvements made?
1 Yes
No NA
DR.01.007
Does the interpreting radiologist provide feedback to the
1 Yes
No NA
1 Yes
No NA
DR.01.009
Is the imaging physician involved in the selection of equipment? 3 Yes
No NA
DR.01.010
Name of interpreting radiologist:
referring physicians regarding utilization of studies, when
appropriate?
DR.01.008
Do you require that sufficient histories be provided by the
referring physicians?
DR.01.011
Signature:
DR.01.012
Date:
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
2
Replaces: April 2008
Diagnostic Imaging – Radiography
Facility Operation
DR.02
Facility Name
DR.02.001
Facility Name
DR.03
Personnel - Medical
Category
(In addition to the information required in the General Questionnaire)
DR.03.001
Consultant Radiologist/Group (If applicable - refer to the definition below)
There shall be a Consultant physician approved for modalities not within the scope of
practice of the Medical Director, as defined above. The Consultant shall be licensed to
practice medicine in the province of Alberta, and be a specialist in those modalities for
which he/she provides consultative services.
DR.03.002
Name of Partnership/Association/Individual:
DR.03.003
Name of Physician assigned to the facility:
DR.03.004
Address for Correspondence:
DR.03.005
Telephone Number:
DR.03.006
Fax Number:
DR.03.007
Email:
Non-Hospital Facilities proceed to section 'Personnel - Technical'
DR.03.008
Does the radiologist have privileges with the region/facility?
DR.04
Personnel - Technical
1 Yes
No
Category
(In addition to the information required in the General Questionnaire)
DR.04.001
Are all technologists currently registered with their professional
association (ACMDTT)?
DR.04.002
No NA
1
Yes
No NA
1
Yes
No NA
Are any x-ray examinations performed by staff members who are not
currently registered with their professional association (as above)?
DR.04.004
Yes
Are all combined technician/technologists currently certified in
radiography with their professional association (ACCLXT)?
DR.04.003
1
If yes, please explain:
1
NA
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
3
Replaces: April 2008
Diagnostic Imaging – Radiography
Medical Records
DR.05
Images
Category
(In addition to the information required in the General Questionnaire)
DR.05.001
Are x-ray images identified with the following:
DR.05.002
Patient name; last name, first name?
1 Yes
No
NA
DR.05.003
Second patient identifier and/or date of birth?
1 Yes
No
NA
DR.05.004
Facility name/site?
1 Yes
No
NA
DR.05.005
Date examination performed?
1 Yes
No
NA
DR.05.006
Time of examination?
2 Yes
No
NA
DR.05.007
Other?
3 Yes
No
NA
DR.05.008
Please state:
DR.06
Digital Image Review/Storage (PACS)
DR.06.001
Are images reviewed on workstations for permanent reporting/
storage?
DR.06.002
Category
3
Yes
No
NA
3
Yes
No
NA
Is the permanent method of image storage a digital archive?
If yes, the Picture Archiving and Communications System (PACS)
Questionnaire must be completed.
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
4
Replaces: April 2008
Diagnostic Imaging – Radiography
Quality Assurance
DR.07
Quality Control
DR.07.001
Who in the imaging department is responsible for monitoring quality
Category
control and assessing relative changes in system performance?
DR.07.002
Name:
DR.07.003
Title:
DR.07.004
3
Does your policy/procedure manual have a section on Quality Control
for:
DR.07.005
Radiographic Equipment?
1
Yes
No
NA
DR.07.006
Processing Equipment?
1
Yes
No
NA
DR.07.007
Film Screens?
1
Yes
No
NA
DR.07.008
Accessories?
1
Yes
No
NA
for light leaks at least annually?
1
Yes
No
NA
DR.07.010
Does your facility keep an image repeat analysis report?
1
Yes
No
NA
DR.07.011
Please enclose the most recent image repeat analysis report?
1
DR.07.012
What is the repeat image rate in your facility?
3
DR.07.013
Is a review of the repeat image analysis done with your staff?
1
Yes
No
NA
DR.07.014
Are all quality control results reviewed by the supervisor?
1
Yes
No
NA
DR.07.015
Are all corrective actions recorded?
1
Yes
No
NA
DR.07.016
Is there an annual review of the quality control by the consultant
radiologist?
1
Yes
No
NA
DR.07.017
Are all quality control results retained for at least two years?
1
Yes
No
NA
DR.08
Diagnostic Imaging Equipment
DR.08.001
Is quality control performed on diagnostic imaging equipment?
1 Yes
No
NA
DR.08.002
Does it include:
DR.07.009
Are all areas where unexposed images are handled or stored checked
Category
DR.08.003
KVP accuracy, linearity, reproducibility?
1 Yes
No
NA
DR.08.004
MAs accuracy, linearity, reproducibility?
1 Yes
No
NA
DR.08.005
Timer accuracy, linearity,reproducibility?
1 Yes
No
NA
DR.08.006
X-ray exposure output?
1 Yes
No
NA
DR.08.007
Beam quality (HVL)?
1 Yes
No
NA
DR.08.008
Focal spot size assessment?
1 Yes
No
NA
DR.08.009
Radiation/light field edge congruence?
1 Yes
No
NA
DR.08.010
Radiation/light field centering?
1 Yes
No
NA
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
5
Replaces: April 2008
DR.08.011
Diagnostic Imaging – Radiography
Maximum entrance dose for fluoroscopy?
1 Yes
No
NA
DR.08.012
Is a record kept of routine maintenance checks and repairs?
1 Yes
No
NA
DR.08.013
Is unsafe equipment clearly labelled?
1 Yes
No
NA
DR.09
Film/Screens
DR.09.001
Are film/screens cleaned and contact tests performed at least
Category
annually?
1
Yes
No
NA
DR.09.002
Is a record kept?
1
Yes
No
NA
DR.10
Processing Equipment
DR.10.001
Is quality control performed on processing equipment?
1
Yes
No
NA
DR.10.002
Does it include:
2
Yes
No
NA
DR.10.003
Daily sensitometry?
DR.10.004
If no, how often?
Category
1
DR.10.005
Daily cleaning of crossover rollers?
1
Yes
No
NA
DR.10.006
Monthly cleaning of crossover racks?
1
Yes
No
NA
DR.10.007
Regular cleaning of processor tanks?
1
Yes
No
NA
DR.10.008
Monthly checking of replenishment rates?
1
Yes
No
NA
DR.10.009
Monthly checking of temperature?
1
Yes
No
NA
DR.10.010
Monthly checking of recirculation?
1
Yes
No
NA
DR.10.011
Are images free from processor artifacts?
1
Yes
No
NA
DR.10.012
Is a record kept of routine maintenance checks and repairs?
1
Yes
No
NA
DR.11
Accessories
DR.11.001
Are lead aprons, gloves and fluoroscopy drapes checked at least
DR.11.002
Category
annually?
1
Yes
No
NA
Are image illuminators checked and cleaned at least annually?
1
Yes
No
NA
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
6
Replaces: April 2008
Diagnostic Imaging – Radiography
Policy and Procedure
DR.12
Fluoroscopy
DR.12.001
Is fluoroscopy performed at your facility?
3 Yes
No
NA
DR.12.002
Is there one person that reviews fluorotimes?
1 Yes
No
NA
DR.12.003
Is feedback regarding excessive times provided to ensure operators
minimize the time?
1 Yes
No
NA
DR.12.004
Is fluorotime documented on patient records?
1 Yes
No
NA
DR.12.005
Is fluoroscopy always performed under the direction and supervision
1 Yes
No
NA
No
NA
No
NA
3 Yes
No
NA
contrast?
1 Yes
No
NA
DR.13.003
Do you have a policy for injectable contrast agents?
1 Yes
No
NA
DR.13.004
Do you have a procedure for injectable contrast agents?
1 Yes
No
NA
DR.13.005
Is the amount of injected contrast agent documented on the patient's
1 Yes
No
NA
1 Yes
No
NA
Category
of a radiologist?
DR.12.006
DR.12.007
DR.12.008
If no, who else performs fluoroscopy and for what procedures. 3
Is an RT always in the facility when fluoroscopy is done?
1 Yes
If no, please explain:
1
Non-Hospital Facilities proceed to subsection "Injectable Contrast Agents"
DR.12.009
Is fluoroscopy performed outside of the x-ray department?
3 Yes
DR.12.010
If yes, where?
3
DR.12.011
Who is responsible?
3
DR.13
Injectable Contrast Agents
DR.13.001
Are examinations performed with the use of injectable contrast
Category
agents?
If no, proceed to section Equipment
DR.13.002
Are patients asked if they have any known allergies prior to injecting
medical record?
DR.13.006
Does your policy/procedure manual outline in detail the circumstances
under which injectable contrast agents are used?
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
7
Replaces: April 2008
DR.13.007
Diagnostic Imaging – Radiography
Who administers injectable contrast agents:
DR.13.008
Radiologist?
3 Yes
No
NA
DR.13.009
Resident Radiologist?
3 Yes
No
NA
DR.13.010
Non-Radiologist Physician?
3 Yes
No
NA
DR.13.011
Registered Nurse?
3 Yes
No
NA
DR.13.012
Technologist?
3 Yes
No
NA
No
NA
DR.13.013
DR.13.014
DR.13.015
Is a physician immediately available during an examination in which an
Intravascular contrast agent has been injected?
1 Yes
Are ionic or high osmolality agents used?
3
If yes, state when:
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
8
Replaces: April 2008
Diagnostic Imaging – Radiography
Equipment
DR.14
Radiography
DR.14.001
Indicate the numbers of pieces of equipment in use at this facility:
DR.14.002
General Radiographic Unit
DR.14.003
Tomographic Unit
DR.14.004
Dental Unit
DR.14.005
Mobile Unit
DR.14.006
Conventional Fluoroscopic Unit
DR.14.007
Remote Control Fluoroscopic Unit
DR.14.008
Conventional Digital Fluoroscopic Unit
DR.14.009
Remote Digital Fluoroscopic Unit
DR.14.010
Mobile C-Arm Fluoroscopic Unit
DR.14.011
Special Procedures Unit
DR.15
Image Recording
DR.15.001
Are images recorded on film?
DR.15.002
If yes, state the method/s used for image processing:
Category
3
Yes
No
NA
DR.15.003
Daylight?
3
Yes
No
NA
DR.15.004
Darkroom?
3
Yes
No
NA
DR.15.005
Type: Automatic?
3
Yes
No
NA
DR.15.006
If manual, please explain:
3
DR.15.007
State the total number of processor units:
DR.15.008
Within the Diagnostic Imaging department:
3
DR.15.009
Outside the Diagnostic Imaging department:
3
DR.15.010
State locations:
DR.15.011
Are any of the following used:
3
DR.15.012
100 mm Camera?
3 Yes No NA
DR.15.013
Laser Camera?
3 Yes No NA
DR.15.014
Cine Camera?
3 Yes No NA
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
9
Replaces: April 2008
Diagnostic Imaging – Radiography
DR.15.015
VCR?
3
Yes
No
NA
DR.15.016
Magnetic Tape?
3
Yes
No
NA
DR.15.017
Laser Disc?
3
Yes
No
NA
DR.15.018
Paper Printer?
3
Yes
No
NA
DR.15.019
Video Imager?
3
Yes
No
NA
DR.15.020
Other?
3
Yes
No
NA
DR.15.021
Name: