Questionnaire for Accreditation
Diagnostic Imaging - Ultrasound
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
March 2006
July 2005
May 2003
February 2003
September 2002
May 2002
September 2001
June 2001
April 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 – Ultrasound
Table of Contents
Interpreting Radiologist/Sonologist ...................................................................................... 1
DU.01 Interpreting Radiologist/Sonologist ................................................................................. 1
Facility Operation ..................................................................................................................... 2
DU.02 Facility Name ............................................................................................................ .2
DU.03 Personnel – Medical ................................................................................................... .2
DU.04 Personnel - Technical .................................................................................................. 3
DU.05 General Information .................................................................................................... 3
Medical Records ..................................................................................................................... 5
DU.06 Requisitions/In-House Worksheet .................................................................................. 5
DU.07 Images ..................................................................................................................... 5
DU.08 Digital Image Review/Storage (PACS) ............................................................................. 5
Quality Assurance ................................................................................................................... 6
DU.09 Quality Control ............................................................................................................ 6
DU.10 Equipment and Accessories .......................................................................................... 6
DU.11 Processing Equipment .................................................................................................. 6
Policy and Procedure .............................................................................................................. 8
DU.12 Injectable Contrast Agents ............................................................................................ 8
Equipment ................................................................................................................................ 9
DU.13 Ultrasound ................................................................................................................ 9
DU.14 Image Recording ........................................................................................................ 9
Remotely Supervised Ultrasound ......................................................................................... 10
DU.15 General .................................................................................................................. 10
DU.16 Quality Assurance ..................................................................................................... 10
Mobile Service Only ............................................................................................................... 11
DU.17 Mobile Service Personnel – Medical .............................................................................. 11
DU.18 Mobile Service Personnel – Technical ........................................................................... 11
DU.19 Mobile Service Medical Records – Retention of Images ..................................................... 11
DU.20 Mobile Service Medical Records – Retention of Reports ................................................... 12
DU.21 Mobile Service Quality Assurance ................................................................................ 12
DU.22 Mobile Service Policy and Procedure ............................................................................. 12
DU.23 Mobile Service Safety................................................................................................. 12
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
1
Replaces: April 2008
Diagnostic Imaging – Ultrasound
Interpreting Radiologist/Sonologist
The following is to be completed by the interpreting radiologist
DU.01
Interpreting Radiologist/Sonologist
DU.01.001
Are unreported images readily available for timely reporting?
DU.01.002
Are reports/images from previous examinations readily available for
Category
1
Yes
No NA
review?
1
Yes
No NA
DU.01.003
Is there an internal process to monitor report turnaround time?
2
Yes
No NA
DU.01.004
Is there an internal process to monitor report content?
2
Yes
No NA
DU.01.005
Is there a process to monitor and provide feedback on the technical
quality of examinations?
1
Yes
No NA
DU.01.006
Are the recommended improvements made?
1
Yes
No NA
DU.01.007
Does the interpreting radiologist provide feedback to the referring
1
Yes
No NA
physicians?
1
Yes
No NA
DU.01.009
Is the imaging physician involved in the selection of equipment?
3
Yes
No NA
DU.01.010
Name of interpreting radiologist:
physicians regarding utilization of studies, when appropriate?
DU.01.008
Do you require that sufficient histories be provided by the referring
DU.01.011
Signature:
DU.01.012
Date:
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
2
Replaces: April 2008
Diagnostic Imaging – Ultrasound
Facility Operation
DU.02
Facility Name
DU.02.001
Facility Name
DU.03
Personnel - Medical
Category
(In addition to the information required in the General Questionnaire)
DU.03.001
Consultant Radiologist/Sonologist Group (refer to 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.
DU.03.002
Name of Partnership/Association/Individual:
DU.03.003
Name of Physician assigned to the facility:
DU.03.004
Address for Correspondence:
DU.03.005
Telephone Number:
DU.03.006
Fax Number:
DU.03.007
Email:
DU.03.008
Which of the following physicians perform ultrasound in your department:
DU.03.009
Radiologists?
3 Yes
No
NA
DU.03.010
Obstetricians?
3 Yes
No
NA
DU.03.011
Vascular Surgeons?
3 Yes
No
NA
DU.03.012
Urologists?
3 Yes
No
NA
DU.03.013
Ophthalmologists?
3 Yes
No
NA
DU.03.014
Cardiologists?
3 Yes
No
NA
DU.03.015
Other?
3 Yes
No
NA
No
NA
DU.03.016
DU.03.017
Please state:
Is ultrasound imaging performed outside of the imaging department by
non-radiologists?
DU.03.018
3
If yes, please state departments:
1 Yes
1
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
3
Replaces: April 2008
DU.03.019
Diagnostic Imaging – Ultrasound
Are all physicians who perform and/or interpret ultrasound approved
by the College?
1 Yes
DU.03.020
If yes, please list physicians:
1
DU.03.021
If no, please explain:
1
DU.03.022
Does the radiologist/sonologist have privileges with the region/facility? 1 Yes
DU.04
Personnel - Technical
No
NA
No
NA
Category
(In addition to the information required in the General Questionnaire)
DU.04.001
Site Manager/Supervisor (If different from Site Manger/Supervisor identified in General
Questionnaire.)
DU.04.002
Name:
DU.04.003
Title:
DU.04.004
Qualifications:
DU.04.005
Address for Correspondence:
DU.04.006
Telephone Number:
DU.04.007
Fax Number:
DU.04.008
Email:
DU.04.009
Are all sonographers who do ultrasound examinations currently registered
with CARDUP or ARDMS?
DU.04.010
If no, please explain:
1 Yes
1
No
NA
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
4
Replaces: April 2008
DU.04.011
Diagnostic Imaging – Ultrasound
Are any examinations performed by staff members who are not currently
registered with their professional association (as above)?
DU.04.012
1 Yes
If yes, please explain:
DU.05
General Information
DU.05.001
Are ultrasound services at your facility provided by:
DU.05.002
Permanent service with on-site installation?
Yes
No
NA
Yes
No
NA
Category
3
How many units?
3
DU.05.004
Mobile service provided on a regular basis?
3
DU.05.006
NA
1
DU.05.003
DU.05.005
No
How often?
3
Is the sonographer(s) provided by:
DU.05.007
Facility?
3
Yes
No
NA
DU.05.008
Consultant Radiologist/sonologist?
3
Yes
No
NA
patient leaving the facility?
1
Yes
No
NA
If no, please clarify:
1
Yes
No
NA
DU.05.009
DU.05.010
DU.05.011
Is a sonologist on-site and available to review each case prior to the
Does the sonologist regularly review the examinations with the
sonographer?
DU.05.012
If no, please clarify:
2
1
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
5
Replaces: April 2008
Diagnostic Imaging – Ultrasound
Medical Records
DU.06
Requisitions/In-House Worksheet
Category
(In addition to the information required in the General Questionnaire)
DU.06.001
DU.06.002
DU.07
Does the requisition/in-house worksheet include the following:
Date of LMP (obstetrical & gynecology studies only)?
Images
1 Yes
No
NA
Category
(In addition to the information required in the General Questionnaire)
DU.07.001
Are archived images identified with the following:
DU.07.002
Patient name; last name, first name?
1
Yes
No
NA
DU.07.003
Second patient identifier and/or date of birth?
1
Yes
No
NA
DU.07.004
Facility name/site?
1
Yes
No
NA
DU.07.005
Date examination performed?
1
Yes
No
NA
DU.07.006
Time of examination?
2
Yes
No
NA
DU.07.007
Other?
3
Yes
No
NA
storage?
3 Yes
No
NA
Is the permanent method of image storage a digital archive?
3 Yes
No
NA
DU.07.008
List:
DU.08
Digital Image Review/Storage (PACS)
DU.08.001
Are images reviewed on workstations for permanent reporting/
DU.08.002
DU.08.003
Category
If yes, also complete the Picture Archiving and Communications
System s (PACS) Questionnaire
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
6
Replaces: April 2008
Diagnostic Imaging – Ultrasound
Quality Assurance
DU.09
Quality Control
DU.09.001
Who in the imaging department is responsible for monitoring quality
Category
control and assessing relative changes in system performance?
DU.09.002
Name:
DU.09.003
Title:
DU.09.004
3
Does your policy/procedure manual have a section on Quality Control for:
DU.09.005
Ultrasound Equipment?
1 Yes
No
NA
DU.09.006
Processing Equipment?
1 Yes
No
NA
DU.09.007
Are all quality control results reviewed by the supervisor?
1 Yes
No
NA
DU.09.008
Are all corrective actions recorded?
1 Yes
No
NA
DU.09.009
Are all areas where unexposed film is handled or stored checked for
1 Yes
No
NA
physician?
1 Yes
No
NA
DU.09.011
Are all quality control results retained for at least two years?
1 Yes
No
NA
DU.10
Equipment and Accessories
DU.10.001
Are image illuminators checked and cleaned at least annually?
1
Yes
No
NA
DU.10.002
Is quality control performed on ultrasound equipment?
1
Yes
No
NA
DU.10.003
Do you follow manufacturer's guidelines for maintenance and quality
1
Yes
No
NA
1
Yes
No
NA
output documented on hard copy images obtained.
1
Yes
No
NA
DU.10.006
How often do you test equipment using the ultrasound phantom?
3
DU.10.007
How often is photography (grey scale) done?
3
DU.10.008
List other quality control performed:
3
light leaks at least annually?
DU.09.010
Is there an annual review of the quality control by the consultant
Category
control equipment?
DU.10.004
Is Fetal Doppler ultrasound only be performed on equipment where
the acoustic power output data can be displayed in Real Time?
DU.10.005
Regardless of the units of measurement, is the acoustical power
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
Replaces: April 2008
7
Diagnostic Imaging – Ultrasound
DU.10.009
Is a record kept of routine maintenance checks and repairs?
1
Yes
No
NA
DU.10.010
Is unsafe equipment clearly labeled?
1
Yes
No
NA
CPSA: May 2009
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8
Replaces: April 2008
Diagnostic Imaging – Ultrasound
DU.10.011
Are there appropriate sterilization protocols for endo-cavitary probes? 1
DU.11
Processing Equipment
DU.11.001
Is quality control performed on processing equipment?
DU.11.002
Does it include:
DU.11.003
DU.11.004
Daily sensitometry?
If no, how often?
Yes
No
NA
1 Yes
No
NA
2 Yes
No
NA
Category
1
DU.11.005
Daily cleaning of crossover rollers?
1 Yes
No
NA
DU.11.006
Monthly cleaning of crossover racks?
1 Yes
No
NA
DU.11.007
Regular cleaning of processor tanks?
1 Yes
No
NA
DU.11.008
Monthly checking of replenishment rates?
1 Yes
No
NA
DU.11.009
Monthly checking of temperature?
1 Yes
No
NA
DU.11.010
Monthly checking of recirculation?
1 Yes
No
NA
DU.11.011
Are images free from processor artifacts?
1 Yes
No
NA
DU.11.012
Is a record kept of routine maintenance checks and repairs?
1 Yes
No
NA
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
9
Replaces: April 2008
Diagnostic Imaging – Ultrasound
Policy and Procedure
DU.12
Injectable Contrast Agents
DU.12.001
Are examinations performed with the use of injectable contrast
Category
agents?
3 Yes
No
NA
contrast?
1 Yes
No
NA
DU.12.003
Do you have a policy for injectable contrast agents?
1 Yes
No
NA
DU.12.004
Do you have a procedure for injectable contrast agents?
1 Yes
No
NA
DU.12.005
Is the amount of injected contrast agent documented on the patient's
1 Yes
No
NA
1 Yes
No
NA
If no, proceed to section "Equipment"
DU.12.002
Are patients asked if they have any known allergies prior to injecting
medical record?
DU.12.006
Does your policy/procedure manual outline in detail the circumstances
under which injectable contrast agents are used?
DU.12.007
Who administers injectable contrast agents:
DU.12.008
Radiologist?
3 Yes
No
NA
DU.12.009
Resident Radiologist?
3 Yes
No
NA
DU.12.010
Non-Radiologist Physician?
3 Yes
No
NA
DU.12.011
Registered Nurse?
3 Yes
No
NA
DU.12.012
Technologist?
3 Yes
No
NA
1 Yes
No
NA
DU.12.013
Is a physician immediately available during an examination in which
an intravascular contrast agent has been injected?
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
10
Replaces: April 2008
Diagnostic Imaging – Ultrasound
Equipment
DU.13
Ultrasound
DU.13.001
Indicate the number of ultrasound units in use at this facility:
DU.14
Image Recording
Category
3
Category
Non-Hospital & Mobile Services proceed to question "Are images permanently recorded?"
DU.14.001
State the total number of processor units:
DU.14.002
Within the Diagnostic Imaging department:
3
DU.14.003
Outside the Diagnostic Imaging department:
3
DU.14.004
State locations:
DU.14.005
Are images permanently recorded?
DU.14.006
How are images documented:
3
1 Yes
No
NA
DU.14.007
Film?
3 Yes
No
NA
DU.14.008
Paper?
3 Yes
No
NA
DU.14.009
Laser disc?
3 Yes
No
NA
DU.14.010
Video tape?
3 Yes
No
NA
DU.14.011
Computer terminals?
3 Yes
No
NA
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
11
Replaces: April 2008
Diagnostic Imaging – Ultrasound
Remotely Supervised Ultrasound
DU.15
General
DU.15.001
Are examination instructions from the sonologist to sonographer
Category
recorded on the requisition/in-house worksheet?
DU.15.002
No
NA
1 Yes
No
NA
Does the interpreting sonologist maintain a substantial on-site
ultrasonology practice in Alberta?
DU.15.003
1 Yes
Does the facility perform remotely supervised studies on the following: 1
DU.15.004
Breasts?
1 Yes
No
NA
DU.15.005
Testicles?
1 Yes
No
NA
DU.15.006
Soft tissue masses?
1 Yes
No
NA
were reviewed at the reporting site before the patient left the facility? 1 Yes
No
NA
1 Yes
No
NA
1 Yes
No
NA
1 Yes
No
NA
2 Yes
No
NA
1 Yes
No
NA
1 Yes
No
NA
1 Yes
No
NA
2 Yes
No
NA
No
NA
DU.15.007
DU.15.008
Are records retained at the acquisition site that shows that the images
Does the system have real-time video and interactive audio capabilities
with the sonographer in the room scanning?
DU.15.009
Are static or video images transmitted for review by an ultrasonologist
before the patient leaves the facility?
DU.15.010
Does the facility have a documented process for referral to a facility
with an on-site ultrasonologist?
DU.15.011
Does each sonographer have a minimum of one year of full-time
post-certification experience?
DU.15.012
Is there some means of communication by audio and test transmission
available between the sonographer and sonologist?
DU.15.013
Do sonographers receive annual hands-on experience in a referral
centre?
DU.15.014
Does the consultant sonologist visit the facility, at a minimum of every
3 months?
DU.15.015
Do the interpretive reports state that the study was performed by
remotely supervised ultrasound?
DU.16
Quality Assurance
DU.16.001
Does the quality assurance program include capture and transmission
of a test image at least weekly?
Category
1
Yes
CPSA: May 2009
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12
Replaces: April 2008
Mobile Service Only
DU.17
Mobile Service Personnel – Medical
DU.17.001
Name of Facility/Group:
DU.17.002
College ID#:
DU.17.003
Address:
DU.17.004
Telephone Number:
DU.17.005
Fax Number:
DU.17.006
Medical Director:
DU.18
Mobile Service Personnel – Technical
DU.18.001
Site #1
DU.18.002
Name:
DU.18.003
Address:
DU.18.004
Sonologist:
DU.18.005
Sonographer:
DU.18.006
Site #2
DU.18.007
Name:
DU.18.008
Address:
DU.18.009
Sonologist:
DU.18.010
Sonographer:
DU.18.011
Site #3
DU.18.012
Name:
DU.18.013
Address:
DU.18.014
Sonologist:
DU.18.015
Sonographer:
DU.18.016
Site #4
DU.18.017
Name:
DU.18.018
Address:
DU.18.019
Sonologist:
DU.18.020
Sonographer:
DU.18.021
Site #5
DU.18.022
Name:
DU.18.023
Address:
Diagnostic Imaging – Ultrasound
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
13
Replaces: April 2008
DU.18.024
Sonologist:
DU.18.025
Sonographer:
Diagnostic Imaging – Ultrasound
CPSA: May 2009
© Copyright 2004 College of Physicians & Surgeons of Alberta (CPSA)
14
Replaces: April 2008
Diagnostic Imaging – Ultrasound
DU.19 Mobile Service Medical Records – Retention of Images Category
DU.19.001
Where are images stored:
DU.19.002
On-Site?
3
Yes
No
NA
DU.19.003
Group providing mobile ultrasound service?
3
Yes
No
NA
DU.19.004
Other?
3
Yes
No
NA
3
Yes
No
NA
DU.19.005
DU.19.006
Does the above apply to all mobile sites?
If no, please specify:
DU.20
Mobile Service Medical Records – Retention of Reports
DU.20.001
Where are reports stored:
3
Category
DU.20.002
On-Site?
3
Yes
No
NA
DU.20.003
Group providing mobile ultrasound service?
3
Yes
No
NA
DU.20.004
Other?
3
Yes
No
NA
3
Yes
No
NA
DU.20.005
DU.20.006
Does the above apply to all mobile sites?
If no, please specify:
3
DU.21
Mobile Service Quality Assurance Category
DU.21.001
Do you comply with the standards as outlined above for each mobile site including:
DU.21.002
Manual?
1 Yes
No
NA
DU.21.003
Quality Control?
1 Yes
No
NA
DU.21.004
Equipment and Accessories?
1 Yes
No
NA
DU.21.005
Processing Equipment?
1 Yes
No
NA
DU.22
Mobile Service Policy and Procedure
DU.22.001
Do you comply with the standards as outlined above for each mobile site including:
Category
DU.22.002
Manual?
1 Yes
No
NA
DU.22.003
Request for Consultation?
1 Yes
No
NA
DU.22.004
Requisitions/In-House Worksheet?
1 Yes
No
NA
DU.22.005
Images?
1 Yes
No
NA
DU.22.006
Reports?
1 Yes
No
NA
CPSA: May 2009
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15
Replaces: April 2008
Diagnostic Imaging – Ultrasound
DU.23
Mobile Service Safety
DU.23.001
Do you comply with the standards as outlined above for each mobile
Category
site including:
DU.23.002
General Facility?
1 Yes
No
NA
DU.23.003
Fire Prevention and Control?
1 Yes
No
NA
DU.23.004
Toxic and Corrosive Material?
1 Yes
No
NA
DU.23.005
Biological Hazards?
1 Yes
No
NA
DU.23.006
Glassware and Sharps?
1
Yes
No
NA
DU.23.007
Crash Cart-Drug Tray/Equipment?
1
Yes
No
NA
DU.23.008
Incident and Accident Reports?
1
Yes
No
NA