Cpa tool - imaging services - revision 7::13 checklist
Continuous performance assessment template
What does this form include?
This form contains 10 sections:
Previous Findings
- Are there any previous CPA findings?
Documents
- Is there a cone exemption policy?
- Is there a P&P for CT radiation dose monitoring?
- Is there a P&P for monitoring lead protective devices?
- Do the CT, IR & MRI staff have injector competences?
- Do all technologists who perform venipuncture have venipuncture certification?
- Documentation of initial and annual competencies (CT, Amrit, & NM Techs).
- Does the facility have quarterly Radiation Safety Committee meetings?
- Are there minutes?
- Is there a quorum?
- Are all protocols (CT, MRI, NM, US) approved by P&T?
- Have the department's policies and procedures been reviewed annually and approved by the MEC?
- Does the department have evidence of quality improvement projects?
- Can staff speak to the QI projects?
- Are there any contract staff being used?
- If yes, can the site provide their HR files?
- If yes, is their documentation of department specific orientation?
- Is there a P&P for administration of IV contrast?
- Do staff follow the P&P?
- Is there a P&P for MRI safety?
- Is there a P&P for monitoring dosimetry badges?
- Can the facility provide 12 months of dosimetry reports?
- We're the reports reviewed and signed by the RSO?
- Is there follow-up on any discrepancies?
- Is there a tracking mechanism to ensure all badges are distributed and collected each month?
- Is there documentation in the RS Mtg Minutes?
- Is there a P&P for weekly fluoroscopy checks?
- Can the facility provide 12 months of documentation for all fluoroscopy units?
- Is each fluoroscopy unit being checked weekly?
- Are the weekly log sheets current?
- Are the NM JD'S approved by the MEC?
- Have all JD's been approved by the MEC?
- Can the facility provide two weeks (14 days, including weekends) of finalized CT reports - 2 for each day of the week?
- SB1237: Does every CT report include in the body of the report the CTDIvol & DLP?
- Is there a P&P for checking eyewash logs?
General Information - All Imaging Areas
- Is there a valid and current PM sticker for all equipment maintained by Clinical Technology?
- Are PM's performed on-time?
- Are actions taken for any discrepancy on a PM or Physicist Report?
- Any issues that haven't been resolved in a timely manner?
- Can staff demonstrate how they access the department P&Ps?
- Are mock codes routinely scheduled in all Imaging areas?
- Are registry staff, including Staffing Partners, being used?
- If yes, what modalities and need to review all HR files.
- Are there good infection control procedures in place?
- Is there a Cleaning process for cleaning x-ray table or upright stand between patients?
- Is there dust on equipment?
- Is linen stored properly? Title 22 70825
- Have the Crash carts been checked per policy?
- Are any dated supplies expired?
- Are the crash carts clean?
Radiology
- Are patient fluoro logs being kept?
- Are weekly fluoroscopy checks being performed?
- Are the weekly fluoro checks log sheets current?
- Are the completed weekly fluoro log sheets signed after fully completed?
- If there are any discrepancies, is their documentation?
- Are dosimetry badges being managed?
- Are occupational radiation staff, who work in areas where ionizing radiation can be generated, wearing dosimetry badges?
- Can the site prove that all badges have monthly oversight?
- Are staff wearing their dosimetry badges?
- Are the dosimetry badges worn properly?
- Caution X-ray signs posted?
- Notice to Employees signs posted (5/09)?
- Radiation Safety Operating Procedures sign posted?
- Pregnancy Warning sign posted?
- Emergency procedures posted?
- X-ray generator affixed?
- X-ray exposure switch affixed?
- Student agreement approval letter from RHB posted?
- Is the information noted on agreement followed by the site (Days of week or hours of operation, etc.)?
- Lead apron checks performed prior to use and annually?
- Are the lead aprons easily identified?
- Are the lead skirts on fluoro towers checked prior to first use and annually?
- Can staff discuss where and why portable units are stored?
- Dose charts posted on all x-ray units?
- Technique charts posted on all x-ray units?
- Physician S&O permits posted & current?
- Technologists licenses posted and current?
- Is there notification as to where copies of the tech certifications and S&O permits are located and in 20 font?
- Are the MD S&O Permits kept on the mobile C-arms, including the mini c-arms?
- Are spacer cones affixed to all mobile c-arms?
- Are the vendor's radiation safety procedures posted on each unit?
- Does the mini c-arm have a label stating "For Extremity Use Only" ?
- Repeat Rates - can Staff identify their or the department's overall repeat rate?
- Is there any escalation process if a repeat rate is higher than acceptable?
- Do staff know how to find MD privileges?
- Is Contrast media secured and accessible only to authorized staff?
- Is there documentation that all staff have had Radiation Safety Training?
CT
- Were the current CT Protocols approved by P&T?
- Are the CT techs following the most recent CT protocols approved by P&T?
- Are the current CT protocols signed the Chief of the department, Section Chief, Lead Tech, and Management?
- Was a CT physicist report completed annually and were any failures resolved? Is there documentation?
- Are Emergency procedures posted?
- Do staff know where the Emergency Stop buttons are located?
- Do staff know if the Emergency Stop buttons work?
- Is there Contrast Media administration documentation?
- Are Reduced technique factors for pediatric and small patients in use?
- Have the CT techs had their original and annual Competencies?
- Does each CT tech have a vendor specific Injector Competency completed?
- Has the crash Crash Cart been checked daily?
- Can the CT techs discuss SAS 916 - CT Radiation Dose Monitoring?
- Can the CT techs discuss SB 1237?
- Can the CT techs describe the Stroke Alert process?
- Can the CT techs describe the Code Blue workflow?
- Is there documentation of Critical Results?
- Are there MD Contrast Orders?
- Is there Contrast media security?
- Are injector syringes secured?
- Are the Dose rates posted for 8, 16, or 64 slice CT?
- Is Medication labeling occurring?
- Is there a blanket warmer?
- Is yes, is it checked daily and following P&P?
- Is there a Contrast Warmer?
- Are Caution X-ray signs posted on all entrances to rooms with x-ray equipment?
MRI
- Are there Emergency procedures?
- Are they posted?
- Can staff verbalize their process?
- Can MRI staff describe the Code Blue process in MRI?
- Were the MRI Protocols approved by P&T?
- Are there MRI Safety Screening procedures?
- Are all MRI Safety Zones posted?
- Do all staff complete MRI Safety Training?
- Is there a list of employees who completed MRI Safety Training?
- Are the O2 tanks non-ferrous?
- Is there a current MRI physicist report?
- Are there MRI Tech Competencies, including vendor specific injector competencies?
- Do the MRI techs have the correct Venipuncture (10/10) documentation?
- Is there documented MRI QC?
- Is the MRI Crash Cart checked daily?
- Can the MRI staff discuss the MRI Safety - SAS 910 process?
- Is there a List of employees with access?
- Is procedural sedation performed in MRI?
IR/CCL
- Are there patient fluoro logs?
- Are weekly fluoro checks performed each week?
- Is there a dosimetry badge P&P?
- Is the dosimetry badge P&P followed?
- Are the dosimetry badge reports being monitored, signed, and actions taken when there are discrepancies such as over exposures or missing badges?
- Are staff and MDs wearing there dosimetry badges?
- Is the control badge kept with the dosimetry badge mailing envelope?
- Is there a lead apron P&P?
- Are the lead aprons identified?
- Are the lead aprons checked prior to use and annually?
- Are the lead apron skirts on fluoro unit checked annually?
- Are current S&O Permits and Tech state certifications posted?
- Is there an injection competency for the IR Tech and specific to the manufacturer used?
- Are time-outs used?
- Are two-patient identifiers used?
- Is side-site verification practiced and the area to be examined marked?
- Are secondary containers labelled appropriately?
- Are there contrast media orders?
NM
- Is the RML current?
- Are initial and annual venipuncture competencies performed on NM techs?
- Is there evidence of annual live stick competencies?
- Is there a Hot Lab Security plan?
- Is there a P&P for stolen radiopharmaceuticals?
Mammography
- Has the RHB Inspected Mammography for ACR accreditation?
- Is there a documented QA program for Interpreting MDs?
- Is there an annual Physicist report?
- Can Mammo Techs discuss their Repeat Rate?
- Is there state Information for breast implant patients?
- Is there side site verification for Interventional procedures?
- Can staff discuss Mammo QC?
- Is there a Technique chart?
- Can staff access department P&Ps?
- Is there a Dose chart?
- Is there a Cleaning procedure for Mammo unit between patients?
- Does each Mammo Tech have a documented Mammo competency?
US
- Does the US department clean their probes or does the SPD?
- If performed by the US department, is there daily QC of the Cidex?
- Can US staff accurately describe and demonstrate the probe cleaning process?
- Is the Cidex temperature monitored?
- Is there a Time-out for IR procedures?
- Is there Side-site verification for an IR procedure?
- Is there a Secondary container labeling practice?
Use this template