Facility Pre-Assessment Questionnaire for Nuclear Medicine

Transcription

1 Facility Pre-Assessment Questionnaire for Nuclear Medicine THE INFORMATION CONTAINED IN THIS DOCUMENT IS ACCURATE TO THE BEST OF MY KNOWLEDGE Signature of Quality Advisor/Medical Director Date Signature of Owner/Operator Date

2 GENERAL 1. Name of Facility: Mailing Address: Telephone Number: Fax Number: 2. Name and mailing address of owner/operator of this facility, if different from above: 3. Name(s) and mailing address(es) of other facilities owned or operated by the licensee of this facility: 4. Name of Manager/Supervisor of facility (if applicable): Mailing Address: Telephone Number: Fax Number: 5. What licensed procedures are your currently performing? 6. Does your facility have separate areas for each of the following functions: Patient waiting area Yes No N/A Change rooms Yes No N/A Patient washrooms Yes No N/A Procedure rooms Yes No N/A Processing areas Yes No N/A Image storage Yes No N/A Facility storage supply Yes No N/A 7. Is the facility wheelchair accessible? Yes No 8. Is your IHF licence posted in the patient waiting area? Yes No If no, where is it presently located? Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 2 of 11

3 GENERAL 1. Name of the Radiation Safety Officer: 2. If imaging physicians are not on-site, describe the method in which technologists consult with him/her on a case-by-case basis? 3. Are TLD monitoring reports provided to the staff? Yes No Where are the reports posted? Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 3 of 11

4 Please complete for each technologist currently working in the facility. 1. Name: 2. Please provide your College of Medical Radiation Technologists (CMRTO) Registration Number: Please attach a copy of your CMRTO Registration Card. 2. Please describe your training in nuclear medicine including location and dates: 4. Have you taken any formal or refresher courses? Yes No How many hours this past year and how many hours in the previous year? If yes, please list location, date and course details: Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 4 of 11

5 List the nuclear medicine equipment currently in use in this facility: TYPE OF EQUIPMENT AND YEAR MANUFACTURED EQUIPMENT MANUFACTURER SERIAL NUMBER DATE ACQUIRED YY/MM/DD DATE MODIFICATIONS & UPGRADES CALIBRATION RECORD AVAILABLE (please attach copy) Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 5 of 11

6 GENERAL 1. Where are the radiation warning signs posted? 2. Where are the pregnancy warning signs posted? 3. Where are the fire exits signs posted and are they clearly marked? 4. Is the following equipment available for managing emergencies related to the types of services provided? First Aid Kit Yes No N/A Emergency/Resuscitation Cart Yes No N/A Fire Extinguishers Yes No N/A Wheelchair Yes No N/A Other Yes No N/A 5. Are staff trained in Basic Cardiopulmonary Resuscitation (BCLS)? Yes No Please provide a copy of your current certificates 6. Have all staff received WHMIS training? Yes No 7. Where are the material safety data sheets posted? 1. Please attach copies of the last two CNSC inspection reports. 2. Name the person responsible for conducting and documenting quality control activities? 1. How often do you clean your processor? 2. Name of the person/company who conducts the processor maintenance? Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 6 of 11

7 1. Does your facility have a policies and procedures manual as described in the Clinical Practice Parameters and Facility Standards for Nuclear Medicine? Yes No Please provide a copy of the manual to the technologist assessor only. 2. Where is the policies and procedures manual kept? 3. How frequently is the policies and procedures manual reviewed by all staff? 4. Who reviews and updates the policies/procedures manual? (i.e. Quality Advisor, Technologists, Managers, etc.) 5. What is the process to advise staff of changes to the policies/procedures manual? 6. Are all changes initialled and dated by staff? Yes No 7. Do all staff sign and date the policies/procedures manual? Yes No Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 7 of 11

8 Please enclose a sample requisition, data collection sheets and a sample (John Doe) report. 1. If a patient arrives with a requisition containing incomplete information, how does the facility obtain the necessary information prior to conducting the procedure? 2. When/how are previous films/images from other IHF/Hospital facilities obtained for the interpreting physician? 3. What is your standard practice for report turnaround time to the referring physician? 4. In point form describe the process from the time an examination is performed until the final report is interpreted and sent to the referring physician. Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 8 of 11

9 5. How are unusual, unexpected or urgent findings communicated to the referring physician by the interpreting physician? How is this documented? 6. Where are your films stored? 7. What is your method of filing each image/storage media? 8. What do you use as your permanent record? 9. How are they stored and protected? 9. How do you view these stored images? 10. How do you flag your unusual and interesting examinations? 11. How long are your records retained and how are they identified for purging? Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 9 of 11

10 1. Who are the members of your Quality Advisory Committee? Please provide a list of their names and title 2. How often does the Quality Advisor Committee meet? 3. Are these meetings documented and minutes maintained? Yes No If yes, please provide a copy of your last minutes of meeting 4. Does your Quality Management Program include the following components: Monitoring of radiation safety policies Yes No Review of data resulting from the implementation of the Yes No radiopharmaceutical quality control activities Review of goals and objectives Yes No Review of policies and procedures Yes No Review of incidents, adverse drug reactions, complications Yes No Review of clinical data e.g. assessing accuracy of Yes No interpretation, appropriateness of examinations Review of recommendations from other assessing bodies Yes No such as Canadian Nuclear Safety Commission and the Health Protection Branch, Health Canada Staff performance appraisals Yes No Evaluations of diagnostic efficacy Yes No 5. What is your mechanism for proofreading reports? 6. Are dispensed radiopharmaceuticals recorded and retained on the appropriate forms? Yes No 7. How do staff contribute to continuously improve the services provided? Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 10 of 11

11 8. How is information communicated to your staff? 9. How often are staff meetings held? Are these meetings documented? Yes No 10. Describe your performance appraisal system: How frequently is this carried out? Facility Pre-Assessment Questionnaire for Nuclear Medicine May 2010 Page 11 of 11