DIAGNOSTIC ACCREDITATION PROGRAM Accreditation Standards 2014 Diagnostic Imaging GOVERNANCE AND LEADERSHIP 1 DGL5.1.3 New Criteria There are processes to receive and resolve ethical dilemmas in a timely manner. Guidance: The timeliness of response is defined and monitored by the diagnostic service. Ethical dilemmas may include decisions not to perform an examination or where an examination is performed against the wishes of the patient. Diagnostic Imaging Page 1 of 12
MEDICAL STAFF 1 DMS2.1.2 The information includes approval from the College of Physicians and Surgeons of British Columbia to perform restricted services. 2 DMS2.3.1 Diagnostic radiology services are provided by physicians licensed to practice Diagnostic Radiology by the College of Physicians and Surgeons of British Columbia. 3 DMS2.4.1 Diagnostic mammography services are provided by physicians licensed to practice Diagnostic Radiology by the College of Physicians and Surgeons of British Columbia. The information includes MSP billing eligibility confirmation from the College of Physicians and Surgeons of British Columbia to bill for restricted services, if not affiliated with a health authority. Physicians providing diagnostic radiology services have the requisite credentials for privileges as outlined in the Provincial Privileging Dictionaries. Guidance: Diagnostic radiology services are considered core and non-core privileges depending on the relevant specialty and therefore may require further training, experience and demonstrated skill. Refer to requirements to perform diagnostic radiology. Physicians providing diagnostic mammography services have the requisite credentials for privileges as outlined in the Provincial Privileging Dictionaries. Guidance: Diagnostic mammography services are considered core and non-core privileges depending on the relevant specialty and therefore may require further training, experience and demonstrated skill. Refer to requirements to perform diagnostic mammography. Diagnostic Imaging Page 2 of 12
4 DMS2.5.1 Diagnostic ultrasound services are provided by physicians licensed to practice Diagnostic Radiology by the College of Physicians and Surgeons of British Columbia. 5 DMS2.6.1 Limited scope ultrasound services, restricted to Obstetrical and Gynecological ultrasound, may be provided by physicians licensed to practice Obstetrics and Gynecology by the College of Physicians and Surgeons of British Columbia. 6 DMS2.6.2 Limited scope ultrasound services, restricted to Obstetrical and Gynecological ultrasound, may be provided by physicians approved to perform this restricted service by the College of Physicians and Surgeons of British Columbia. 7 DMS2.7.1 Limited scope ultrasound services, restricted to vascular ultrasound, may be provided by physicians licensed to practice vascular surgery by the College of Physicians and Surgeons of British Columbia. 8 DMS2.7.2 Limited scope ultrasound services, restricted to vascular ultrasound, may be provided by physicians approved to perform this restricted service by the College of Physicians and Surgeons of British Columbia. Physicians providing diagnostic ultrasound services have the requisite credentials for privileges as outlined in the Provincial Privileging Dictionaries. Guidance: Diagnostic ultrasound services are considered core and non-core privileges depending on the relevant specialty and therefore may require further training, experience and demonstrated skill. Refer to requirements to perform diagnostic ultrasound. Diagnostic Imaging Page 3 of 12
9 DMS2.8.1 Diagnostic echocardiography services are provided by physicians licensed to practice Diagnostic Radiology, Cardiology or Internal Medicine by the College of Physicians and Surgeons of British Columbia. 10 DMS2.8.2 Diagnostic echocardiography services are provided by physicians approved to perform the restricted service of transthoracic echocardiography (TTE) by the College of Physicians and Surgeons of British Columbia. 11 DMS2.8.3 Diagnostic echocardiography services are provided by physicians approved to perform the restricted service of transesophageal echocardiography (TEE) by the College of Physicians and Surgeons of British Columbia. 12 DMS2.9.1 Diagnostic computed tomography (CT) services are provided by physicians licensed to practice Diagnostic Radiology by the College of Physicians and Surgeons of British Columbia. Physicians providing diagnostic echocardiography services have the requisite credentials for privileges as outlined in the Provincial Privileging Dictionaries. Guidance: Diagnostic echocardiography services are considered core and non-core privileges depending on the relevant specialty and therefore may require further training, experience and demonstrated skill. Refer to requirements to perform diagnostic echocardiography. Physicians providing diagnostic CT services have the requisite credentials for privileges as outlined in the Provincial Privileging Dictionaries. Guidance: Diagnostic CT services are considered core and non-core privileges depending on the relevant specialty and therefore may require further training, experience and demonstrated skill. Refer to requirements to perform diagnostic CT. Diagnostic Imaging Page 4 of 12
13 DMS2.10.1 Diagnostic magnetic resonance imaging (MRI) services are provided by physicians licensed to practice Diagnostic Radiology by the College of Physicians and Surgeons of British Columbia. 14 DMS2.10.2 Diagnostic magnetic resonance imaging (MRI) services are provided by physicians approved to perform this restricted service by the College of Physicians and Surgeons of British Columbia. 15 DMS2.11.1 Diagnostic nuclear medicine services are provided by physicians licensed to practice Nuclear Medicine by the College of Physicians and Surgeons of British Columbia. 16 DMS2.11.2 Diagnostic nuclear medicine services are provided by physicians familiar with Computed Tomography anatomy where non-diagnostic CT services are performed using SPECT/CT hybrid systems. Physicians providing diagnostic MRI services have the requisite credentials for privileges as outlined in the Provincial Privileging Dictionaries. Guidance: Diagnostic MRI services are considered core and non-core privileges depending on the relevant specialty and therefore may require further training, experience and demonstrated skill. Refer to requirements to perform diagnostic MRI. Physicians providing diagnostic nuclear medicine services have the requisite credentials for privileges as outlined in the Provincial Privileging Dictionaries. Guidance: Diagnostic nuclear medicine services are considered core and non-core privileges depending on the relevant specialty and therefore may require further training, experience and demonstrated skill. Refer to requirements to perform diagnostic nuclear medicine. Diagnostic Imaging Page 5 of 12
17 DMS2.12.1 Limited scope nuclear medicine services, restricted to nuclear cardiology, are provided by physicians licensed to practice Cardiology by the College of Physicians and Surgeons of British Columbia. 18 DMS2.12.2 Limited scope nuclear medicine services, restricted to nuclear cardiology, are provided by physicians approved to perform the restricted service of nuclear cardiology by the College of Physicians and Surgeons of British Columbia. 19 DMS2.12.3 Limited scope nuclear medicine services, restricted to nuclear cardiology, are provided by physicians familiar with Computed Tomography anatomy where nondiagnostic CT services are performed using SPECT/CT hybrid systems. 20 DMS2.13.1 Limited scope nuclear medicine services, restricted to second reader status, are provided by physicians licensed to practice Diagnostic Radiology by the College of Physicians and Surgeons of British Columbia. 21 DMS2.13.2 Limited scope nuclear medicine services, restricted to second reader status, are provided by physicians approved to perform limited scope nuclear medicine, restricted to second reader status, by the College of Physicians and Surgeons of British Columbia. Diagnostic Imaging Page 6 of 12
22 DMS2.13.3 Limited scope nuclear medicine services, restricted to second reader status, are provided by physicians familiar with Computed Tomography anatomy where nondiagnostic CT services are performed using SPECT/CT hybrid systems. 23 DMS2.14.1 Diagnostic bone densitometry services are provided by physicians licensed to practice Diagnostic Radiology or Nuclear Medicine by the College of Physicians and Surgeons of British Columbia. 24 DMS2.14.2 Diagnostic Bone Densitometry services are provided by physicians who have current certification from the International Society for Clinical Densitometry (ISCD). 25 DMS2.15.1 Complex interventional procedures are provided by physicians with training in complex interventional procedures acceptable to the governing body/ownership. Physicians providing diagnostic bone densitometry services have the requisite credentials for privileges as outlined in the Provincial Privileging Dictionaries. Guidance: Diagnostic bone densitometry services are considered core and non-core privileges depending on the relevant specialty and therefore may require further training, experience and demonstrated skill. Refer to requirements to perform diagnostic densitometry. Diagnostic Imaging Page 7 of 12
GLOBAL MODALITY 1 GM5.1.5 New Criteria The diagnostic imaging staff follow care plans when patients have been sedated or received general anesthesia within the imaging service. Guidance: A care plan is a carefully prepared outline of nursing care which identifies all of the patient s needs during the procedure and how to address those needs. Diagnostic Imaging Page 8 of 12
RADIATION SAFETY 1 RS5.2.7 The survey report includes results of radiation measurements carried out both inside and outside the controlled area under typical operating conditions and the locations at which the measurements are made. The survey report includes results of radiation measurements carried out both inside and outside the controlled area under typical operating conditions and the locations at which the measurements are made. Guidance: For a mammography facility with shielding design/calculations requiring only standard construction materials, a visual survey of the integrity of the standard construction materials provides an adequate assessment for the radiation protection survey. Construction materials for radiation shielding are based on the shielding calculations required in RS6.1. Diagnostic Imaging Page 9 of 12
MAGNETIC RESONANCE IMAGING 1 MR12.1.1 Acceptance testing procedures include an assessment and identification of fringe fields. Intent: The 5 gauss line is used to define the pacemaker safety margins. 2 MR12.1.3 Acceptance testing procedures include an assessment of RF shield integrity. 3 MR12.1.4 Acceptance testing procedures include an RF calibration. 4 MR12.1.5 Acceptance testing procedures include an assessment of the system signal to noise ratio. 5 MR12.1.6 Acceptance testing procedures include an assessment of signal uniformity. 6 MR12.1.8 Acceptance testing procedures include geometric and positioning accuracy or equivalent tests of gradient performance and RF pulse characteristics. 7 MR12.1.9 Acceptance testing procedures include a measurement of high contrast spatial resolution. Acceptance testing procedures include an assessment and identification of fringe fields. Intent: At a minimum the 5 gauss line is defined. Additional fringe fields may be required depending on the conditional equipment used by the imaging service. Acceptance testing procedures include an assessment of RF shield integrity and ambient RF noise. Acceptance testing procedures include an assessment of MR spectroscopy using a Braino Phantom or equivalent. Acceptance testing procedures include an assessment of the system signal to noise ratio using the manufacturer s recommended settings. Acceptance testing procedures include an assessment of signal uniformity of the body coil. Acceptance testing procedures include an assessment of geometric and positioning accuracy and gradient performance in all dimensions. Acceptance testing procedures include a measurement of high contrast spatial resolution. Guidance: An ACR phantom is required to perform this measurement. Diagnostic Imaging Page 10 of 12
8 MR12.1.13 New criteria descriptor. Acceptance testing procedures include an assessment of acoustic noise in and outside the magnet room. 9 MR12.1.14 New criteria descriptor. Acceptance testing procedures include an assessment of MRI signal stability. 10 MR13.4.2 Annual testing includes a measurement of spatial linearity. 11 MR13.4.3 Annual testing includes a measurement of high contrast spatial resolution. 12 MR13.4.5 Annual testing includes an assessment of eddy current compensation and system shim. 13 MR13.4.6 Annual testing includes a review of weekly quality control testing records. 14 MR13.4.8 Annual testing includes an assessment of geometric accuracy (gradient calibration). Annual testing includes a measurement of high contrast spatial resolution. Annual testing includes an assessment of magnet homogeneity and system shim. Annual testing includes a review of weekly and monthly quality control testing records. Annual testing includes an assessment of geometric accuracy (gradient calibration). 15 MR13.4.9 New criteria descriptor. Annual testing includes an assessment of fringe fields used for conditional equipment. Diagnostic Imaging Page 11 of 12
NUCLEAR MEDICINE 1 NM3.6.11 New Criteria When a patient requires hospitalization as part of receiving radiotherapy, the staff responsible for the patient follow a care plan. Guidance: A care plan is a carefully prepared outline of nursing care which identifies all of the patient s needs during the procedure and how to address those needs. Diagnostic Imaging Page 12 of 12