D.9 VAMC Imaging Policy, 36C25522R0052.pdf

TABLE OF CONTENTS

POLICY & PROCEDURE MANUAL REVIEW

MEDICAL CENTER MISSION STATEMENT

FUNCTIONAL STATEMENT-CLINICAL SUPPORT SERVICE LINE

CS/IMAGING SCOPE OF CARE (GOALS AND MISSION)

CS/IMAGING MISSION STATEMENT (FUNCTIONAL STATEMENT)

HUMAN RESOURCES

CS/IMAGING STAFFING PLAN

CS/IMAGING PERSONNEL LISTING .................................................. Error! Bookmark not defined.

CS/IMAGING PHYSICIANS & TECHOLOGISTS IN TRAINING

ORIENTATION - STAFF RADIOLOGIST

ORIENTATION - CLERICAL EMPLOYEE

ORIENTATION - IMAGING NURSE

ORIENTATION – RADIOLOGIC TECHNOLOGIST

ORIENTATION - RESIDENT PHYSICIAN

ORIENTATION - MRI TECHNOLOGIST

PHYSICIAN PRIVILEGING

COMPETENCY POLICY

TECHNOLOGIST COMPETENCY

NUCLEAR MEDICINE TECHNOLOGIST COMPETENCY

COMPETENCY FOR VENIPUNCTURE

SHORT NOTICE COVERAGE & EQUAL ACCESS TO OVERTIME

ON CALL TECHNOLOGIST COVERAGE

TWENTY-FOUR HOUR AVAILABILITY OF SERVICE

TECHNOLOGIST AVAILABILITY

QUALITY MANAGEMENT

QUALITY IMPROVEMENT PLAN

QUALITY IMPROVEMENT INDICATORS

QUALITY CONTROL

INTERNAL MANAGEMENT

INFORMATION SECURITY POLICY

DIAGNOSTIC WORKSTATION QUALITY CONTROL

DOUBLE READING & EMERGENCY ROOM INTERPRETATION POLICY

ORDERING AND APPROVING OF IMAGING STUDIES……………………………………………82

SAFETY POLICY IMAGING SECTION

RADIATION SAFETY RULES

IMAGING DEVICE QUALITY CONTROL MONITORING

FILM BADGE REQUIREMENTS

DECLARED PREGNANCY POLICY

EXAMINATIONS DURING PREGNANCY

FLUOROSCOPIC TIME DOCUMENTATION

ELECTRICAL SAFETY

CONTINGENCY PLAN - UTILITY FAILURE POLICY

HAZARDOUS MATERIALS POLICY (MSDS)

HAZARDOUS WASTE MANAGEMENT

INJURY AVOIDANCE/REDUCTION PLAN

LIFTING POLICY

EMERGENCY CARTS AND PHARMACEUTICAL MAINTENANCE

D.9 VAMC Imaging Policy, 36C25522R0052

INFECTION CONTROL POLICY

GENERAL SECURITY POLICY

FIRE RESPONSE PLAN

EVACUATION PLAN RADIOLOGY SECTION

EVACUATION PLAN NUCLEAR MEDICINE SECTION

SEVERE WEATHER POLICY

DISASTER (RECEIVING PATIENTS)

DISASTER CALL BACK PLAN

PATIENT CARE POLICIES

POSITIVE PATIENT IDENTIFICATION POLICY

TIME OUT POLICY – INTERVENTIONAL RADIOLOGY PROCEDURES

MEDICAL EMERGENCY – MOBILE MRI/PET

MEDICAL EMERGENCY POLICY

HANDLING THE CRITICALLY ILL PATIENT POLICY

PATIENT ASSESSMENT

CONSCIOUS SEDATION POLICY

AGE SPECIFIC STATEMENT

PEDIATRIC HUMANITARIAN CARE

CONTRAST MATERIAL POLICY

INFORMED CONSENT POLICY

REQUESTS FOR PROCEDURES BY RNs

MRI SEDATION POLICY

GUIDELINES FOR NURSING CARE

CLINICAL ALERT - NOTIFICATION OF ABNORMAL FINDINGS

FILM CHECKOUT POLICY

POLICY & PROCEDURE MANUAL REVIEW

A review of the Policy and Procedure Manual was completed October 31, 2009.

All issues are found to be appropriate and current at this time.

Submitted by: Reviewed by:

LANCE C. LOCHMANN RICHARD POELLING

Supervisor, CS/Imaging Radiation Safety Officer

Reviewed by:_______________________ Reviewed by: _____________________

JIMMIE D. COY, D.O. THOMAS DRESSER, M.D.

Medical Director, Radiology Medical Director, Nuclear Medicine

Approved by: Date:

THOMAS DRESSER, M.D.

Director, Clinical Support

MEDICAL CENTER MISSION STATEMENT

Mission: To improve the health of the veterans we serve by providing primary care, specialty care, extended care and related social support services in an integrated healthcare delivery system.

Core Values: Trust, Respect, Commitment, Compassion and Excellence

FUNCTIONAL STATEMENT-CLINICAL SUPPORT SERVICE LINE

SERVICE LINE DESCRIPTION: The Clinical Support Service Line is composed of a rather eclectic group of professionals. The uniting theme of the service line is that we provide support services to patients and providers of the Primary Care, Specialty Care and Mental Health service lines.

GOALS AND MISSION OF CLINICAL SUPPORT SERVICE LINE: The Clinical Support Service Line supports Primary Care, Mental Health, and Specialty Care by providing the highest quality, diagnostic, rehabilitative and therapeutic services to all qualified patients. Clinical Support also provides pastoral and counseling service through our chaplain program. As appropriate, Clinical Support provides humanitarian care and supports the educational and research missions of this facility. Through our affiliation with the University of Missouri- Columbia, Clinical Support provides educational opportunities for resident physicians, medical students, and student technologists and student therapists.

CLINICAL SUPPORT SERVICE LINE SECTIONS:

IMAGING

Imaging and therapeutic resources available include general radiology, radiography/fluoroscopy, ultrasound, computed tomography (CT), bone densitometry (DEXA), angiography, magnetic resonance imaging (MRI), positron emission tomography (PET), interventional radiology and nuclear medicine imaging (diagnostic and therapeutic). Mammograms and other women's health services are provided through a contract. All Images are digitally acquired and stored in electronic format in a picture archiving and communication system (PACS).

Interventional procedures are accomplished through a scarce medical contract. Imaging has an affiliation with the University of Missouri School of medicine for resident physicians and nuclear medicine technologists. Imaging has an affiliation with the State Fair Community College for diagnostic radiology technologist.

PHYSICAL MEDICINE AND REHABILITATION

Physical Medicine and Rehabilitative section provides an inpatient program, outpatient program and an active consultation program. PM&R provides EMGs, brace & amputee, spinal cord and multiple sclerosis, pain clinic, and diabetic foot clinic. Both physical and occupational therapy provides evaluation, education, training/fitting of prosthetic devices and therapeutic interventions to alleviate impairment of functional limitations. OT provides wheel chair assessment, activities of daily living, perceptual motor activities, psycho-social and physical disability assessment. Physical therapy provides fitting, training, equipping with prosthetic devices for ambulation, evaluating cardiac, rehabilitation clients, evaluating community nursing home requests for physical therapy. PM&R has affiliations with the University of Missouri School of medicine for resident physicians, occupational, physical therapy students.

PATHOLOGY AND LABORATORY MEDICINE

The Pathology and Laboratory Medicine section provides a full range of testing services including chemistry, immunology/blood bank, ancillary testing, urinalysis, hematology, coagulation, virology, and microbiology. Our laboratory has a sharing agreement and affiliation with the University of Missouri. UMC provides testing for anatomical pathology, cytology, and toxicology tests on VA patients and the VA provides testing for UMC immunology and virology testing. The morgue serves the VA and UMC hospitals for autopsy services. Pathology provides some testing for the VAMC at Marion.

CHAPLAIN SECTION

Chaplain Section includes pastoral care, memorial services, and worship services, spiritual assessments for patients, group counseling, and is actively involved with end of life planning and Advance Directives

PROSTHETICS

The Prosthetic section provides artificial limbs, braces, wheelchairs, durable medical equipment, hearing aids, eyeglasses, and manages the home oxygen, automotive adaptive equipment and clothing allowance programs.

Surgical implant procurement and the prosthetic bar coding program for inventory are also managed. Prosthetics maintains a small consolidated inventory with most items ordered for specific patients.

COMMITMENT TO QUALITY: The patient care, consultative services and products of the Clinical Support Service Line will be performed in a timely fashion and of high quality.

ACADEMIC MISSION: Through our affiliation with the University of Missouri-Columbia we provide an educational opportunity for resident physicians, medical students, and student technologists and student therapists.

CS/IMAGING SCOPE OF CARE (Goals and Mission)

CS/Imaging will support primary care and specialty care by providing the highest quality diagnostic and therapeutic services to all qualified patients referred. Some services may be obtained from or provided to other health care organizations as part of an integrated healthcare delivery system. In addition to services provided to all eligible patients referred we will provide, as appropriate, humanitarian care.

Resources available will include nuclear medicine imaging, radiography/fluoroscopy, ultrasound, CT, angiography, bone densitometry and interventional radiology.

CS/Imaging will provide a qualified professional, technical, and support staff.

The product of CS/Imaging will be high quality and timely diagnostic and therapeutic services.

Through our affiliation with the University of Missouri-Columbia we provide an educational opportunity for resident physicians, medical students, and student radiographers and nuclear medicine technologists. We also have an affiliation with the State Fair Community College Radiography program.

Diagnostic services are limited to the following imaging modalities: routine radiography, fluoroscopy, conventional tomography, portable radiography and portable fluoroscopy, angiography, interventional radiology, computed tomography, ultrasonography, bone densitometry, nuclear medicine imaging and therapeutic services.

• MRI studies are provided by a contract service.

• Mammogram examinations are obtained from outside sources. Radiation therapy is provided at other facilities and is not monitored by CS/Imaging.

• Patient and family education is provided by the CS/Imaging nurses, physicians and technologists.

• Care is provided to all eligible patients. Our clientele is disproportionately adult male and above the age of 40.

• Services provided and future planning are guided by patient needs, facility mission statement, facility strategic plan, professional practice standards, the Clinical Executive Board and referral patterns.

Approved by Clinical Executive Board - June 16, 1998

CS/IMAGING MISSION STATEMENT (Functional Statement)

CS/Imaging will support primary care and specialty care by providing the highest quality diagnostic and therapeutic services to all qualified patients referred. Some services may be obtained from or provided to other health care organizations as part of an integrated healthcare delivery system. In addition to services provided to all eligible patients referred we will provide, as appropriate, humanitarian care.

Resources available will include nuclear medicine imaging, radiography/fluoroscopy, ultrasound, CT, angiography, bone densitometry, and interventional radiology.

MRI, PET/CT, mammography, and radiation therapy are provided by contract vendors.

CS/Imaging will provide a qualified professional, technical, and support staff.

The product of CS/Imaging will be high quality and timely diagnostic and therapeutic services.

Through our affiliations with the University of Missouri and State Fair Community College we provide an educational opportunity for resident physicians, medical students, and student technologists.

CS/IMAGING ORGANIZATIONAL STRUCTURE

CS/Imaging includes the services normally associated with Nuclear Medicine and Diagnostic Radiology.

CS/Imaging has two major sections:

• Nuclear Medicine Section

• Radiology Section

The Director, Clinical Support, manages CS/Imaging with the Medical Director, Nuclear Medicine and Medical Director, Radiology providing specialty management. Staff physicians, physicists, administrative personnel, technical personnel, and clerical support staff assist the Nuclear Medicine and Radiology Medical Directors.

QUALITY MANAGEMENT PROGRAM

Quality Improvement programs and Quality Management programs will be developed and implemented at the section level. Meeting minutes, data gathering results and actions taken to improve the quality of services provided will be reported to the service chief and through the CS/Imaging Staff Meeting.. After review and approval the section level data/reports will be unified and provided to the appropriate hospital officials.

POLICY AND PROCEDURES

Each section of CS/Imaging will develop and maintain the policies and procedures specific to that section.

HUMAN RESOURCES

CS/IMAGING STAFFING PLAN

PURPOSE: To establish policy and procedures to ensure appropriate staffing.

SCOPE: All technical and support positions are covered by this plan.

POLICY: It is the policy of CS/Imaging to provide personnel with appropriate skills and in appropriate numbers to deliver quality patient care and administrative services.

MISSION STATEMENT: CS/Imaging will provide the highest quality diagnostic and therapeutic services to all qualified patients referred. In addition to services provided to all eligible patients referred we will provide, as appropriate, humanitarian care.

Resources available will include nuclear medicine, radiography/fluoroscopy, ultrasound, CT, angiography, MRI, bone densitometry and interventional radiology.

CS/Imaging will provide a qualified professional, technical, and support staff.

The product of CS/Imaging will be high quality and timely diagnostic and therapeutic services.

Through our affiliation with the University of Missouri-Columbia and State Fair Community College we provide an educational opportunity for resident physicians, medical students, and student technologists.

CS/IMAGING ORGANIZATIONAL STRUCTURE: CS/Imaging includes the services normally associated with Nuclear Medicine and Diagnostic Radiology. CS/Imaging has two major sections;

The Medical Director of CS/Imaging is the clinical director. The Supervisor, CS/Imaging is the administrative director. The Supervisor and Medical Director of CS/Imaging are assisted by staff physicians, physicists, administrative personnel, technical personnel, and clerical support staff.

STAFFING LEVELS:

Medical directors (physician): 2.0

Staff Radiologists/Physicians: 4.0

Interventional Radiologist Contract

Administrative Officer 1.0

Clinical Preceptor 0.8

Nuclear Medicine Coordinator: 1.0

Nuclear Medicine Technologists: 2.0

CT Technologists: 2.0

Special Procedures Technologists: 2.0

Ultrasound Technologists: 3.0

Staff Technologists 5.0

Clerical Supervisor: 1.0

Radiology Receptionist 1.0

Nuclear Medicine Receptionist: 1.0

File Clerks: 1.0

Transcriptionist: 1.0

Nurses: 2.0

STAFFING MANAGEMENT: Multi-functional personnel are the heart of our staffing management strategy.

All of our technologists, including supervisory staff are capable of performing routine radiography.

• Special procedure technologists are cross functional with CT, angio and radiography.

• All clerical staff are capable of managing the film library.

• Ultrasound technologists are cross functional with radiography.

• Three clerical employees are capable of managing the reception area and patient scheduling.

TECHNOLOGIST COMPETENCY POLICY: All technologists will have demonstrated competency in the performance of imaging examinations prior to independently delivering patient care.

Competency will be reevaluated at regularly scheduled intervals (annually).

If competency is not appropriately demonstrated measures will be taken to aid the technologist in acquiring skills required to obtain the desired competency. This could include proctored work assignment and/or additional education. Upon completion of the remedial action(s) reassessment will be performed.

A summary of the competencies demonstrated will be attached to the employee’s Performance Appraisal Form.

STUDENT PROGRAMS: All physicians and technologists in training will work under the supervision of an attending physician or technologist as appropriate.

The level of supervision will be commensurate with the level of training, i.e. a forth year resident will be granted a higher level of independence and responsibility than that of a first year resident.

No physician or technologist in training will be required to serve in an on-call capacity without attending physician backup.

All examination reports dictated by residents are considered preliminary reports and must be reviewed/verified by an attending physician prior to being considered complete.

All examinations performed by student technologists must be approved by a staff technologist prior to submission for interpretation.

Student technologists will never perform nuclear medicine therapeutic procedures or radiology invasive/interventional procedures without direct supervision.

TWENTY-FOUR HOUR AVAILABILITY OF SERVICE: A radiology and nuclear medicine physician and radiology, nuclear medicine, CT and ultrasound technologists are available twenty-four hours per day, seven days per week. During normal operating hours (8:00 a.m. - 4:30 p.m., Monday - Friday) the full range of services provided are performed by in-house physicians and technologists. These services include routine radiography, fluoroscopy, portable radiography, CT, angiography, interventional radiology, ultrasonography, bone densitometry and nuclear medicine imaging. Radiation therapy, mammography, and after hours MRI are provided by outside vendors.

During other than normal operating hours an in-house technologist is available to provide emergent and indicated radiography and to assist the radiologist with fluoroscopic studies. A callback system is in place which provides radiologist and technologist coverage for emergent/indicated and difficult radiography, fluoroscopy, angiography, interventional radiology procedures, ultrasound, CT studies and nuclear medicine procedures.

The pager and telephone numbers of on-call personnel are available through CS/Imaging, the hospital operator, and the medical administrative assistant (AOD).

OB/Gyn ultrasound emergencies are referred by the radiologist on-call to the University of Missouri hospital.

In those cases where after hours MRI services are indicated to be performed on an emergent basis it can be arranged by the on-call radiologist following approval by the Medical director acting for the Chief of Staff.

REACTION TO INADEQUATE STAFFING: In the event that we are not able to provide adequate staffing patient care will not be compromised.

With the assistance of the professional staff, examinations requested will be prioritized. Emergent examinations will be performed first.

To adjust for temporary staffing limitations clinic schedules may be reduced or canceled.

If limiting of workload, employee reassignment, and examination prioritization are not adequate responses to meet patient care needs the examinations requested will be acquired using the fee basis technologists, contract technologists and/or fee basis system at other area hospitals.

CS/IMAGING PHYSICIANS & TECHOLOGISTS IN TRAINING

1. Purpose: To establish guidelines for the supervision of professional and technical staff during clinical rotations at our hospital.

2. Scope: All radiology and nuclear medicine fellows, resident physicians and all radiography and nuclear medicine technology students are covered under this policy.

3. Policy:

a. All physicians and technologists in training will work under the supervision of an attending physician or technologist as appropriate.

b. The level of supervision will be commensurate with the level of training, i.e. a forth year resident will be granted a higher level of independence and responsibility than a first year resident.

c. No physician in training will be required to serve in an on-call capacity without attending physician backup.

d. All examination reports dictated by residents are considered preliminary reports and must be reviewed/verified by an attending physician prior to being considered complete.

e. All examinations performed by a student technologist must be approved by staff technologist prior to submission for interpretation.

f. Student technologists will never perform nuclear medicine therapeutic procedures or radiology invasive/interventional procedures without direct supervision.

ORIENTATION - STAFF RADIOLOGIST

It is the policy of our service to provide service level orientation to all employees. As an employee of a company that provides clinical services at our hospital we want you to have the information needed for you to complete your work in a safe and clinically effective environment.

The following information is provided to ensure that you are comfortable with our environment.

1. IMAGING MISSION STATEMENT

CS/Imaging will support primary care and specialty care by providing the highest quality diagnostic and therapeutic services to all qualified patients referred. Some services may be obtained from or privided to other health care organizations as part of an integrated healthcare delivery system. In addition to services provided to all eligible patients referred we will provide, as appropriate, humanitarian care.

Resources available will include nuclear medicine imaging, radiography/fluoroscopy, ultrasound, CT, angiography, bone densitometry and interventional radiology.

CS/Imaging will provide a qualified professional, technical, and support staff.

The product of CS/Imaging will be high quality and timely diagnostic and therapeutic services.

Through our affiliation with the University of Missouri we provide an educational opportunity for resident physicians, medical students, and student technologists.

2. CS/IMAGING ORGANIZATIONAL STRUCTURE

CS/Imaging has two major sections;

3. QUALITY MANAGEMENT PROGRAM

Quality Improvement programs and Quality Management programs will be developed and implemented at the departmental level. Meeting minutes, data gathering results and actions taken to improve the quality of services provided will be reported to the service chief and through the CS/Imaging Staff Meeting.. After review and approval the section level data/reports will be unified and provided to the appropriate hospital officials.

4. POLICY AND PROCEDURES

A complete copy of the Policy and Procedure Manual is available at the reception desk of Radiology and in the Chief Tech's office (A181).

5. KEY IMAGING STAFF

Position Incumbent Phone Number Radiology Medical Director Jimmie Coy, D.O. 52572 Nuclear Med Medical Director Thomas Dresser, M.D. 56420 Supervisor, CS/Imaging Lance Lochmann, R.T. 56412 Radiology Nurse Phyllis Brandt 52562 Nuclear Medicine Nurse Linda Fischer 52581 Clerical Supervisor Liza Meyer 52549 Radiation Safety Officer Richard Poelling 52590

6. EMERGENCY CODES

Emergency Type Code Phone Number Fire Red 3333 Clinical Emergency Blue 3333 Combative patient/guest Orange 3333 Missing Patient Green 3333 Hazardous Material Spill Yellow 3333

7. SPECIAL INSTRUCTIONS:

a) Fire – Call 3333 and then Follow the RACE System (Rescue, Alarm, Contain, and Evacuate).

b) Infection Control questions – Contact the Supervisor, CS/Imaging who can reach the infection control nurse.

c) Equipment or physical plant problems – Contact the Supervisor, CS/Imaging who can reach the Bio Medical staff or engineering staff as appropriate.

8. ACTING LEADERS: Dr Coy acts in Dr Dresser's absence. Kim Sipe acts Lance's absence.

9. DICTATION OF REPORTS:

Please give the editor the following information:

• Begin each dictating session with the date, your name, and the name of your co-signer when applicable.

• Case number (be sure you give the case number and not the patient's age, doctor's pager number, etc.).

• Patient's first and last name.

• Last four (4) of social security number.

• Type of exam.

IMPORTANT: Failure to provide the editor with the necessary information may cause your dictation to be skipped and you will need to re-dictate the report.

DIAGNOSTIC CODES:

Our department has a program in operation to enhance patient care at this facility. When a report warrants special attention, the radiologist informs the editor at the end of the dictation that the report is to be coded as a clinical alert, significant finding, attention to provider.

Clinical alert, code 99 is used for a new significant finding; a new tumor, fracture, free air, or foreign body, that warrants special attention.

Further exam recommended code is self explanatory, however, when using this code it would be helpful to give a specific recommendation or date for follow-up when possible.

In more emergent cases, contact the referring physician. The success and type of contact should be noted in the report. For example: Dr. Jones contacted and report given by phone at 2:00 pm, on January 1, 2007.

VERIFICATION OF REPORTS

Each physician should electronically verify reports at least three times per day. Suggested times are 9:00 AM, 12 Noon, and 4:00 PM.

Verification of reports on the computer makes the report available via computer to the hospital medical staff.

If your report needs revision or corrections, the reports can be edited while reviewing the reports at the time of verification. Bear in mind while dictating that this should be a final copy and not a rough draft. Thorough reading and review of all reports is of extreme importance as sometimes reports will contain errors which will need to be completed prior to verification.

FILM CHECKOUT

Films cannot be released to medical staff personnel without having a report dictated. Exception to this rule can only be made in a case of an extreme emergency or if films are going to outpatient clinic areas. Only clerical staff or technologists with knowledge of proper file room procedures may check films out to other hospital personnel.

HOSPITAL COMPUTER SYSTEM

If you have not already received an access code for our computer system, contact IMD personnel to obtain one.

There are a couple of options on the computer system which you could find useful that are not obvious upon signing into the computer.

1. After signing on to the computer system (Vista) you can type the word PAGER and enter a physician's name to obtain his pager number. You may also enter a pager number and get the name of a physician.

2. Vista has a MAILMAN MENU that you may or may not find useful. After signing on, enter the word

MAIL to see mail menus. If you are interested in learning more about Mailman contact the clerical supervisor. Please note, your electronic mail contains important information which should not be ignored or left unread.

TELEPHONE AND PAGING SYSTEM

VA Voice Pager Number - dial 2 and three-digit number, give message after tone.

VA Numeric Pager Number - dial 2, three-digit number and at the tone key in the extension you are to be called at.

UMMC Tone Numeric Pager Number

To Call an MU Pager from the VA:

a. Dial 7 (to access University line). This gives you a dial tone.

b. Dial 51#. Wait for the beep, then dial in the beeper number ----, and wait for one telephone ring and further verbal instructions.

To Call the VA pager from MU:

a. After hearing the verbal instructions, dial 57* (asterisk) ---- (VA extension; example 57*6700).

b. After hearing the recorded voice tell you "thank you", hang up.

Local Call Outside the VA - dial 9 plus the phone number.

FTS lines are available in the hospital for official government use only. Phone calls made on this system are monitored.

OTHER INFORMATION

The following information is contained within the CS/Imaging Policy and Procedure Manual. A copy of this manual is located in the reading room.

1. Phone numbers

2. Personnel listing

3. Equipment listing

4. Examination policies

5. General principles for patient care

6. Examination preparations

7. Examination standards

I have reviewed and understand the information above. I feel comfortable providing clerical services at the Harry S.

Truman Memorial Veterans Hospital. As questions arise from time to time I know I can contract Dr. Dresser, Dr.

Coy or Lance Lochmann as appropriate.

Signed: ____________________________ Date: ________________________

ORIENTATION - CLERICAL EMPLOYEE

It is the policy of our service to provide service level orientation to all employees. As an employee of a company that provides clinical services at our hospital we want you to have the information needed for you to complete your work in a safe and clinically effective environment.

The following information is provided to ensure that you are comfortable with our environment.

1. IMAGING MISSION STATEMENT

CS/Imaging will support primary care and specialty care by providing the highest quality diagnostic and therapeutic services to all qualified patients referred. Some services may be obtained from or provided to other health care organizations as part of an integrated healthcare delivery system. In addition to services provided to all eligible patients referred we will provide, as appropriate, humanitarian care.

Resources available will include nuclear medicine imaging, radiography/fluoroscopy, ultrasound, CT, angiography, bone densitometry and interventional radiology.

CS/Imaging will provide a qualified professional, technical, and support staff.

The product of CS/Imaging will be high quality and timely diagnostic and therapeutic services.

Through our affiliation with the University of Missouri we provide an educational opportunity for resident physicians, medical students, and student technologists.

2. CS/IMAGING ORGANIZATIONAL STRUCTURE

The medical/administrative director of CS/Imaging is the Chief, CS/Imaging. The Chief, CS/Imaging is assisted by staff physicians, physicists, administrative personnel, technical personnel, and clerical support staff.

3. QUALITY MANAGEMENT PROGRAM

Quality Improvement programs and Quality Management programs will be developed and implemented at the department level. Meeting minutes, data gathering results and actions taken to improve the quality of services provided will be reported to the service chief and through the CS/Imaging Staff Meeting.. After review and approval the section level data/reports will be unified and provided to the appropriate hospital officials.

4. POLICY AND PROCEDURES

A complete copy of the Policy and Procedure Manual is available at the reception desk of Radiology and in the

Radiology Medical Director Jimmie Coy, D.O. 2572 Nuclear Med Medical Director Thomas Dresser, M.D. 6420 Supervisor, CS/Imaging Lance Lochmann, R.T. 6412 Radiology Nurse Phyllis Brandt 2562 Clerical Supervisor Liza Meyer 2549

Clinical emergency Blue 3333 Combative patient/guest Orange 3333 Hazardous materials spill Yellow 3333 Missing patient Green 3333

a) Fire – Call 3333 and then Follow the RACE System (Rescue, Alarm, Contain, and Evacuate).

b) Infection Control questions – Contact the Supervisor, CS/Imaging who can reach the infection control nurse.

c) Clinical Questions – Refer clinical questions to the radiologist or radiology nurse as appropriate.

d) Equipment or physical plant problems – Contact the Supervisor, CS/Imaging who can reach the Bio Medical staff or engineering staff as appropriate.

8. ACTING LEADERS: Dr Coy acts in Dr. Dresser's absence and Lynn Sipe acts in Lance's absence. If the clerical supervisor is absent Lance will assume those duties.

I have reviewed and understand the information above. I feel comfortable providing clerical services at the Harry S.

Truman Memorial Veterans Hospital. As questions arise from time to time I know I can contract Elizabeth Meyer, Clerical Supervisor, CS/Imaging

ORIENTATION - CS/IMAGING NURSING

It is the policy of our service to provide service level orientation to all employees. As a nurse that provides clinical services in CS/Imaging we want you to have the information needed for you to complete your work in a safe and clinically effective environment.

The following information is provided to ensure that you are comfortable with our environment.

1. IMAGING MISSION STATEMENT

CS/Imaging will support primary care and specialty care by providing the highest quality diagnostic and therapeutic services to all qualified patients referred. Some services may be obtained from or provided to other health care organizations as part of an integrated healthcare delivery system. In addition to services provided to all eligible patients referred we will provide, as appropriate, humanitarian care.

Resources available will include nuclear medicine imaging, radiography/fluoroscopy, ultrasound, CT, MRI, angiography, bone densitometry and interventional radiology.

CS/Imaging will provide qualified professional, technical, and support staff.

The product of CS/Imaging will be high quality and timely diagnostic and therapeutic services.

Through our affiliation with the University of Missouri we provide an educational opportunity for resident physicians, medical students, and student technologists.

2. CS/IMAGING ORGANIZATIONAL STRUCTURE

CS/Imaging has two major sections.

CS/Imaging is a section of the Clinical Support Service Line. The Director, Clinical Support is the Chief, CS/Imaging. The Chief, CS/Imaging is assisted by staff physicians, physicists, administrative personnel technical personnel, and clerical support staff.

3. QUALITY MANAGEMENT PROGRAM

Quality improvement programs and quality management programs will be developed and implemented at the department level. Meeting minutes, data gathering results and actions taken to improve the quality of services provided will be reported to the service chief and through the CS/Imaging staff meeting. After review and approval the section level data/reports will be unified and provided to the appropriate hospital officials.

4. POLICY AND PROCEDURES

A complete copy of the Policy and Procedure Manual is available at the reception desk of Radiology and in the

Position Incumbent Phone Extension Radiology Medical Director Jimmie D. Coy, D.O. 2572 Nuclear Med Medical Director Thomas Dresser, M.D. 6420 Supervisor, CS/Imaging Lance Lochmann 6412 Radiology Nurse Cathy Beamer 2562 NM Nurse Tara Stemme 6420 Clerical Supervisor Liza Meyer 6414

Emergency Type Code Phone Extension

Clinical emergency Blue 3333 Combative patient/guest Orange 3333 Hazardous materials spill Yellow 3333

7. GENERAL SECURITY POLICY

PURPOSE: This policy is intended to provide employees with a standard procedure that promotes general security.

SCOPE: All employees are included in this policy.

RESPONSIBILITY: The Supervisor, CS/Imaging is responsible for compliance with this policy. The Supervisor, CS/Imaging will monitor daily activities and take actions needed to ensure the objectives of this policy are met.

PROCEDURES PHYSICAL PLANT SECURITY:

1. The storage rooms will be closed at all times.

2. Examination rooms not in use will have the exterior doors closed.

3. All offices will be locked during other than normal hours of operations.

4. The long-term film file area (basement) will be locked at all times.

5. Hallways and interior corridors will be on the emergency lighting system.

6. All medications will be stored in locked or attended areas. Only the amount of medication needed for the current procedure will be unsecured.

7. Employees will be familiar with the emergency alarm system, intercom system, and hospital emergency code standards.

8. All unusual conditions will be reported to a supervisor or the hospital police.

9. In the event of a bomb or similar threat the disaster and/or evacuation plans will be used.

10. All defective equipment will be marked as "out of service".

PROCEDURES BEHAVIORAL PROBLEMS:

1. Remain calm

2. If a serious threat is present Call 3333 and state “CODE ORANGE room number ####.

3. To the extent possible give the person what they want.

4. Use the person’s name when possible.

5. Report all threats to the supervisor.

8. FIRE RESPONSE PLAN

1. PURPOSE: To establish policy and procedures to be used in the event of a fire or should the need to evacuate the service area become necessary.

2. POLICY: All CS/Imaging personnel will be familiar with the policy and procedures outlined in this plan.

3. RESPONSIBILITIES:

a. The Supervisor, CS/Imaging is responsible for ensuring compliance with this policy.

b. The Supervisor, CS/Imaging and Leadership staff are responsible for ensuring that staff are provided the training needed to fulfill their responsibilities as outlines by this plan.

c. Staff are responsible for understanding and being able to follow the procedures described below.

4. PROCEDURES:

a. We will use the RACE method when a fire is present and the PASS method will be used for operating a fire extinguisher.

R = rescue A = alarm C = confine E = extinguish

P = pull A = aim S = squeeze S = sweep

b. Hospital Fire Alarm System: Upon activation a tone will be sounded and the strobe light warning system will flash. You will hear an automated voice state "May I have your attention please: Code Red, Code Red, stand by for further instructions". The telephone operators will then announce the exact location of the reported problem

c. When the fire does not threaten our area be sure the corridor doors are closed and listen to the P.A. for information. Always follow the instructions of Engineering Section employees and/or professional fire-fighters.

d. If you discover a fire or become aware of a fire in your work area:

1) rescue persons in immediate danger

2) it must be reported. To report a fire call extension 3333 and/or pull the nearest fire alarm. The nearest fire pull alarm is located near stairwell number 4 (by Dr. Coy's office) and by the stairwell near the nuclear medicine entrance.

3) alert other staff members

4) remove all patients and visitors from the area.

5) seal the area by closing doors and windows. Place wet towels or blankets at the base of all doors in the sealed area.

6) turn off main O2 supply. The O2 cut-off valves are located in the corridors between rooms 178 and 181 and the corridor outside room 175 in the radiology section and between rooms B001l and B001M in the nuclear medicine section.

7) attempt to extinguish only small fires or when life is in immediate danger.

8) use only an ABC fire extinguisher. Fire extinguishers are located in each examination room, the reception area, the radiology file room, I.V. prep room, CT scan area, and in Angio. Do not attempt to use the high pressure water/fire hoses.

9) For larger or threatening fires, after reporting and sealing the area, follow the evacuation plan.

9. EVACUATION PLAN RADIOLOGY SECTION

1. All employees will read and be familiar with both station and departmental fire and disaster plans.

2. All doors within the department will be closed.

Responsibilities:

a. Examination rooms and support spaces - technologist assigned to that area.

b. Reception/waiting room areas - receptionist.

c. All offices – Office automation assistants

3. The Imaging Supervisor and Office Automation Supervisor will determine number and status of all patients and/or visitors and employees within the Radiology Section.

4. The reception area will serve as the control point for all emergency activity. The Safety and Emergency

Plans Manual will be brought to the reception area. The Medical Director, CS/Imaging, Supervisor, CS/Imaging, Radiology Coordinator, and Clerical Coordinator will meet in this area.

5. The Medical Director or other radiologists under his/her direction will assess the condition of all patients within our section and direct any special care required.

6. The Supervisor CS/Imaging will also serve as liaison between departmental staff and professional fire fighting personnel until Facilities Management staff arrive.

7. Once a decision has been reached by professional fire fighting personnel that evacuation is necessary the radiology coordinator facilitates evacuation of patients and visitors. The special procedure technologists and ultrasound technologist will assist all non-ambulatory patients in evacuating.

8. If evacuation is necessary, the evacuation exit of choice is the exit at stairwell number 4 (by Dr. Coy's office) by room A133. The second area of evacuation exit is stairwell number 9 proceeding either right or left through the exits to the rear of the building at the basement level.

9. During evacuation the Imaging Supervisor will inspect the entire department to ensure that all patients, visitors, and section personnel have been properly integrated into the evacuation process.

10. After the evacuation process has been completed, all personnel will meet in the visitor's parking lot and report to the section chief for further assignments.

10. IMAGING NURSE STANDARDS

a. Assuring patient privacy – No procedure will be performed in an environment where the requirements of patient privacy cannot be assured.

b. Pre-procedural assessment – No interventional procedures will be performed without a pre-procedural nursing assessment.

c. Conscious sedation – Procedures requiring conscious sedation or where it is likely that the procedure will "slip" to a situation where conscious sedation is required will follow the hospital conscious sedation policy.

d. Informed consent – The hospital policy regarding informed consent will be strictly enforced.

e. Adherence to this institution's philosophy of nursing care – The practice of the CS/Imaging nurse will incorporate the institution's philosophy of nursing care.

f. Patient education – Patients will be given an opportunity to become informed participants in their radiologic or nuclear medicine care.

g. Quality improvement activities – The imaging nurse will be an active participant in the quality improvement process for CS/Imaging.

h. Post procedure communications -- The imaging nurse will communicate all relevant information to the care giver assuming responsibility for the patient following an interventional radiologic or nuclear medicine procedure. This may be done face-to-face or by use of a nursing progress note.

i. Time-out – Verify that a pre-procedural "Time-out" is performed and documented for all interventional radiology procedures.

11. SIGNIFICANT DUTIES:

a. Assist during angiography and other interventional procedures and monitor patients during conscious sedation.

b. Perform pre-procedural nursing assessment, with documentation.

c. Verify that the patient received education regarding the imaging procedure and complete a nursing note as documentation.

d. Call patients scheduled for CT, fluoroscopic, nuclear medicine, ultrasound and interventional procedures prior to their appointment date to provide education, answer questions and conform appointment time and complete a nursing note as documentation.

e. Assist with critically ill patients during their examinations.

f. Provide pre and post vital signs on MRI patients that receive sedation.

g. Ensure that the necessary lab values are within normal range prior to the procedure, by entering lab order for physician to ensure recent values are available.

h. Must accompany conscious sedation patients to and from the imaging area.

i. Assist with the management of IV lines, IV pump devices, etc.

j. Assist with cardiac stress testing in nuclear medicine.

I have reviewed and understand the information above. I feel comfortable providing clinical nursing services at the Harry S. Truman Memorial Veterans Hospital. As questions arise from time to time I know I can contract Lance Lochmann, Supervisor, CS/Imaging.

ORIENTATION – RADIOLOGIC TECHNOLOGIST

It is the policy of our service to provide service level orientation to all employees. As an employee of a company that provides clinical services at our hospital we want you to have the information needed for you to complete your work in a safe and clinically effective environment.

The following information is provided to ensure that you are comfortable with our environment.

1. IMAGING MISSION STATEMENT

CS/Imaging will support primary care and specialty care by providing the highest quality diagnostic and therapeutic services to all qualified patients referred. Some services may be obtained from or provided to other health care organizations as part of an integrated healthcare delivery system. In addition to services provided to all eligible patients referred we will provide, as appropriate, humanitarian care.

Resources available will include nuclear medicine imaging, radiography/fluoroscopy, ultrasound, CT, angiography, bone densitometry, and interventional radiology.

CS/Imaging will provide a qualified professional, technical, and support staff.

The product of CS/Imaging will be high quality and timely diagnostic and therapeutic services.

Through our affiliation with the University of Missouri we provide an educational opportunity for resident physicians, medical students, and student technologists.

2. CS/IMAGING ORGANIZATIONAL STRUCTURE

CS/Imaging includes the services normally associated with nuclear medicine and diagnostic radiology. CS/Imaging has two major sections.

The medical/administrative director of CS/Imaging is the Medical Director, CS/Imaging. The Medical Director, CS/Imaging is assisted by staff physicians, physicists, administrative personnel, technical personnel, and clerical support staff.

3. QUALITY MANAGEMENT PROGRAM

Quality improvement and quality management programs will be developed and implemented at the department level. Meeting minutes, data gathering results and actions taken to improve the quality of services provided will be reported to the medical director and through the CS/Imaging Staff Meeting. After review and approval the section level data/reports will be unified and provided to the appropriate hospital officials.

4. POLICY AND PROCEDURES

A complete copy of the Policy and Procedure Manual is available at the reception desk of Radiology, in the Chief Tech's office (A181), and on the E-drive under Imaging Public.

Medical Director Jimmie D. Coy, D.O. 2572 Nuclear Med Medical Director Thomas Dresser, M.D. 6420 Supervisor, CS/Imaging Lance Lochmann 6412 Radiology Nurse Phyllis Brandt 2562 NM Nurse Linda Fischer 6420 Clerical Supervisor Liza Meyer 6414 Radiation Safety Officer Richard Poelling 2590

Clinical emergency Blue 3333 Combative patient/guest Orange 3333 Hazardous material spill Yellow 3333 Missing patient Green 3333

7. SPECIAL INSTRUCTIONS

a. Fire – Call 3333 and then follow the RACE system (Rescue, Alarm, Contain, and Evacuate).

b. Infection control questions – contact the Supervisor, CS/Imaging who can reach the infection control nurse.

c. Clinical questions – refer clinical questions to the radiologist or radiology nurse as appropriate.

d. Equipment or physical plant problems – contact the Supervisor, CS/Imaging who can reach the Bio Medical staff or engineering staff as appropriate.

8. ACTING LEADERS

• Dr. Dresser acts as Medical Director in Dr. Coy's absence.

• Lance acts in Elizabeth Meyer's absence.

I have reviewed and understand the information above. I feel comfortable providing clinical services at the Harry S.

Truman Memorial Veterans Hospital. As questions arise from time to time I know I can contact Lance Lochmann, Supervisor, CS/Imaging.

Signed: Date:

NEW TECHNOLOGIST ORIENTATION POLICY

It is the policy of our service to provide service level orientation to all employees. As an employee of a company that provides clinical services at our hospital we want you to have the information needed for you to complete your work in a safe and clinically effective environment.

The following information is provided to ensure that you are comfortable with our environment.

1. IMAGING MISSION STATEMENT

2. CS/IMAGING ORGANIZATIONAL STRUCTURE

3. QUALITY MANAGEMENT PROGRAM

Quality Improvement programs and Quality Management programs will be developed and implemented at the department level. Meeting minutes, data gathering results and actions taken to improve the quality of services provided will be reported to the service chief and through the CS/Imaging Staff Meeting.. After review and approval the section level data/reports will be unified and provided to the appropriate hospital officials.

4. POLICY AND PROCEDURES

CS/Imaging will develop and maintain the policies and procedures specific to the service line and annually reviewed by the Chief, CS/Imaging and the Radiation Safety Officer. A complete copy of the Policy and Procedure Manual is available at the reception area of the Radiology Department and on the E-drive under Imaging Public.

Service Line Director Thomas Dresser, M.D. 56420 Radiology Medical Director Jimmie Coy, D.O. 52572 Nuclear Med Medical Director Thomas Dresser, M.D. 56420 Radiology Interventional Stephen Fafiinski. Pgr: 443-8343 x0440 Radiologist Adel Abu-Saif 52544 Radiologist James Connors 52543 Radiologist Anil Malhotra 52546 Radiologist Mary Murphy 56415 Supervisor, CS/Imaging Lance Lochmann 56412 Radiology Nurse Phyllis Brandt 52562 Clerical Supervisor Liza Meyer 52549 Radiation Safety Officer Richard Poelling 52590

Clinical emergency Blue 3333 Behavioral Emergency Orange 3333

Hazardous materials spill Yellow 3333

a) Fire – Call 3333 and then Follow the RACE System (Rescue, Alarm, Contain, and Evacuate).

b) Infection Control questions – Contact the Supervisor, CS/Imaging who can reach the infection control nurse..

c) Clinical Questions – Refer clinical questions to the radiologist or radiology nurse as appropriate.

d) Equipment or physical plant problems – Contact the Supervisor, CS/Imaging who can reach the Bio Medical staff or engineering staff as appropriate. After hours contact Graphic Control at ext. 2433.

e) Computer problems after-hours – Contact the AOD at phone number 53096.

8. ACTING LEADERS: Lynn Sipe acts in Lance's absence and Dr. Coy acts in Dr. Dresser’s absence.

I have reviewed and understand the information above. I feel comfortable providing clerical services at the Harry S.

Truman Memorial Veterans Hospital. As questions arise from time to time I know I can contract Lance Lochmann, Supervisor, CS/Imaging.

9. KEY PHONE and PAGER NUMBERS:

Front Desk (receptionist) 814-6414

Ultrasound 52565

CT 52551

Interventional 52561

QC area (radiology) 52558

AOD (also for computer problems) 53096

Resident Radiologist on call 397-9152

In-house Tech 75-5622

Hospital main number 814-6000

Employee Signature: ____________________________ Date: ________________________

IMAGING TECHNOLOGIST AND SUPPORT STAFF ORIENTATION CHECK LIST

Name:

1. Tour (Supervisor, CS/Imaging and/or Coordinator)

a. Radiology & Nuclear Medicine Sections

b. Hospital and Clinics

c. Human Resources

d. Storeroom

e. O.R.

f. Employee Health:

2. Policy and procedures (Supervisor, CS/Imaging)

a. Receive and review Policy and procedure Manual emphasizing

1) Radiation safety (technologists only)

2) Infection control

3) Safety - fire, weather, electrical etc.

4) Information security reviewed and received access code

5) Emergencies i.e. code blue, fire, and disaster policy

6) Leave usage

b. Discuss adherence to standard exam views and technical factors (technologists only)

3. Work Requirements and Limitations (Coordinators)

a. Position description and…