Draft P01. SOW - Medical Health Physicist.pdf

STATEMENT OF WORK

TITLE: Medical Health Physicist ~ Certified Medical Physicist/Radiation Safety Officer

OVERVIEW:

Contractor shall provide on-site annual, and as needed, performance evaluation of imaging equipment and Medical Health Physicist services at the St. Cloud VA Health Care System (SCVAHCS) and Brainerd Community Based Outpatient Clinic (CBOC).

Contractor shall provide Radiation Safety services to fulfill the Radiation Materials Licensing requirement as specified by the National Health Physics Program (NHPP).

PLACES OF PERFORMANCE:

St. Cloud VA Health Care System 4801 Veterans Drive St. Cloud, MN 56303

Brainerd Community Based Outpatient Clinic (CBOC) 722 NW 7th Street Brainerd, MN 56401

PERIOD OF PERFORMANCE:

This contract will be a Single Award, Firm Fixed Price Service Contract for one (1) Base Year with four (4) Option Years.

QUALIFIED PERSONNEL:

All Radiation Physicists performing services under this contract shall work under a board certified Medical/Health Physicist from one of the following boards: American Board of Radiology, American Board of Health Physicists or American Board of Medical Physicists.

Personnel must have experience in Hospital Medical Physics and be familiar with Minnesota and VA regulations.

Physicist must be approved by the NHPP program to function as a Radiation Safety Officer (RSO) on the SCVAHCS Radiation Materials License.

The personnel will be identified in the proposal and shall be considered key personnel as essential for the successful completion of the work performed.

Any changes to the assignment of personnel must be communicated to the Contracting Officer Representative (COR) and Imaging Supervisor at least five (5) days before new personnel will visit the SCVAHCS.

SCOPE OF WORK:

Contractor shall furnish all labor, travel, materials, supplies, equipment, and qualified personnel to provide on-site Radiation Physicist services and Radiation Safety Officer services in accordance with the terms and conditions stated herein.

The St. Cloud VA HCS will provide a person to operate the equipment and be present during the inspection.

RSO must perform radiation safety surveys within SCVAHCS facilities to ensure compliance with the current VA policies and National Health Physics Program (NHPP) as required.

VA may increase the number of equipment items or tests covered under this contract at no change to the applicable contract price schedule.

Contractor will provide equipment calibration records for all equipment used to test equipment.

WORK SCHEDULE:

The work shall be performed during normal business hours of 8:00 am to 5:00 pm, Monday through Friday excluding Federal Holidays, unless otherwise coordinated with the COR. There may be times when the Contractor could be needed after normal business hours.

Inspection dates and times will be mutually agreed upon and established. Policy reviews may be provided via electronic means and submitted for recommendation.

Change of times or dates of survey visits must be coordinated with the Imaging Department and/or COR at least two (2) weeks in advance.

A list of federal holidays is available at: https://www.opm.gov/policy-data-oversight/pay-leave/federal-holidays/#url=2024

Any other day specifically declared by the President of the United States to be a Federal Holiday.

If the holiday falls on a Saturday, the previous Friday will be observed and if the holiday falls on a Sunday, the following Monday will be observed.

MEDICAL PHYSICIST SERVICE SPECIFICTIONS:

Annual Performance Evaluation of Diagnostic Imaging Equipment:

• Annual performance, radiation safety, and regulatory compliance evaluation and as needed.

• Annual evaluation shall include, but is not limited to, the following tests when appropriate for the specific equipment to include testing of image acquisition display monitors for maximum and minimum luminance, uniformity, resolution, and spatial accuracy.

1. Radiographic equipment evaluation to assess the following:

o X-ray generator analysis: kVp and timer accuracy, mA linearity, exposure reproducibility and assessment of radiation, and kV waveforms (non-invasive testing) o Radiation output (consistency and typical patent exposures) o Beam alignment and beam quality analysis o Spatial resolution o Phototimer operation o Collimator operation (manual and automatic) o Source to image accuracy, including distance measuring tools o Mechanical performance and electrical cable integrity inspection o Interlocks and exposure switch operation o Dose Area Product (DAP)accuracy, if applicable o Monitor calibration and image evaluation https://www.opm.gov/policy-data-oversight/pay-leave/federal-holidays/#url=2024 https://www.opm.gov/policy-data-oversight/pay-leave/federal-holidays/#url=2024

a) Direct Digital Radiographic equipment Uniformity, high-contrast resolution, and low-contrast detectability Artifact evaluation Exposure indicator accuracy Anti-Aliasing analysis Digital/Post collimation errors and positioning

b) Fluoroscopic equipment System resolution and contrast analysis kVp accuracy and beam quality (non-invasive testing) Air Kerma and/or DAP accuracy Beam alignment and collimation accuracy with respect to viewing field Timer operation Table side shields and tower aprons Compliance with state and/or federal regulations for exposure rate conditions

2. Computed Tomography (CT) equipment evaluation (to include use of phantom) to assess the following:

o Image uniformity throughout o Scout prescription accuracy o Beam alignment accuracy o Radiation beam width o High contrast resolution o Low contrast detectability o kVp, mA, scan time, and scan diameter accuracy o Artifact evaluation o Evaluation of all images

3. Magnetic Resonance Imaging (MRI) equipment evaluation (to include us of phantoms) to assess the following:

o Set-up and table position accuracy o Center frequency o Transmitter gain or attenuation o Signal to noise ratio (SNR) for all coils used clinically o Image uniformity for all coils used clinically o Slice thickness accuracy o Slice position accuracy o Alignment light accuracy o High contrast spatial resolution o Low contrast detectability o Geometric or distance accuracy o Magnetic field homogeneity and artifact evaluation o RF shielding integrity o Scanner suite evaluation o Electrical cable integrity

Audits/Reports/Reviews/Recommendations

• Annual review (with recommendations for improvement if applicable) and approval of CT protocols

• Annual review (with recommendations for improvement if applicable) and approval of MRI protocols

• MR Safety program assessment

• MRI Quality Control program evaluation and recommendations for improvement.

• Provide report of all survey findings for each equipment/device for use as a permanent record in a format acceptable to all regulatory agencies and The Joint Commission (TJC).

• Calculate and provide patient exposure levels in accordance with the recommendation of

FDA’s Center for Devices and Radiologic Health (CDRH) and the rules of the TJC as needed.

• Provide a Shielding Plan/Evaluation (per the State of Minnesota) including a report for new radiation producing equipment rooms added during base/option periods.

• Provide availability to discuss radiation safety by telephone and/or email.

• Provide expert knowledge and experience for advising and recommending investigation levels for personnel exposures and area surveys (dose rate and contamination)

Medical Health Physicist SERVICE SPECIFICTIONS:

• Be qualified in training and knowledge concerning all hazards and precautions involved in operating and using radiologic equipment and devices at SCVAHCS and Brainerd CBOC

• Provide instruction concerning hazards and safety practices to individuals who may be exposed to radiation

• Inform/instruct individuals on As Low As Reasonably Achievable (ALARA) principles to meet regulatory/license requirements

• Stop any unsafe ionizing radiation activity, investigates deviations from approved radiation safety practices, and implement corrective actions

• Review incidents involving ionizing radiation with respect to cause and subsequent actions taken and report / notify medical events per regulation in a timely manner

• Review health physics program to ensure continued safe operation of equipment

• Review the radiation safety program to ensure compliance with applicable requirements including records for FDA and state / federal compliance

• Complete annual audits to ensure documentation of formal training, policies, procedures, test results, calibrations, safety surveys, equipment performance tests, and maintenance on all x-ray equipment and radiographic imaging devices at SCVAHCS and Brainerd CBOC

• Review dosimetry monitoring program to ensure monitoring devices are used and worn appropriately, advise on individuals to be monitored, and provide instruction as necessary

• Provide instruction on current patient radiation safety practices and protection of pregnant patient / fetus

• Perform quarterly review of occupational doses and prepare summary reports for individuals exceeding trigger levels and regulatory limits with recommendation for action

• Provide instruction on declared pregnant employee guidelines and advise worker on dose reduction if applicable

• Participate in quarterly Radiation Safety Committee meetings

• Ensure copies of all records, reports, regulations, policies, and procedures are kept for appropriate timeframes

• Consult on facility design and shielding for areas of radiologic use

• Interact with regulatory agencies as necessary

• Perform (or coordinate) radiation safety surveys and other procedures as required

• Ensure doors / rooms / equipment have proper postings or labels to meet regulatory requirements and regulatory notice to employees is posted

QUALITY CONTROL:

Work performed under this contract shall be subject to evaluation by the COR in accordance with the contract terms and conditions.

SPECIAL REQUIREMENTS:

Provision of 24 hour on-call services a day, 7 days a week, of contractor Certified Health Physicist or Medical Physicist (Radiation Safety Officer) response to emergency situations within one (1) hour by phone and on-site within 8 hours if requested.

Provide written report of results to Imaging Supervisor or designee within 30 working days of performance of the survey.

GENERAL PROVISIONS:

• Contractor staff performing inspection will be subject to a background investigation and must receive a favorable adjudication from the VA Security Center (VSC). If security clearance is not completed prior to the start of the contract, the Contractor will be responsible for the actions of those individuals they provide to perform services for the VAHCS.

• The position sensitivity has been designated as low sensitivity. The level of background investigation is a National Agency Check with Written Inquiries. The level of risk associated with the contracted employee position is equivalent to the level required of a VA Employee working in such a position.

• Contractor staff performing inspections will complete and sign VA’s National Rules of Behavior and Privacy Policy training prior to performing inspections.