Medical Physicist SOW.docx

Scope of Work Medical Physicists To meet Joint Commission Requirements it is required that a medical physicists perform a Radiation Output and Safety Survey to ensure we meet federal regulatory standards. Surveys are to be done annually and after installation of new Radiology equipment and the replacement of Mammography unit x-ray tube. Contractor to perform initial Medical Physicist evaluations for our Mammography unit, Regular Radiology room (2), and GSU New dental units (19), Mobile X-ray units (3), Rad/Fluoro X-ray rooms (2), Mobile C-arm unit (4), Must be certified by the American Board of Radiology in Diagnostic Radiological Physics, and must be approved and certified by Federal or State Radiation Regulatory Agency to provide the services.

Annual Medical Physicist’s Survey:

The medical physicist must perform the QC tests listed in the table below for screen-film system and manufacture specified QC for full-field digital mammography system when equipment is installed and at least annually thereafter. The medical physicist should provide a written report of the survey’s findings to responsible physician(s) and professional(s) responsible for service of the equipment. Although FDA regulations all the medical physicist 30 days from the date of the survey to send a report, a 30-day delay in getting the report to the facility allows the facility no time to take corrective actions. The ACR strongly recommends that written reports be submitted in time to give facilities the opportunity to take corrective actions in case of an adverse finding.

Annual Medical Physicist’s Survey - Mammography

Required By MQSA

Timeframe for Corrective Action

Measurement of View box Luminance Room Illuminance

Required annually, a diagnostic medical physicist or individual(s) who have the required training and skills, as determined by the physicist, shall:

Digital Mammographic units Test performed to comply with ACR/FDA/MQSA requirements.

1. Flat Field

2. Image Quality – Conventional and Tomosynthesis.

3. MTF Measurement (as described in radiologic technologist tests)

4. AOP Mode and Signal-to-Noise (SNR) – Conventional and Tomosynthesis.

5. Collimation Assessment – Conventional and Tomosynthesis.

6. Evaluation of Focal Spot Performance

7. Breast Entrance Exposure, Average Glandular Dose and Reproducibility– Conventional and Tomosynthesis.

8. Artifact Evaluation and Flat Field Uniformity – Conventional and Tomosynthesis.

9. Viewing Condition Check and Setting

10. Display Device (Monitor) Calibration (Brightness/Contrast)

11. Image Quality – SMPTE Pattern

12. Analysis of Reviewer Work Station (RWS) Screen Uniformity

13. kVp Accuracy and Reproducibility

14. Beam Quality Assessment (Half-Value Layer Measurement)

15. Radiation Output

16. Mammographic Unit Assembly Evaluation

17. Evaluation of QC program

ACR and Annual Test will be performed according to the latest ACR, and state requirements. Additional tests may be performed based on the units designated use.

Quality control test performed:

· Contrast Scale

· Nominal Tomographic Section Thickness

· Resolution of the system for high and low contrast objects

· The mean CTN for water

· The CTN's for other reference material

· Beam Alignment and Noise

· Measurement of Tomographic Plane and Reference Plane

· Deviation of Scan Increment

· Nominal Tomographic Section Thickness

· Spatial Resolution

· Contrast Sensitivity

· Dose Measurements

· ACR Test

· Phantom and Scanner Alignment

· CT Number Calibration and Slice Thickness

· Low Contrast Resolution

· Uniformity and Noise

· High Contrast (Spatial) Resolution

· Radiation Dose – Adult Head

· Radiation Dose – Ped Head

· Radiation Dose – Adult Body

· Radiation Dose – Ped Body

R/F Rooms (2) – X-ray room 1 & X-ray room 2 The measurements were made in accordance with Federal Radiation Regulatory Requirements and the ACR Standard for Diagnostic Medical Physics Performance Monitoring of Radiologic and Fluoroscopic Equipment. Listed is a summary of typical tests. Additional tests are performed based on the units designated use.

· Entrance Skin Exposure rates

· kVp Accuracy

· Beam Quality

· Linearity

· Reproducibility

· Timer Accuracy (when applicable)

· Fluoroscopy output (when applicable)

· Fluoroscopy Beam Quality (when applicable)

· Fluoroscopy Maximum Dose (when applicable)

· Collimator Congruency

· Safety evaluation

Radiology room (2) – X-ray room 3 & THC Rad Room The measurements were made in accordance with Federal Radiation Regulatory Requirements and the ACR Standard for Diagnostic Medical Physics Performance Monitoring of Radiologic and Fluoroscopic Equipment. Listed is a summary of typical tests. Additional tests are performed based on the units designated use.

Mobile X-ray units (3) The measurements were made in accordance with Federal Radiation Regulatory Requirements and the ACR Standard for Diagnostic Medical Physics Performance Monitoring of Radiologic and Fluoroscopic Equipment. Listed is a summary of typical tests. Additional tests are performed based on the units designated use.

Mobile C-arm units (4) The measurements were made in accordance with Federal Radiation Regulatory Requirements and the ACR Standard for Diagnostic Medical Physics Performance Monitoring of Radiologic and Fluoroscopic Equipment. Listed is a summary of typical tests. Additional tests are performed based on the units designated use.

GIMC Dental units (19) – Panorex units (2) Test performed to comply with state and federal requirements.

The measurements were made in accordance with Radiation Regulatory Requirements and the NCRP Report No. 145, Radiation Protection In Dentistry. ACR Standard for Diagnostic Medical Physics Performance Monitoring of Radiologic and Fluoroscopic Equipment. Listed is a summary of typical tests. Additional tests are performed based on the units designated use.

· Entrance Skin Exposure rates

· kVp Accuracy

· Beam Quality

· Linearity

· Reproducibility

· Timer Accuracy (when applicable)

· Radiation output

· Collimator Congruency

· Safety Evaluation

· Unit Assembly Evaluation

THC Dental units (6) – Panorex units (1) Test performed to comply with state and federal requirements.

The measurements were made in accordance with Radiation Regulatory Requirements and the NCRP Report No. 145, Radiation Protection In Dentistry. ACR Standard for Diagnostic Medical Physics Performance Monitoring of Radiologic and Fluoroscopic Equipment. Listed is a summary of typical tests. Additional tests are performed based on the units designated use.

· Entrance Skin Exposure rates

· kVp Accuracy

· Beam Quality

· Linearity

· Reproducibility

· Timer Accuracy (when applicable)

· Radiation output

· Collimator Congruency

· Safety Evaluation

· Unit Assembly Evaluation

The essential responsibility of the Qualified Medical Physicist is to assure the safe and effective delivery of radiation to achieve a diagnostic or therapeutic result as prescribed in patient care. The medical physicist performs and reviews technical aspects of procedures necessary to achieve this objective. The responsibilities of the medical physicist include: protection of the patient and others from potentially harmful or excessive radiation the measurement and characterization of radiation; the determination of delivered dose; advancement of procedures necessary to ensure image quality; and assistance to other health care professionals in optimizing the balance between the beneficial and deleterious effects of radiation; and compliance with applicable federal and state regulations.

· Plan and specify thickness, material, and placement of shielding needed to protect patients, workers, the general public and the environment from radiation produced incident to diagnosis or treatment of humans

· Assess and evaluate installed shielding designed to protect patients, workers, and the general public from radiation produced incident to diagnosis or treatment of humans

· Develop radiation protection equipment specifications

· Develop procedures for the initial and continuing evaluation of radiation protection equipment and procedures

· Monitor compliance with radiation protection, policies and procedures, regulations, accreditation organization(s) standards, and national recommendations

· Perform acceptance testing and commissioning of radiation protection equipment and devices and commissioning of facilities

· Perform acceptance testing and evaluation of radiation protection computer systems, their algorithms, data, and output

· Evaluate radiation safety procedures prior to use

· Development, manage and/or evaluate a radiation safety program

· Provide radiation-protection training for medical practitioners, and other health-care providers

· Determine presence, evaluate and assess any radiological hazard resulting from the use of ionizing radiation or radioactivity for compliance with appropriate regulatory and accreditation agencies

Provide Medical Physicist site planning for radiation protection for planning new imaging equipment installations and specification compliance medical physicist surveys after installation.

Serves as Gallup Service Unit Radiation Safety officer including review of dosimetry reports with Diagnostic Imaging Supervisory Technologist and SU Safety officer

The medical physicist must summarize the Annual Medical Physicist’s Survey results on the Medical Physicist Mammography QC Test Summary form. Contractor shall provide a copy of the report to:

Contact Individuals: Stephen Friedman, M.D., Chief- 505-722-1162 Aaron Yuselew RT(R), Imaging Supervisor - 505-722-1164

TOTAL SUMMERY OF EQUIPMENT: