S02 36C24525Q0098 Diagnostic Medical Physicist.pdf

PAGE 1 OF 1. REQUISITION NO.

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NO. 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

a. NAME b. TELEPHONE NO. (No Collect Calls) 8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY CODE 10. THIS ACQUISITION IS UNRESTRICTED OR SET ASIDE: % FOR:

SMALL BUSINESS

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BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

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SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

17a. CONTRACTOR/OFFEROR CODE FACILITY CODE 18a. PAYMENT WILL BE MADE BY CODE

TELEPHONE NO. UEI: EFT:

PHONE: FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19. 20. 21. 22. 23. 24.

ITEM NO. SCHEDULE OF SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Govt. Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________ 29. AWARD OF CONTRACT: REF. ___________________________________ OFFER COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DATED ________________________________. YOUR OFFER ON SOLICITATION DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY (BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

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AUTHORIZED FOR LOCAL REPRODUCTION (REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

36C24525Q0098 11-14-2024

Sue Lepore, sue.lepore@va.gov (410) 642-2411 Ext. 26065 11-22-2024

1400 EST

Department of Veterans Affairs VA Maryland Health Care System Crystal Hinton, Contracting Officer (90C) Sue Lepore, Contracting Specialist (90C) P.O. Box 1000, Bldg. 101, Room 26 Perry Point MD 21902

X 100

X

541690

N/A

X

Contracting Officer (90C) P.O. Box 1000, Bldg. 101, Room 26

Sue Lepore, Contracting Specialist (90C) P.O. Box 1000, Bldg. 101C Room 3

Baltimore VA Medical Center 10 N Greene Street Baltimore, MD 21201

PAYMENT WILL BE MADE BY

FSC e-Invoice Payment Invoice must be submitted electronically http://www.fsc.va.gov/einvoice.asp Invoice Setup Information 1-877-489-6135

See CONTINUATION Page

Baltimore VA Medical Center is seeking Diagnostic Medical Physicist services for the Baltimore, Perry Point, and Loch Raven VAMCs. Contractor shall provide all labor, material, supplies, equipment, and qualified personnel to provide On-site diagnostic medical physics support or services in accordance with the attached Performance Work Statement.

Period of Performance: Base plus 4 option years.

Base: 12/01/2024 – 11/30/2025

OY 1: 12/01/2025 – 11/30/2026

OY 2: 12/01/2026 – 11/30/2027

OY 3: 12/01/2027 – 11/30/2028

OY 4: 12/01/2028 – 11/30/2029

Contractor shall be responsible for correct wages, titles, and compliance with applicable wages and hour laws.

See CONTINUATION Page

X X

X ONE

Crystal Hinton, Contracting Officer

36C24525Q0098

Table of Contents

SECTION A

A.1 SF 1449 SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

B.2 PRICE/COST SCHEDULE

ITEM INFORMATION

B.3 PERFORMANCE WORK SCHEDULE (PWS)

B.4 IT CONTRACT SECURITY

B.5 CONTRACTOR’S RESPONSIBILITY – CONTRACTORS PERFORMANCE ASSESSMENT

REPORTING SYSTEM (CPARS)

SECTION C - CONTRACT CLAUSES

C.1 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES (NOV 2023)

ADDENDUM to FAR 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL

PRODUCTS AND COMMERCIAL SERVICES

C.2 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

C.3 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000)

C.4 52.237-3 CONTINUITY OF SERVICES (JAN 1991)

C.5 SUPPLEMENTAL INSURANCE REQUIREMENTS

C.6 852.203-70 COMMERCIAL ADVERTISING (MAY 2018)

C.7 852.219-73 VA NOTICE OF TOTAL SET-ASIDE FOR CERTIFIED SERVICE-DISABLED

VETERAN-OWNED SMALL BUSINESSES (NOV 2022)

C.8 852.219-75 VA NOTICE OF LIMITATIONS ON SUBCONTRACTING—CERTIFICATE OF

COMPLIANCE FOR SERVICES AND CONSTRUCTION (JAN 2023) (DEVIATION)

C.9 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV 2018)

C.10 852.237-75 KEY PERSONNEL (OCT 2019)

C.11 852.242-71 ADMINISTRATIVE CONTRACTING OFFICER (OCT 2020)

C.12 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

C.13 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT STATUTES

OR EXECUTIVE ORDERS - COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES (MAY

2024)

C.14 MANDATORY WRITTEN DISCLOSURES

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

D.2 CONTRACTOR RULES OF BEHAVIOR

D.3 CONTRACTOR CERTIFICATION: IMMIGRATION AND NATIONALITY ACT OF 1952, AS

AMENDED

SECTION E - SOLICITATION PROVISIONS

E.1 52.212-1 INSTRUCTIONS TO OFFERORS – COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES (SEP 2023)

ADDENDUM to FAR 52.212-1 INSTRUCTIONS TO OFFERORS—COMMERCIAL PRODUCTS

AND COMMERCIAL SERVICES

E.2 52.201-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATION AND VIDEO

SURVEILLANCE SERVICES OR EQUIPMENT (NOV 2021)

E.3 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)

E.4 52.216-1 TYPE OF CONTRACT (APR 1984)

E.5 52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS AND VIDEO

SURVEILLANCE SERVICES OR EQUIPMENT (NOV 2021)

E.6 852.201-70 CONTRACTING OFFICER'S REPRESENTATIVE (DEC 2022)

E.7 852.233-70 PROTEST CONTENTI/ALTERNATIVE DISPUTE RESOLUTION (SEP 2018)

E.8 ALTERNATE PROTEST PROCEDURE (SEP 2018)

E.9 52.212-2 EVALUATION—COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES (NOV

2021)

E.10 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—COMMERCIAL

PRODUCTS AND COMMERCIAL SERVICES (MAY 2024)

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

BUSINESS NAME

ADDRESS

CITY/STATE/ZIP CODE

UEI

POINT OF CONTACT

EMAIL ADDRESS

TELEPHONE NUMBER

b. GOVERNMENT: Contracting Officer 36C245

Crystal Hinton, Contracting Officer Sue Lepore, Contracting Specialist Department of Veterans Affairs Department of Veterans Affairs VA Maryland Health Care System VA Maryland Health Care System NCO 5 Contracting Office (90C) NCO 5 Contracting Office (90C) Perry Point, MD 21902 Perry Point, MD 21902 Crystal.Hinont@va.gov Sue.Lepore@va.gov

(410) 642-2411 Ext. 26065

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

[X] 52.232-33, Payment by Electronic Funds Transfer—System for Award Management, or

[ ] 52.232-36, Payment by Third Party

3. INVOICES: Invoices shall be submitted in arrears:

a. Quarterly [ ]

b. Semi-Annually [ ]

c. Other [X] Monthly, in arrears

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

PAYMENT WILL BE MADE BY

FSC e-Invoice Payment Invoice must be submitted electronically http://www.fsc.va.gov/einvoice.asp Invoice Setup Information 1-877-489-6135

ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

AMENDMENT NO. DATE

5. CONTRACT MODIFICATIONS: The Contractor is advised that only the Contracting Officer, acting within the scope of the contract and his/her duties and responsibilities and after advice and consultation with the Contracting Officer’s Representative (COR), has the authority to make changes that will affect contract prices, quantity, quality, delivery terms and conditions, or the term of the contract. In no event shall any understanding or agreement, modification, change order, or other matters in deviation from the terms of this contract between Contractor and a person other than the Contracting Officer be effective or binding upon the Government. All such actions must be formalized by the proper contractual document executed by the Contracting Officer.

6. CONTRACTING OFFICER REPRESENTATIVE: The Contractor shall be provided a copy of the letter of delegation authorizing the Contracting Officer Representative (COR) at the commencement of the term of this contract. No other person shall be authorized to act in such capacity unless appointed in writing by the Contracting Officer.

7. CONTRACT PERFORMANCE: Contractor shall be required to begin providing Diagnostic Medical Physicist services under the contract awarded as a result of this solicitation beginning on the first date of the base period listed in the Schedule of Services. Failure to understand the contract requirements shall not relieve the Contractor from performing in accordance with the strict meaning and intent of the specifications. The Government will not reimburse any costs not incorporated into the Contractor’s price.

8. SOLICITATION/CONTRACT: This solicitation and resulting contract adheres to the format defined in Federal Acquisition Regulation (FAR) Part 13. An official copy of the FAR can be obtained at https://www.acquisition.gov/far/ .

9. STATUS AS INDEPENDENT ENTITIES: None of the provisions of this contract are intended to create or shall be deemed or construed to create any relationship between VA and the Contractor other than that of independent entities contracting with each other solely for the purpose of effecting the provisions of this contract. Neither VA nor the Contractor, nor any of their respective agents, employees or representatives, shall be construed to be the agent employee or representative of the other.

10. NON-SOLICITATION: Neither the Contractor nor any employee, agent or subcontractor of the Contractor shall solicit or attempt to convince or otherwise persuade any veteran not to participate or to discontinue participation in the services provided under this contract.

11. SECURE FAX: All faxes should contain the following language: “This fax is intended only for the use of the person or office to which it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that the receipt of this fax does not waive any applicable privilege or exemption for disclosure and that any dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please notify this office immediately at the telephone number listed above.”

12. PRIVACY AND CONFIDENTIALITY: Contractors to the Department of Veterans Affairs may be exposed to sensitive information. Information may be overheard, seen on documents or electronic devices, or observed that could potentially violate the privacy and confidentiality of our Veterans, employees, volunteers and their families. Regulations such as, but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Freedom of Information (FOIA) and Privacy Act of 1974 have been enacted to protect sensitive information from being improperly disclosed. Information should not be divulged or released to anyone unless specifically authorized by this contract or its attached documents accordance with the contracted services. Failure to comply with applicable statutes and regulation can result in the termination of this contract and civil and criminal penalties, including fines and imprisonment. All suspected or actual breeches of privacy and confidentiality should be reported immediately to the Contracting Officer, Contracting Officer Representative (COR) or the Facility Privacy Officer.

B.2 PRICE/COST SCHEDULE

The Contractor shall furnish key personnel to provide services necessary to perform onsite Diagnostic Medical Physicist Services at the Department of Veterans Affairs, Baltimore, Perry Point, and Loch Raven VA Medical Centers.

The Veterans Health Administration (VHA) has mandated that medical care facilities utilizing medical devices that emit radiation, both ionizing and non-ionizing, for diagnostic purposes, comply with American College of Radiology (ACR), American Association of Physicists in Medicine (AAPM) and The Joint Commission (TJC) standards. These standards require that medical physicists, are certified for the modality(ies) they test, have inspected, calibrated, and reviewed the system(s) to ensure they are safe for patient use and produce images that meet set standards.

Place of Performance: Services shall be provided on site.

VA Maryland Health Care System, 10 N. Greene St., Baltimore, MD 21201

Loch Raven VA Medical Center, 3901 The Alameda, Baltimore, MD 21218

Perry Point VA Medical Center, 361 Boiler House Road, Building 361, Perry Point, MD 21902

Period of Performance: Base plus four option years.

Base Year: December 1, 2024 – November 30, 2025

Option Year One (1): December 1, 2025 – November 30, 2026

Option Year Two (2): December 1, 2026 – November 30, 2027

Option Year Three (3): December 1, 2027 – November 30, 2028

Option Year Four (4): December 1, 2028 – November 30, 2029

Pricing Instructions: Offerors must fill out the cells in the following columns in the Price Schedule for each Contract Line-Item Number (CLIN). The contractor is to provide an Onsite Board-Certified Diagnostic Medical Physicist in accordance with Performance Work Statement for VAHMCS to test, inspect, calibrate, and review the system(s) to ensure they are safe for patient use and produce images that meet set standards.

ITEM INFORMATION

NAICS: 541690; PSC: Q522

Base Year: December 1, 2024 – November 30, 2025

CLIN Description Qty Unit Unit Cost

Total Annual

Cost

0001 PET 1 EA

0002 CT for PET 1 EA

0003 Nuc med Camera 3 EA

0004 Monitors for MRI 3 EA

0005 Dentals 22 EA

0006 Dental Pano 2 EA

0007 Radiographic 6 EA

Option Year One (1): December 1, 2025 – November 30, 2026

0008 CT 5 EA

0009 Cysto 2 EA

0010 R/F 4 EA

0011 MRI 3 EA

0012 Mammography 1 EA

0013 IR suites 3 EA

0014 Cardia Cath 1 EA

0015 New area survey 2 EA

0016 C-arm 10 EA

0017 Portables 6 EA

0018 Annual report 1 EA

0019 Nuc Med Qty Audit Report 4 EA

Base Year

Total

CLIN Description Qty Unit Unit Cost

Total Annual

Cost

1001 PET 1 EA

1002 CT for PET 1 EA

1003 Nuc med Camera 3 EA

1004 Monitors for MRI 3 EA

1005 Dentals 22 EA

1006 Dental Pano 2 EA

1007 Radiographic 6 EA

1008 CT 5 EA

1009 Cysto 2 EA

1010 R/F 4 EA

1011 MRI 3 EA

1012 Mammography 1 EA

1013 IR suites 3 EA

1014 Cardia Cath 1 EA

1015 New area survey 2 EA

1016 C-arm 10 EA

1017 Portables 6 EA

1018 Annual report 1 EA

1019 Nuc Med Qty Audit Report 4 EA

Option Year 1

Option Year Two (2): December 1, 2026 – November 30, 2027

Option Year Three (3): December 1, 2027 – November 30, 2028

CLIN Description Qty Unit Unit Cost

Total Annual

Cost

2001 PET 1 EA

2002 CT for PET 1 EA

2003 Nuc med Camera 3 EA

2004 Monitors for MRI 3 EA

2005 Dentals 22 EA

2006 Dental Pano 2 EA

2007 Radiographic 6 EA

2008 CT 5 EA

2009 Cysto 2 EA

2010 R/F 4 EA

2011 MRI 3 EA

2012 Mammography 1 EA

2013 IR suites 3 EA

2014 Cardia Cath 1 EA

2015 New area survey 2 EA

2016 C-arm 10 EA

2017 Portables 6 EA

2018 Annual report 1 EA

2019 Nuc Med Qty Audit Report 4 EA

Option Year 2

Cost

Total Annual

Cost

3001 PET 1 EA

3002 CT for PET 1 EA

3003 Nuc med Camera 3 EA

3004 Monitors for MRI 3 EA

3005 Dentals 22 EA

3006 Dental Pano 2 EA

3007 Radiographic 6 EA

3008 CT 5 EA

3009 Cysto 2 EA

3010 R/F 4 EA

3011 MRI 3 EA

3012 Mammography 1 EA

3013 IR suites 3 EA

3014 Cardia Cath 1 EA

3015 New area survey 2 EA

3016 C-arm 10 EA

Option Year Four (4): December 1, 2028 – November 30, 2029

FAR 52.217-8 Six (6) Months: December 1, 2029 – June 30, 2030

3017 Portables 6 EA

3018 Annual report 1 EA

3019 Nuc Med Qty Audit Report 4 EA

Option Year 3

Cost

Total Annual

Cost

4001 PET 1 EA

4002 CT for PET 1 EA

4003 Nuc med Camera 3 EA

4004 Monitors for MRI 3 EA

4005 Dentals 22 EA

4006 Dental Pano 2 EA

4007 Radiographic 6 EA

4008 CT 5 EA

4009 Cysto 2 EA

4010 R/F 4 EA

4011 MRI 3 EA

4012 Mammography 1 EA

4013 IR suites 3 EA

4014 Cardia Cath 1 EA

4015 New area survey 2 EA

4016 C-arm 10 EA

4017 Portables 6 EA

4018 Annual report 1 EA

4019 Nuc Med Qty Audit Report 4 EA

Option Year 4

Cost

Total Annual

Cost 4001a PET 0.5 EA

4002a CT for PET 0.5 EA

4003a Nuc med Camera 1.5 EA

4004a Monitors for MRI 1.5 EA

4005a Dentals 11 EA

4006a Dental Pano 1 EA

4007a Radiographic 3 EA

4008a CT 2.5 EA

4009a Cysto 1 EA

4010a R/F 2 EA

4011a MRI 1.5 EA

4012a Mammography 0.5 EA

4013a IR suites 1.5 EA

4014a Cardia Cath 0.5 EA

4015a New area survey 1 EA

4016a C-arm 5 EA

4017a Portables 3 EA

4018a Annual report 0.5 EA

4019a Nuc Med Qty Audit Report 2 EA

B.3 PERFORMANCE WORK SCHEDULE (PWS)

1. GENERAL

1.1 PURPOSE: The Veterans Health Administration (VHA) has mandated that medical care facilities utilizing medical devices that emit radiation, both ionizing and non-ionizing, for diagnostic purposes, comply with American College of Radiology (ACR), American Association of Physicists in Medicine (AAPM) and The Joint Commission (TJC) standards. These standards require that medical physicists, are certified for the modality(ies) they test, have inspected, calibrated, and reviewed the system(s) to ensure they are safe for patient use and produce images that meet set standards.

1.2 BACKGROUND: The VHA is responsible for ensuring qualified personnel provide on-site diagnostic medical physics services under the terms and conditions stated herein and must adhere to VHA Directive 1105.04 Fluoroscopy Safety, VHA Directive

1105.05 Magnetic Resonance (MR) Safety, and VHA Directive 1129 Radiation Protection for Machine Sources of Ionizing Radiation. Medical devices that are used to measure radiation or radioactive materials must comply with Nuclear Regulatory Commission (NRC) regulations and VHA permit conditions for the facility under the VHA MML (Master Materials License). These devices are required to be calibrated and tested annually by qualified medical physicists to ensure the devices are safe for measuring patient radiation doses, radiation being emitted from patients, or radioactive samples.

1.3 SCOPE: The Contractor shall comply with radiation protection standards in 29 CFR

1910.1096 and immediately report any unsafe conditions with the potential to adversely impact the facility radiation workers or patients to the Radiation Safety Officer (RSO). The contract requires one contractor to provide a “turnkey operation,” i.e., all inspection testing and calibration done by qualified diagnostic medical physicists directed to execute this contract, and their associated physics support equipment and services, shall be provided by one single qualified contractor/firm.

1.4 PLACES OF PERFORMANCE:

VA Maryland Health Care System, 10 N. Greene St., Baltimore, MD 21201

Loch Raven VA Medical Center, 3901 The Alameda, Baltimore, MD 21218

Perry Point VA Medical Center, 361 Boiler House Road, Building 361, Perry Point, MD 21902

1.5 PERIOD OF PERFORMANCE:

Base Year: December 1, 2024 – November 30, 2025

Option Year One (1): December 1, 2025 – November 30, 2026

Option Year Two (2): December 1, 2026 – November 30, 2027

Option Year Three (3): December 1, 2027 – November 30, 2028

Option Year Four (4): December 1, 2028 – November 30, 2029

1.6 AUTHORITY: Title 38 USC 8153, Health Care Resources (HCR) sharing authority

1.7 POLICY/HANDBOOKS:

1.7.1 VA Directive 1663: Health Care Resources Contracting – Buying https://www.va.gov/vapubs/viewPublication.asp?Pub_ID=969&FType=2

1.7.2 VHA Handbook 1907.01 Health Information Management and Health Records:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235

1.7.3 VHA Directive 1105 Management of Radioactive Materials:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9188

1.7.4 VHA Directive 1105.02 Nuclear Medicine and Radiation Safety Administrative Services: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=7519

1.7.5 VHA Directive 1105.03 Mammography Program Procedures and Standards:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=6423

1.7.6 VHA Directive 1105.04 Fluoroscopy Safety:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=7454

1.7.7 VHA Directive 1105.05 Magnetic Resonance (MR) Safety:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=6430

1.7.8 VHA Directive 1129 Radiation Protection for Machine Sources of Ionizing Radiation: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3081

1.7.9 VHA Directive 1200.05 Requirements for the Protection of Human Subjects in Research:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8171

1.7.10 US Nuclear Regulatory Commission for management and use of radioactive materials for medical use and radiation safety requirements, to include (but not limited to) 10 CFR Parts 19, 20, 30, 33, 35, and 71 https://www.ecfr.gov/current/title-10/chapter-I

1.7.11 Privacy Act of 1974 (5 U.S.C. 552a) as amended

http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm

1.8 DEFINITIONS/ACRONYMS:

1.8.1 AAPM: American Association of Physics in Medicine ABR: American Board of Radiology

1.8.2 ACR: American College of Radiology ACO: Administrative Contracting Officer

1.8.3 ALARA: As Low as Reasonably Achievable (least & lowest radiation exposure possible)

1.8.4 BAA: Business Associate Agreement

1.8.5 CAMPEP: Commission on Accreditation of Medical Physics Educational Programs

1.8.6 CDC: Centers for Disease Control and Prevention

1.8.7 CEU: Certified Education Unit

1.8.8 CME: Continuing Medical Education

1.8.9 CMS: Centers for Medicare and Medicaid Services CO: Contracting Officer

1.8.10 COR: Contracting Officer’s Representative COS: Chief of Staff

1.8.11 CPARS: Contractor Performance Assessment Reporting System

1.8.12 CPRS: Computerized Patient Record keeping System - electronic health record system used by the VA

1.8.13 CQI: Continuous Quality Improvement

1.8.14 CS: Contract Specialist

1.8.15 CT: Computed Tomography

1.8.16 DMP: Diagnostic Medical Physicist

1.8.17 DOT: Department of Transportation

1.8.18 DRL: Diagnostic Reference Level

1.8.19 EMR: Electronic Medical Record

1.8.20 HHS: Department of Health and Human Services

1.8.21 HICPAC: Healthcare Infection Control Practices Advisory Committee

1.8.22 HIPAA: Health Insurance Portability and Accountability Act

1.8.23 ISO: Information Security Officer J

1.8.24 PSR: Joint Patient Safety Reporting

1.8.25 MRI: Magnetic Resonance Imaging

1.8.26 NHPP: National Health Physics Program

1.8.27 NRSC: National Radiation Safety 1.8.27 Committee

1.8.28 OEM: Original Equipment Manufacturer

1.8.29 PET: Positron Emission Tomography

1.8.30 PACS: Picture Archiving and Communication System

1.8.31 POP: Period of Performance

1.8.32 PWS: Performance Work Statement

1.8.33 QASP: Quality Assurance Surveillance Plan

1.8.34 QAP: Quality Assurance Program

1.8.35 RSO: Radiation Safety Officer

1.8.36 SPE: Senior Procurement Executive

1.8.37 SPECT: Single-photon Emission Computed Tomography

1.8.38 TJC: The Joint Commission

1.8.39 TLD: Thermoluminescent Dosimeter

1.8.40 VA: Department of Veterans Affairs

1.8.41 VAMHCS: Veterans Affairs Maryland Health Care System

1.8.42 VHA: Veterans Health Administration

1.8.43 VISN: Veterans Integrated Service Network

1.8.44 MQSA: Mammography Quality Standards Act

2. HOURS OF WORK:

2.1 Normal business hours vary by department or service. Service shall be coordinated with the Contracting Officer Representative (COR) to minimize the impact to patient care.

2.2 Federal Holidays: The following holidays are observed by the Department of Veterans Affairs:

New Year’s Day

President’s Day

Martin Luther King’s Birthday

Memorial Day

Independence Day

Juneteenth

Labor Day

Columbus Day

Veterans Day

Thanksgiving

Christmas

Any day specifically declared by the President of the United States to be a national holiday.

3. QUALIFICATIONS:

3.1. Staff/Facility: All work shall be performed by a qualified diagnostic medical physicist.

3.1.1 Holds board certification in diagnostic radiologic physics or radiologic physics by the American Board of Radiology (ABR) or in Diagnostic Imaging Physics by the American Board of Medical Physics, or in Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine

3.1.2 Or for diagnostic computed tomography (CT), nuclear medicine, PET, or MRI, a minimum or three (3) years of documented clinical experience in CT, nuclear medicine, PET, or MRI is required.

3.1.3 For mammography, a qualified medical physicist must meet MQSA qualifications to perform mammography inspections.

4. SERVICES TO BE PROVIDED:

4.1. Equipment Testing – The qualified diagnostic medical physicist shall perform a full inspection of imaging equipment inspections annually or at a minimum every 14 months of the imaging equipment listed below. Ensure the imaging equipment’s compliance with applicable Federal regulations and ACR recommendations, and shall include, but not be limited to, monitoring the following basic performance characteristics.

4.1.1. Radiographic Fluoroscopic Equipment - Physics inspections of radiographic and fluoroscopic equipment shall comply with the ACR-AAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of Radiographic Equipment (Revised 2021) and ACR-AAPM Technical

Standard for Diagnostic Medical Physics Performance Monitoring of Fluoroscopic Equipment (Revised 2021). The performance of each radiographic and fluoroscopic unit must be evaluated at least annually. This evaluation must include, but not be limited to, the following tests (as applicable):

1. Mechanical and system safety evaluation

2. Functionality of all system indicators and interlocks

3. Radiation protection equipment

4. Acquisition display monitor performance (quantitative and visual assessment)

5. Integrity of unit assembly

6. Collimation and radiation beam alignment

7. Fluoroscopic system spatial resolution

8. Automatic exposure control system performance

9. Radiation beam centering and light field congruency

10. Accuracy of displayed radiation field size

11. Positive beam limitation functionality

12. Image quality: high contrast spatial resolution

13. Image quality: low contrast resolution

14. Image quality: flat-field artifact evaluation

15. kVp accuracy and reproducibility

16. Linearity of exposure versus mA or mAs

17. Exposure reproducibility

18. Timer accuracy and reproducibility

19. Collimation and radiation beam alignment

20. Beam quality assessment (half-value layer)

21. Image receptor entrance exposure

22. Equipment radiation safety functions

23. Review of adult protocols (fluoroscopic and acquisition)

24. Identification of isocenter location

25. Table/pad attenuation measurement

26. Fluoroscopic system high contrast spatial resolution

27. Fluoroscopic automatic brightness control performance (high-dose-rate, pulsed modes, field-of-view [FOV] variation)

28. Image quality assessment – system low contrast sensitivity

29. Patient dose monitoring system verification. This includes, for fluoroscopy systems, the displays of cumulative air Kerma and, if available, DAP

30. Digital image receptor performance

31. Grids used with portable x-ray units shall be imaged for uniformity.

32. Measurement of entrance skin exposure (or air Kerma) for a standard size patient for common radiographic projections and comparison to published diagnostic reference levels and achievable doses (e.g., ACR practice parameter.) (Minimally chest, abdomen, and lumbar spine)

33. Fluoroscopic phantom image quality.

34. Fluoroscopic entrance exposure rate (or air Kerma rate). Maximum output and output using a phantom representing a standard size patient for all clinically used settings. [The mode of operation [e.g., magnification mode, frame rate, and any other mode selected) must be documented for each measurement.]

35. Fluorographic (image recording) entrance exposure rate (or air Kerma rate) for cine imaging, if performed and entrance exposure (or air Kerma) for spot images (if performed). Maximum output and output using a phantom representing a standard size patient for all clinically used settings. [The mode of operation (e.g., magnification mode, frame rate, etc.) must be documented for each measurement.]

36. Scatter exposures to staff in both fluoroscopic and cine mode.

Note: The information on entrance exposure rates (or air Kerma rates) from fluoroscopy and from fluorography, for each fluoroscope, shall be in a format suitable for providing to the physicians who operate the fluoroscope

4.1.2. Computed Radiography (CR) and Digital Radiography (DR) - Physics inspections of CR and DR equipment shall comply with the American Association of Physicist in Medicine (AAPM) Report Number 93, Acceptance Testing and Quality Control of Photostimulable Storage Phosphor Imaging Systems. The performance of CR and DR must be evaluated at least annually and documented. This evaluation should include, but not be limited to, the following tests (as applicable):

1. Component and Imaging Plate Physical Inspection and Inventory

2. Imaging Plate Dark Noise and Uniformity

3. Exposure Indicator Calibration

4. Linearity and Auto-ranging Response

5. Laser Beam Function

6. Limiting Resolution and Resolution Uniformity

7. Noise and Low-Contrast Resolution

8. Spatial Accuracy

9. Erasure Thoroughness

10. Aliasing/Grid Response

11. IP Throughput

12. Positioning and Collimation Errors

4.1.3. Dental - The physics inspection shall conform to the Acceptance Testing and Quality Control of Dental Imaging Equipment, The Report of AAPM Task Group 175, September 2016. The performance of dental x- ray inspections shall be evaluated annually. This evaluation should include, but not be limited to, the following tests (as applicable):

1. Collimation

2. Beam quality (half value layer)

3. Timer Accuracy and Reproducibility

4. kVp Accuracy and Reproducibility

5. mA or mAs Linearity

6. Exposure Reproducibility

7. Entrance Skin Exposure Evaluation, with comparison to published diagnostic reference levels and achievable doses (e.g., NCRP Report No. 172)

8. Technique Chart Evaluation

9. Image uniformity (artifact evaluation)

10. Scattered Radiation Survey

11. Review of the technical QA program

4.1.4. Dental CBCT Performance Testing - Each CBCT unit shall undergo periodic quality control tests to ensure that the performance of the machine has not significantly deteriorated and is operating within the manufacturer’s technical specifications. This performance testing is performed by a qualified expert annually, at intervals not to exceed 14 months, and after repairs to the CBCT unit that may affect the radiation output or image quality. Some manufacturers provide a phantom and procedures to perform machine specific quality assurance (QA) tests. In cases where the manufacturer provides a phantom and procedures to perform specific tests, but the tests are not included in this PWS, then the manufacturer’s machine-specific QA tests shall be performed in addition to the QA tests in this PWS. Tests to include:

1. Radiation output Repeatability

2. kVp Accuracy

3. kVp Repeatability

4. kVp Reproducibility

5. Beam quality

6. Radiation field of view (FOV)

7. Image Quality

8. Image the phantom provided by the manufacturer or another suitable phantom. Assess high contrast spatial resolution, uniformity of trans axial images, and image noise. Imaging uniformity shall be assessed over the entire range of axial images.

9. Accuracy of Linear Measurements

10. Using images of an appropriate phantom, assess the accuracy of distance measurements.

11. Accuracy of Patient Dose Metric Indication

12. Assess the accuracy of the indicated dose metric (typically DAP)

13. Patient Dose Assessment-From a scan or scans using the facility’s standard techniques, record the dose metric (typically DAP) and compare to achievable levels and diagnostic reference levels (if available)

14. Review of the technical QA program.

15. Viewing Conditions - Assess the viewing conditions for the area in which the monitor used to evaluation the CBCT studies is located.

4.1.5. CT Scanners - The physics inspection shall conform to the ACR 2017

Computed Tomography Quality Control Manual (Revised 12-12-19) and ACR-AAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring (2017). The performance of each CT scanner shall be evaluated at least annually and documented. This evaluation should include, but not be limited to, the following tests (as applicable) and information:

1. Review of Clinical Protocols

2. Image Uniformity

3. Scout Prescription Accuracy

4. Alignment Light Accuracy

5. Image Thickness – Axial Mode

6. Table Travel Accuracy

7. Radiation Beam Width

8. High-Contrast Spatial Resolution

9. Low-Contrast Sensitivity and resolution

10. Noise

11. Spatial Resolution

12. Geometric or Distance Accuracy

13. CT Number Accuracy

14. CT Number Uniformity

15. Artifact Evaluation

16. Safety Evaluation

17. Visual Inspection-workload assessment

18. Scatter and stray radiation measurements

19. Audible/visual signals

20. Posting requirements

21. Image quality

22. Acquisition Display monitor assessment

23. Measures radiation dose (in CTDI vol) for imaging protocols for Adult brain, Adult Abdomen and verifies the radiation dose produced is within +/- 20% of the measured CTDIvol values)

24. Measurement of radiation output of scanner (CT dose index [CTDIvol] or other metric accepted by nationally recognized organization)

25. Measurement of doses for verification of scanner performance and to allow for calculation of dosimetric quantities relevant to patient examination estimates

26. Comparison of calculated values to scanner-reported values using both 16 cm and 32 cm dosimetry phantoms

27. Gray Level Performance of CT Acquisition Display Monitors.

28. Review of the technical QC program to ensure it includes:

29. Water CT number accuracy

30. Noise (CT number standard deviation)

31. Artifact Evaluation

32. Display devices (acquisition workstation and hard copy display unit)

33. Visual Checklist

4.1.6 MRI – The physics inspection shall conform to the 2015 ACR Magnetic Resonance Imaging Quality Control Manual. The performance of each MRI scanner shall be evaluated at least annually and documented. This evaluation should include, but but not be limited to, the following tests (as applicable):

1. ACR Phantom Tests:

a. Magnetic field homogeneity

b. Geometric or Distance accuracy

c. Inter-slice RF interference

d. Slice position accuracy

2. High-Contrast Spatial Resolution:

a. Low-contrast resolution

b. Slice thickness accuracy

c. Alignment light accuracy

d. Soft copy displays

e. Site phantom inventory

f. Site RF coil inventory

g. RF Coil Performance Tests

h. Image Uniformity for all RF coils used:

i. Volume coils’ signal-to-noise ratio

ii. Volume coils’ image uniformity

iii. Volume coils’ ghosting ratio

iv. Phased array coils' signal-to-noise ratio

v. Surface coils’ signal-to-noise ratio

i. Review of the technical QC weekly program to ensure it includes:

i. Setup and Position Accuracy

ii. Center Frequency

iii. Transmitter Gain/Attenuation

iv. Geometric Accuracy Measurements

v. High-contrast Spatial Resolution Measurements

vi. Low-contrast Detectability

vii. Artifact Assessment

viii. Visual Checklist

ix. Acquisition Display monitor assessment

4.1.7 Dual-Energy X-Ray Absorptiometry (DXA) - The physics inspection shall conform to the ACR-AAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of Dual-Energy X-Ray Absorptiometry (DXA) Equipment, 2020. The performance of DXA inspections shall be evaluated annually. This evaluation should include, but not be limited to, the following tests (as applicable):

1. Unit assembly integrity assessment

2. Tube-image receptor assembly motion assessment

3. Review of routine QC to verify that the density results remain in control

4. Radiographic uniformity assessment if provided by the vendor

5. Measurement of the entrance air Kerma for the most common clinical procedures

6. Verification of display dose and radiation output metrics (if applicable)

7. Acquisition display monitor’s performance

4.1.8 Nuclear Medicine SPECT/Gamma - The physics inspection shall conform to the ACR-AAPM Standard for Nuclear Medicine Physics Performance of Gamma cameras. The qualified diagnostic medical physics shall also review the quarterly testing as outlined by the ACR. The performance of each nuclear medicine scanner shall be at least annually. This evaluation should include, but not be limited to, the following tests (as applicable):

1. Intrinsic Uniformity (for each camera head) (NEMA method)

2. System Uniformity for all collimators

3. Intrinsic or System Spatial Resolution/linearity

4. System sensitivity (counter rate per unit activity & inter detector variability)

5. Relative Sensitivity

6. Energy Resolution

7. Count Rate Performance

8. Acquisition Display monitor assessment

9. Physical inspection, System Interlocks, and emergency shutdown mechanisms

10. Overall System Performance for SPECT

11. Uniformity and Artifact evaluation

12. Low contrast resolution

13. Spatial Resolution

14. Additionally, a review of the quality control program performed by the technologist must be reviewed for:

a. Daily uniformity Check

b. Daily CT Check (SPECT/CT)

c. Uniformity Calibration (monthly or as specified by Manufacturer)

d. Center-of-Rotation/Head Alignment (SPECT Systems)

4.1.9 PET/CT- The physics inspection shall conform to the ACR PET Phantom

Instructions for Evaluation of PET Image, ACR Nuclear Medicine Accreditation Program PET Module. The performance of each PET scanner shall be evaluated annually. For PET/CT units the CT must be inspected at least annually per CT requirements listed above. This evaluation should include, but not be limited to, the following tests (as applicable):

1. Image Uniformity

2. Count rate performance (count rate versus activity), including count loss correction

3. Spatial resolution

4. Image quality

5. Accuracy of CT-based attenuation and scatter correction, and SUV analysis

6. Image Co-registration

7. Safety Evaluation (mechanical and electrical)

8. Acquisition Display monitor assessment

9. Additionally, a review of the quality control program performed by the technologist must be reviewed for:

a. Daily PET Detector Check

b. Daily Water CT Number and SD Check

c. Daily Artifact Check

d. Visual Checklist

e. Monthly display Monitor SMPTE

4.1.10 Mammography – vendor shall perform an ACR Full Field Mammography Accreditation program evaluation, review of technologists Quality Control Guidelines and most current MQSA Final Rules and verify compliance with most current Mammography Quality Standards Act (MQSA). The vendor shall provide qualified personnel to perform and/or test FFD Mammography equipment to include but not limited to:

4.1.10.1 Physicist Performance evaluation of 3D Mammography equipment

a. Mammography Unit Assembly Evaluation

b. Collimation Assessment

c. Flat Field Uniformity Test

d. System Limiting Resolution

e. Detector Signal-to-Noise (SNR) measurement

f. AOP Mode and SNR Check

g. Phantom Image Quality

h. Contrast-to-Noise Ratio (CNR) Measurement

i. Signal-to-Noise Ratio versus Thickness

j. MTF Test

k. Focal Spot Evaluation

k. Artifact Evaluation

l. kVp Accuracy and Reproducibility

m. Beam Quality (Half-Value Layers [HVL]) Measurement

n. Breast Entrance Exposure, Average Glandular Dose and Radiationo.

Output Rate

p. Display Monitor Image Quality

q. Viewing Conditions Map

4.1.10.2 Review technologist Quality Control Program for Mammography – At the time of annual mammography equipment inspection, the vendor shall evaluate Mammography QC records for compliance with current MQSA requirements and educate/train as required, technologists involved in quality control testing (as defined by MQSA regulation and the OEM recommendations) of mammography equipment to include but not limited to:

a. Monitor Cleanliness & Viewing conditions

b. Flat Field Uniformity

c. Phantom Image quality

d. Compression Force Test & Summary Checklist

e. Repeat/Reject analysis

f. View box & Viewing conditions test

g. CNR Test – weekly Test

h. Review Workstation Monitor Check

i. Visual checklist

j. MTF Measurement

k. AOP Mode Check

l. QC Record Keeping

4.1.11 Display Monitors - The annual performance evaluation conducted by the diagnostic medical physicist includes testing of image acquisition display monitors for maximum and minimum luminance, luminance uniformity, resolution, and spatial accuracy. The image acquisition display monitors for nuclear medicine, PET, CT, MRI, and Mammography units shall be tested.

This shall be done as listed below:

4.1.11.1 Perform a visual analysis of the SMPTE test pattern.

a. Display the test pattern on the imaging console. Set the display window width/level to the manufacturer-specified values for the pattern. Do not set the window/level by eye; doing so invalidates the procedure.

b. Examine the pattern to confirm that the gray level display in the imaging console is subjectively correct.

c. Review the line pair patterns in the center and at each of the corners.

d. Review the black-white transition.

e. Look for any evidence of “scalloping” (loss of bit depth) or geometric distortion.

f. Use a photometer to measure the maximum and minimum monitor brightness (0% and 100% steps).

g. Measure additional steps within the pattern to establish a response curve.

h. Measure the brightness near the center of the monitor and near all 4 corners (or all 4 sides, depending on the test pattern used).

i. Viewing conditions – assess the viewing conditions for the area in which the monitor is used for evaluation of the studies are located.

5. Acceptance/new installation testing and annual testing of additional radiologist workstation monitors, located off VA campus in Radiologist’s home office –

5.1 Refer to Display monitors above regarding testing performance evaluation for these workstation monitors.

6. New equipment testing – the vendor shall perform, upon request, performance testing of new or relocated imaging equipment prior to first patient usage. The acceptance Testing shall comply with ACR, TJC, NHPP and MQSA requirements. Any deficiencies or non-conformances discovered during the inspection shall be verbally communicated to the RSO prior to the qualified diagnostic medical physicist leaving the facility. Deficiencies or non-conformances which represent unsafe conditions with the potential to adversely impact the facility radiation workers or patients shall be reported the RSO immediately upon discovery. A written report of the results shall be provided within 5 working days after completion of the inspection.

7. Nuclear Medicine Quarterly Audits – the diagnostic medical physicist shall perform quarterly testing on the below nuclear medicine equipment:

7.1 Dose Calibrators/Well Counter Systems - The services listed below shall be provided by a qualified medical physicist. The assessment shall be in accordance with manufacturers requirements both dose calibrator and well (most used isotopes). The tests shall be performed to help ensure compliance with applicable State, Federal, NRC, Joint Commission, NHPP, and ACR regulations and guidelines.

a. Dose Calibrator - Assessment for performance in accordance with manufacturers requirements (most used isotopes). Tests to include:

a. Constancy

b. Accuracy

c. Review that linearity and geometry has been performed. If not, then perform linearity (over the range of activity used using sleeve method) and geometry tests.

d. Geometrical variation shall be done after repair, replacement or if the equipment is relocated.

b. Well counter - Assessment for performance in accordance with manufacturers requirements (most used isotopes). Tests to include:

1. Minimal detectable activity verification

2. Review of correction factors

3. Auto calibration

4. Constancy

5. Reproducibility - Chi-Squared

6. Minimal detectible activity

7. Isotope Efficiencies both through factory installed software and manually

c. Sealed Source leak tests and inventory – the qualified medical physicist shall complete the following items quarterly:

1. Sealed source inventory

2. Sealed source leak test

7.2 Thyroid Uptake/Well Counter System - Assessment for performance in accordance with manufacturers requirements both uptake and well (most used isotopes). Tests to include:

a. Auto calibration

b. Constancy

c. Reproducibility – Chi-Squared

d. Minimal detectible activity verification

e. Isotope Efficiencies both through factory installed software and manually

f. Review of QC program

7.3 Shielding Design - The qualified diagnostic medical physicist shall provide shielding design calculations for each new, replaced, or relocated x-ray imaging system.

a. The calculations for each shall comply with the National Council for Radiation Protection and Measurements (NCRP) Report No. 147 X-ray imaging, for dental units, NCRP Report No. 145 applies and for PET/CT TG-108 for PET portion and NCRP 147 for CT portion.

b. Medical Physicist calculations shall be documented in a written report which includes a diagram showing adjacent areas, all lead shielding requirements shall be documented in US standards not metric standards. The qualified diagnostic medical physicist shall perform a shielding survey after construction completion to verify the structural shielding was installed per the shielding design report and complies with the design goals. A verbal approval may be provided, and a written report of the shielding survey shall be provided to the RSO within 14 calendar days after the shielding survey has been completed.

7.4 Electronic reports shall include:

a. Cover memo summarizing any results, issues (pass or fail) or recommendations for the equipment/device tested.

b. Specific to a single device (one report per device tested)

7.5 Written reports will contain documentation of the following:

1. Date of testing

2. Room number/Location of device tested

3. Name of device tested including serial number and VA Inventory number (EE/MX)

4. Protocol of test performed (for each test)

5. Test performed including all measured data, all data analysis

6. Copies of all acquired images analyzed (NM and PET systems)

7. Equipment used for testing, including phantoms

8. Evaluation results

9. Recommendations for correcting any problems identified

10. Annually, copies of calibration reports for equipment used in testing of any device.

11. Annually, copies of continuing education for each physicist who performed any testing of devices.

7.6 Perform a full inspection of imaging equipment after repairs or modifications that may affect the radiation output or image quality (X-ray tube, generator, or image receptor, repair, or replacement)

1. Deficiencies or non-conformances discovered during the inspection shall be verbally communicated to the service supervisor or RSO prior to the qualified diagnostic medical physicist leaving the facility

2. Deficiencies or non-conformances which represent unsafe conditions with the potential to adversely impact the facility radiation workers or patients shall be reported to the RSO immediately upon discovery.

3. A written report of the results shall be provided to the RSO within 14 calendar days after performing of the inspection.

7.7 Provide safety training – the qualified medical physicist shall provide DOT shipping and handling training for Nuclear Medicine staff. The training shall meet the requirements of 49 CFR, Part 172.700 which includes Hazardous regulations per HDR:

49 CFR.

7.8 Review CT protocols at least annually – the qualified medical physicist shall review and sign all CT protocols annually. The results of the annual review shall be documented in a report.

7.9 Review Fluoroscopy protocols at least annually – the qualified medical physicist shall review and sign fluoroscopy protocols. The results of the annual review shall be documented in a report.

7.10 Review patient doses – the qualified medical physicist shall review patient doses to determine compliance with TJC Sentinel Alert 147 at least annually and provide report to RSO. Staff and patient dose evaluation and /or dose reconstruction will be performed using industry recognized standards and best practices. Requested by the RSO on a needed basis.

7.11 QA annual program review – the qualified medical physicist shall review at least annually the radiation safety program. A written report of the results shall be provided to the RSO within 14 calendar days after performing the inspection.

7.11.1 Report to include but not be limited to

1. Personnel Dosimetry

2. Incidents, Accidents, Misadministration’s

3. Receipt of radioactive material

4. Procedures

5. Educational requirements

6. Inspections

7. NRC license status

8. Authorized users

9. Other ALARA considerations

7.12 If requested, the contractor shall assist in the development of a comprehensive technical quality assurance (QA) program, which complies with ACR recommendations, for all modalities.

1. Review at least annually the QA program (e.g., technique charts, repeat/reject analysis monitoring, monitoring of exposure indices to radiographic image receptors, QA program for display monitors, QA for CT, monitoring of dose metrics from fluoroscopy studies).

2. Written report of the results shall be provided to the service supervisor or RSO within 14 calendar days after performing the inspection.

3. Perform a follow-up inspection to verify compliance of any necessary corrective action performed to correct deficiencies found.

7.13 List of x-ray, MRI, and nuclear medicine machines

Baltimore

a. 1 - Mammography (3D)

b. 1 - Mammography Monitor

c. 2 - R/F Rooms (4 x-ray tubes)

d. 3 - Radiographic Rooms (digital)

e. 1 - Cardiac Cath Lab Fluoro unit

f. 2 - Angiography Suites (4 x-ray tubes)

g. 2 - MRI 3.0T and 1.5T

h. 4 - CT

i. 5 - Portable units

j. 10 - Portable C-Arms

k. 2 - Cysto Rooms

l. 3 - Nuclear medicine…