Medical Physicist/Radiation Safety Officer St. Cloud VAMC

SOURCES SOUGHT NOTICE
The Department of Veterans Affairs is seeking interested sources for the below listed requirement. The performance location will be at the St. Cloud, MN VAMC.
This sources-sought announcement is a tool to identify concerns with the capability to accomplish the work. This is not a solicitation.
Please provide the following to Mr. David A. Raad via email to david.raad@va.gov.
A capability statement expressing interest in this requirement, describing your company and its capability to complete this work. Include a statement detailing any special qualifications and certifications, applicable to the scope of this project, held by your firm and/or in-house personnel. Please indicate your business concern status, large business, small business, SDVOSB/VOSB.
The requirement consists of the following draft Statement of Work:
VA ST. CLOUD HEALTH CARE SYSTEM (SCVAHCS)
STATEMENT OF WORK
Certified Medical Physicist/Radiation Safety Officer
BACKGROUND:
The service of a Certified Medical or Health Physicist to provide on-site annual, and as needed, performance evaluation of imaging equipment and Radiation Safety Officer (RSO) duties for the St. Cloud VA Health Care System (SCVAHCS) in St. Cloud, Minnesota.
OBJECTIVES:
The SCVAHCS is seeking a solution to provide services of Medical Physicist/Radiation Safety Officer to fulfill the requirements of annual performance evaluation of imaging equipment and a Radiation Safety Officer. The incumbent will perform on-site annual, and as needed, performance evaluation of specified imaging equipment. The incumbent will also serve as the RSO for the organization and is responsible for the comprehensive Radiation Safety Program for the St. Cloud VA Health Care System, St. Cloud MN.
QUALIFIED PERSONNEL:
All Radiation Physicists performing services under this contract shall be 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. Certification must be maintained throughout the contract performance period. Personnel must also have experience in Hospital Medical Physics and be familiar with Minnesota and VA regulations. 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 5 days before new personnel will visit the SCVAHCS.
SCOPE OF WORK:
The Medical Physicist/RSO will complete annual, and as needed, performance evaluations on all specified imaging equipment. The Medical Physicist/RSO will perform radiation safety surveys within SCVAHCS facilities for the safe and effective use of its imaging equipment as established by the Occupational Health and Safety Administration (OSHA), Food and Drug Administration (FDA), Environmental Protection Agency (EPA), Department of Transportation (DOT), Veterans Health Administration (VHA), Officer Inspector General, The Joint Commission, the National Health Physics Program (NHPP), and the American College of Radiology (ACR).
RESPONSIBILITIES:
The Medical Physicist/Radiation Safety Officer is responsible to:
Annual performance evaluation and radiation safety for x-ray equipment
Annual performance evaluation of MRI, CT, Dexascan and Fluoroscopy equipment
Perform hazards testing
establish and implement radiation safety procedures and to review them periodically to assure their conformity with regulations, VA requirements, and good radiation safety and medical physics practices
instruct personnel in regulatory requirements and proper radiation protection practices
ensure the performance of radiation surveys, room shielding inspections, equipment testing and calibrations where indicated, and to keep records of such tests and surveys, including summaries of corrective measures recommended and/or instituted
assure that personnel monitoring devices are used where indicated, that records are kept of the results of such monitoring, and to review the monitoring reports promptly to ensure that personnel doses do not exceed regulatory limits and are ALARA
assure that required signs and notices are properly posted
To investigate each known or suspected case of excessive or abnormal exposure, to determine the causes, to take steps to prevent its recurrence, and make required reports
Able to provide 24 hour/365 day coverage for Radiation Safety emergencies
Implement and oversee the operational aspects of the Radiation Protection Program (RPP)
Ensure that radiation safety activities are being performed in accordance with approved procedures and regulatory requirements
Ensure quality control programs are working effectively and follow the local, state, national
regulations.
Ensure local guidelines and policies for the safe, effective use of diagnostic x-ray equipment are established by the Health Care System s Radiation Safety Committee.
Help identify and investigate radiation safety problems
Initiate, recommend, or provide corrective actions for identified safety problems
Verify implementation of corrective actions
Stop operations identified as unsafe
Notify management of radiation safety problems, unsafe operations, and corrective actions
Attend Radiation Safety Committee (RSC) quarterly meetings and make recommendations as needed
Ensure appropriate documentation is executed and available; RSO will provide a summary of major activities/tasks performed, including recommended corrective actions and consultations
Be available for contact by facility staff per regulations and license conditions
Provide Oversite
Inventory of survey meters, fixed/portable diagnostic & therapeutic x-ray devices, and ensures that quality controls are implemented including periodic surveys for exposure, calibration, linearity studies, safety equipment, and storage.
Coordinate with the SCVAHCS Imaging and BioMed department to assure annual hazard testing, and newly installed equipment and shielding acceptance testing is performed. This includes review of testing results and implementation of any corrections and/or recommendations.
Communicate with the facility Chief of Staff (COS), Chief of Imaging, Imaging Supervisor, and Administrative Officer to COS (Contracting Officer Representative - COR).
Facility dosimetry program from a National Voluntary Laboratory Accreditation Program (NVLAP) certified vendor for occupational exposure to ionizing radiation including monthly additions, collection, evaluation, reporting, distribution, and deletion of personal monitoring devices. Provides oversight of the personnel monitoring program and eliminating/reducing or controlling exposure to radiation hazards.
Instruction and consultation to personnel in Imaging, and support services who work or frequent nearby restricted areas where ionizing radiation is authorized.
Conduct onsite Annual Imaging Audits of the Imaging department: General X-Ray, Dexascan, CT, MRI and Fluoroscopy to include quality control, and quality assurance
MEDICAL PHYSICIST/RSO DUTY SPECIFICTIONS
Annual Performance Evaluation of Imaging Equipment
Annual performance evaluation and radiation safety of x-ray equipment
Annual performance evaluation of Computed Tomography (CT) equipment to include, but not limited to, the use of phantoms to assess the following imaging metrics:
Image uniformity
Scout prescription accuracy
Alignment light accuracy
Table travel accuracy
Radiation beam width
High contrast resolution
Low contrast detectability
Geometric or distance accuracy
CT number accuracy and uniformity
Artifact evaluation
Annual performance of Magnetic Resonance Imaging (MRI) equipment to include, but not limited to, the use of phantoms to assess the following imaging metrics
Image uniformity for all radiofrequency (RF) coils used clinical
Signal to noise ratio (SNR) for all coils clinically
Slice thickness accuracy
Slice position accuracy
Alignment light accuracy
High contrast resolution
Low contrast resolution (or contrast to noise ratio)
Geometric or distance accuracy
Magnetic field homogeneity artifact evaluation
Annual performance of Fluoroscopy equipment to include, but not limited to the assessment of the following:
Beam alignment and collimation
Tube potential/kilovolt peak (kV/kVp) accuracy
Beam filtration (half-value layer)
High-contrast resolution
Low-contrast detectability
Maximum exposure rate in all imaging modes
Displayed air-kerma rate and cumulative-air kerma accuracy (when applicable)
Testing of image acquisition display monitors for maximum and minimum luminance, luminance, uniformity, resolution, and special accuracy.
Provide a 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.
Provide a Shielding Plan/Evaluation (per the State of Minnesota) including a report for new x-ray rooms added during base/option periods.
Provide availability to discuss radiation safety by telephone and/or email.
Equipment will be inspected on an annual basis and as needed.
Action or Trigger Levels
Establish investigation levels for:
Personnel exposures
Patient exposures
As Low as Reasonably Achievable (ALARA)
Enforce the ALARA regulatory/license requirements
Inform/instruct workers of licensee/management commitment to ALARA
Investigate deviations from ALARA practices for cause, and implement changes
Audits/Reports/Reviews
Review (at least annually) the RPP content and implementation with management
Onsite Annual Imaging Audits of the Imaging department: general x-ray, dexa, CT, and Fluoroscopy to include quality control, and quality assurance
Audit (at least semiannually) the RPP and the ALARA program; document and report results to
management
Review (quarterly) occupational doses and prepares a summary report including individuals
exceeding trigger levels and regulatory limits
Audit (at least annually) the adequacy of procedures for preventing medical events; including,
written directive compliance and patient identification
Review incidents involving ionizing radiation with respect to cause and subsequent actions
taken
Report and notification of a medical event per regulation
Report and notification of an unintended dose to an embryo/fetus or a nursing child that
exceeds the regulatory limits
Annually review and update of the EPA s National Emission Standards for Hazardous Air Pollutants (NESHAPs), if required.
Annually review and update of the Fluoroscopy Safety Program including ALARA, shielding surveys, inventories, and equipment, calibration, and performance testing, quality management
program; policies, procedure and written directives
Annually review and update of OIG checklist on quality control, quality assurance
Annual onsite safety audit of surgery and dental department radiation practices
Attend quarterly Radiation Safety meetings
Review quarterly MRI quality control documents and sign
Facility Designation, Design, and Shielding
Identify addresses and areas of use
Identify restricted, unrestricted, and controlled areas
Consult on facility design and shielding
Instruction of Workers
Instruct workers likely to receive >100 mRem/year
Provide review and summary of the radiation safety program and summary to the Radiation Safety Committee.
Provide Annual Radiation safety training, which includes a radiation safety PowerPoint, and test for staff and personnel commensurate with risk of exposure to ionizing radiation from use of fluoroscopy, or x-rays covering the local, state, and federal regulations
Instruct supervised staff in radiation protection and radiation protection revisions before implementation, including:
Individuals of exceeding the regulatory dose limits
Report and notification of a medical event per regulation
Report and notification of an unintended dose to an embryo/fetus or a nursing child that
exceeds the regulatory limits
Operating procedures
Department of Transportation (DOT) training
Declared Pregnant Woman (DPW) regulations
Notification of RSO
Regulations and license conditions
Written directive procedures
Where do I wear my radiation badge training
Maintain a current license, submit amendment, and renewal requests in a timely manner
Develop, distribute, and implement up-to-date RPP procedures
Machine Registration/Calibration
Maintain current machine registrations
Assure that calibration and testing are performed per regulations and/or license conditions and
according to professional standards of good practice
Medical Events
Maintain written procedures to prevent medical and other addressable
events
Investigate medical events as to cause(s); identify and take timely, appropriate corrective
action(s)
Report medical events to management and to regulatory authorities per regulations
overexposures, accidents, medical events and other deviations from approved radiation safety practice, report event to the
appropriate authorities, and implement corrective
Patient Protection
Establish dose calibrator calibration and quality control procedures per regulations
Perform dose calibrator calibration and quality control procedures
Establish prescribed dosage list (AU approved)
Assay and record patient dosages
Enforce policy for identifying pregnant patients
Perform fetal dose measurements/estimations
Release per approved criteria/regulations
Radiation safety instructions provided
Personnel Monitoring
Establish a system to ensure that monitors are worn and returned in a timely manner, including:
Advise on who and when individuals should be monitored
Advise on where and how personnel monitoring devices shall be worn
Enforce the use of personnel monitoring devices
Establish a bioassay program consistent with regulatory requirements and use, if required
Perform and record bioassay measurements, if required
Interpret the results of personnel monitoring and bioassay measurements, if required
Advise the staff of their personnel monitoring and bioassay results, if required
Investigate doses exceeding trigger levels as to cause
Provide annual written reports to badge wearing staff
Provide written dose reports to staff who are separated from the facility
Post/Reference Documents and Notices
Post or reference:
Applicable rules or regulations
Post Notices of radiation effects in Imaging department
Notice to Employees
Posting and Labeling
Post or label:
Doors and/or rooms and areas
Pregnant Workers
Review previous occupational doses
Advise worker on dose reduction
Discuss Declared Pregnant Woman (DPW) status
Monitor monthly doses
Modify DPW job functions as necessary to keep conceptus dose below regulatory limit
Radiation Accidents
Attend institution s radiation accident committee and advise as necessary
Advise on the design of the radiation accident response plan
Assist in the response to radiological accidents or emergencies
Records
Provide a record system to help assure that the appropriate records are maintained in
accordance with applicable Regulations.
Surveys and Survey Instruments
Surveys for ambient radiation exposure rate
Radiation survey instrument calibrations
Management Skills
Interact effectively with medical facility staff
Present radiation safety information in a clear manner
Organize and maintain a record keeping system
Interact with regulatory agencies.
RSO Authority
The RSO will be provided sufficient authority to:
Implement the written RPP
Identify radiation safety problems
Initiate, recommend, or provide corrective actions
Terminate unsafe operations
Verify implementation of corrective actions and applicable State or Federal regulations
QUALITY CONTROL:
Work performed under this contract shall be subject to evaluation by the Contract Officers Representative (COR) in accordance with the contract terms and conditions.
PLACE(s) OF PERFORMANCE:
VA St. Cloud Health Care System
4801 Veterans Drive
St. Cloud, MN 56303
PERIOD OF PERFORMANCE:
Period of Performance will be one year post award with four (4) option periods.
EQUIPMENT:
Contractor shall furnish all labor, material, supplies, equipment and qualified personnel to provide on-site Radiation Physicist services and Radiation Safety Officer Duties at the St. Cloud VA 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.
TRAVEL:
Travel expenses will be covered under the contract.
SPECIAL REQUIREMENTS:
The work shall be performed during the St. Cloud VA Health Care System (SCVAHCS) regular administrative working hours of 8:00 AM through 4:30 PM, Monday through Friday excluding Federal Holidays. However, there may be times when the Contractor could be needed after regular working hours.
Federal Holidays: The 10 holidays observed by the Federal Government are:
New Year s Day Martin Luther King Day
President s Day Memorial Day
Independence Day Labor Day
Columbus Day Veterans Day
Thanksgiving Day Christmas Day
Any other day specifically declared by the President of the United States to be a
Federal Holiday.
Provision of 24 hour on-call services a day, 7 days a week, of contractor
Certified Health Physicist or Medical Physicist (Radiation safety officer) respond to emergency
situations within one (1) hour by phone and on-site within 8 hours if requested.
Physicist must be approved on Radiation Materials License by NHPP.
Change of times or dates of survey visits must be coordinated with the above-mentioned department at least two weeks in advance.
Provide written report of results to Imaging Supervisor or designee within ten (10) working days of performance of the survey
GENERAL PROVISIONS:
Services will be provided at the St. Cloud VA Health Care System (VAHCS), 4801 Veterans Drive, St. Cloud, Minnesota 56303-2099, and Brainerd Community Based Outpatient Clinic (CBOC), 722 NW 7th Street, Brainerd, Minnesota 56401.
Services will be provided at SCVAHCS during the hours of 8:00am 6:00pm, Monday through Friday, excluding Federal Holidays. Services will be provided the Brainerd CBOC during the hours of 8:00am-4:30pm, Monday through Friday excluding Federal Holidays. Inspection dates and times will be mutually agreed upon and established. Policy reviews may be provided via electronic means and submitted for review.
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.
Vendor will provide equipment calibration records for all equipment used to test equipment.
VA may increase the number of equipment items or test covered under this contract at no change to the applicable contract price schedule.
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