Q522--Health Physics - Dosimetrist

RFI 36C24522Q0580

MEDICAL PHYSICS AND RADIATION SAFETY SUPPORT

VAMC MARTINSBURG

The Martinsburg VA Medical Center is conducting this Sources Sought to identify contractors who possess capabilities to provide the services described in the Statement of Work below.

As permitted by the FAR Part 10, this is a market research tool being utilized for the informational and planning purposes. Your responses will assist the Government in the development of its acquisition strategy.

Response is strictly voluntary it is not mandatory to submit a response to this notice to participate in formal RFQ process that may take place in the future. However, it should be noted that information gathered through this notice may significantly influence our acquisition strategy. All interested parties will be required to respond separately to any solicitation posted as a result of this sources sought notice.

Respondents will not be notified of the results of the evaluation. We appreciate your interest and thank you in advance for responding to the sources sought.

This service will be implemented using the North American Industry Classification System (NAICS) Code 621399.

If a small business is interested in this procurement, they must provide at least 51 percent of the services rendered.

NOTES

All Capability Statements/Responses to this Sources Sought Notice shall be submitted via email only to Phillip.Duba@va.gov. Telephone, Fax, or any other form of communication inquiries will not be reviewed or accepted. Responses to this Sources Sought Notice must be received no later than May 20, 2022 at 3:00 p.m. (Eastern Standard Time). This Sources Sought Notice may or may not assist the VA in determining sources only. A solicitation is not currently available. If a solicitation is issued, it may or may not be announced at a later date, and all interested parties shall respond to that solicitation announcement separately from the responses to this Sources Sought Notice.

DISCLAIMER

This RFI is issued for information and planning purposes only and does not constitute a solicitation. All information received in response to this RFI that is marked a proprietary will be handled accordingly in accordance with (IAW) Federal Acquisition Regulation (FAR) 15.201(e), RFIs may be used when the Government does not presently intend to award a contract, but wants to obtain price, delivery, other market information, or capabilities for planning purposes. Responses to these notices are not offers and cannot be accepted by the Government to form a binding contract. Responders are solely responsible for all expenses incurred associated with responding to this RFI.

STATEMENT OF WORK

MEDICAL PHYSICS AND RADIATION SAFETY SUPPORT

VAMC MARTINSBURG

1. OBJECTIVES:

The contractor will assist in developing, maintaining, and overseeing a comprehensive Radiation Safety Program for Imaging Services at Veteran Affairs Medical Center Martinsburg (VAMCM) 510 Butler Avenue, Martinsburg, WV consistent with the requirements and/or guidelines of:

US Food and Drug Administration (FDA)

US Nuclear Regulatory Commission (NRC)

VHA National Health Physics Program (NHPP)

American College of Radiology (ACR)

The Joint Commission (TJC)

VHA Directive 1105 2015-02-05-Management of Radioactive Materials

VHA Directive 1105.02 2015-08-29- Nuclear Medicine and Radiation Safety Service

VHA Directive 1105.04 D 201806/21-Fluoroscopy Safety

VHA Directive 1105.05 D 2018-05-29- Magnetic Resonance Imaging Safety

VHA Directive 1129-2015-Radiation Protection for Machine Sources of Ionization

2. GENERAL PROVISIONS OF SERVICES:

The contractor shall provide the names, titles and licenses and delineate their role. This also shall include all ACR Certified Medical Physicist that oversees operations of the contractor work and organizational chart.

The contractor must have at least ten years of experience providing health physics support to medical facilities.

The contractor shall provide all labor, material, supplies, equipment, and qualified personnel for initial acceptance and periodic Quality Assurance Testing of all diagnostic imaging equipment. The diagnostic imaging equipment consists of diagnostic X-ray units, Fluoroscopy, Computerized Tomography (CT), Ultrasound (US), Magnetic Resonance Imaging (MRI), Nuclear Medicine gamma cameras, Positron Emission Tomography (PET), and Dental X-ray units.

The contractor shall perform Quality Assurance Testing in accordance with the latest ACR requirements and Joint Commission standards. This shall include CT, MRI, NM Cameras with CT capability Dental X-ray, and Ultrasound. This service shall be performed by ACR Certified Medical Physicist(s).

The contractor shall provide QA on machines initially installed or repaired with issues that could affect the radiation output of the machine.

The physicist shall have the basic ability to operate the equipment with minimal input from VAMCM personnel.

Perform dose estimates form radiation producing machined or radioactive material exposure and provide a report within a minimum of 10 business days.

The contractor shall review the departments radiation safety policies and procedures on an annual basis. This will be in accordance with standards set forth by regulatory authority, as week as recommendations of accreditation bodies. Assistance will be provided in the development of written procedures.

The contractor shall have the ability to have an ACR Certified Medical Physicist on site within 48 hours in cases of emergency to certify newly repaired equipment that is essential to hospital operations. This includes Computerized Tomography (CT), Magnetic Resonance Imaging (MRI). All other equipment will be expected to certify equipment ASAP but no later than 72 hours.

The contractor shall have the capability to provide an ACR Certified Medical Physicist or Qualified Health Physicist to be on site within 1.5 hrs. driving distance of our facility to assist if urgent radiation safety or regulatory matters that may arise.

The contractor shall be familiar with the Radmetix to monitor exposure analysis of CT exams at least quarterly, and report results to the Radiation Safety Committee.

QA performed on radiation producing machines, Nuclear Medicine gamma cameras and PET/CT will be provided to the COR. The documentation will contain the standards set forth by regulatory authority and accreditation bodies.

The contractor shall provide radiation dosimetry devices for all employees designated by VAMCM as radiation workers. The review of dose exposure will be conducted by the contractor upon request of VAMC Martinsburg (VAMCM) or at least quarterly and presented to the Radiation Safety Committee

The contractor will check the integrity of the lead aprons, skirts, vests, thyroid shields, and gloves.

The contractor will provide consultation by telephone of email when needed.

The contractor shall provide an annual schedule of duties that will be performed

3. EQUIPMENT LIST:

7 Diagnostic x-ray machines

2 CT units

1 MRI unit

6 C-Arms

1 Hybrid X-ray Unit (OR)

1 IR Unit

4 Portable x-ray machines

5 Ultrasound machines (annually)

3 Gamma cameras, one of which is a SPECT/CT

1 DEXA camera

1 PET-CT unit

25 Dental x-ray machines

4. DIAGNOSTIC RADIOLOGY

The contractor will perform annual Quality Assurance testing of all diagnostic radiation producing machines in accordance with American College of Radiology (ACR), and Joint Commission (JC) standards. This includes major repairs involving x-ray tube replacement, detector assembly replacement, HV generator replacement or software upgrades.

The survey criteria are those of the National Council on Radiation Protection, Report No. 102, "Medical X-ray and Gamma Ray Protection for Energies Up to 50 MeV"; Report No. 105, "Radiation Protection for Medical and Allied Health Personnel"; Report No. 147, "Structural Shielding Design and Evaluation for Medical X-Ray Imaging Facilities, and applicable State regulations.

Evaluation of radiographic equipment will include:

A visual inspection of the room/unit ensuring that applicable warning labels and caution signs are present and a determination of proper function of all radiographic control devices.

SID measurement versus indicated SID distance.

Alignment of the X-ray field versus the visual field.

Measurement of X-ray field versus indicated field.

Measure of alignment between center of the X-ray field and center of image receptor/light field.

Measurement of illuminance of light localizer.

Automatic collimation accuracy determination if applicable.

Evaluation of timer accuracy and reproducibility if applicable.

Evaluation of exposure reproducibility.

kVp evaluation.

Radiation output measurements at kVp ranges used clinically. Bean filtration (Half Value Layer).

Determination of mA station linearity.

Annual update of the Patient Radiation Exposure Monitoring Program in accordance with guidelines established by the U.S. Department of Health and Human Services, Food and Drug Administration (FDA). Our program will satisfy the current Joint Commission standard for monitoring doses from diagnostic radiology procedures.

Additional evaluations specific to direct capture digital radiographic units:

High Contrast Resolution

Low Contrast Resolution

Dynamic range of System

Evaluation of fluoroscopic equipment will include:

A visual inspection of the room/unit ensuring that applicable warning labels and caution signs are present and a determination of proper function of all fluoroscopic control devices.

Beam alignment and collimation.

Evaluation of fluoroscopic interlock system.

Maximum Exposure Rate in all imaging modes.

Displayed air-kerma rate and cumulative air kerma accuracy (when applicable).

High-contrast resolution.

Low-contrast detectability.

Beam filtration (Half Value Layer).

Radiation measurement of primary beam transmission and secondary scatter radiation.

Evaluation of fluoroscopic field size versus visible area.

Measurement of fluoroscopic source to skin distance.

STATEMENT OF WORK

MEDICAL PHYSICS AND RADIATION SAFETY SUPPORT

VAMC MARTINSBURG

OBJECTIVES:

The contractor will assist in developing, maintaining, and overseeing a comprehensive Radiation Safety Program for Imaging Services at Veteran Affairs Medical Center Martinsburg (VAMCM) 510 Butler Avenue, Martinsburg, WV consistent with the requirements and/or guidelines of:

US Food and Drug Administration (FDA)

US Nuclear Regulatory Commission (NRC)

VHA National Health Physics Program (NHPP)

American College of Radiology (ACR)

The Joint Commission (TJC)

VHA Directive 1105 2015-02-05-Management of Radioactive Materials

VHA Directive 1105.02 2015-08-29- Nuclear Medicine and Radiation Safety Service

VHA Directive 1105.04 D 201806/21-Fluoroscopy Safety

VHA Directive 1105.05 D 2018-05-29- Magnetic Resonance Imaging Safety

VHA Directive 1129-2015-Radiation Protection for Machine Sources of Ionization

GENERAL PROVISIONS OF SERVICES:

The contractor shall provide the names, titles and licenses and delineate their role. This also shall include all ACR Certified Medical Physicist that oversees operations of the contractor work and organizational chart.

The contractor must have at least ten years of experience providing health physics support to medical facilities.

The contractor shall provide all labor, material, supplies, equipment, and qualified personnel for initial acceptance and periodic Quality Assurance Testing of all diagnostic imaging equipment. The diagnostic imaging equipment consists of diagnostic X-ray units, Fluoroscopy, Computerized Tomography (CT), Ultrasound (US), Magnetic Resonance Imaging (MRI), Nuclear Medicine gamma cameras, Positron Emission Tomography (PET), and Dental X-ray units.

The contractor shall perform Quality Assurance Testing in accordance with the latest ACR requirements and Joint Commission standards. This shall include CT, MRI, NM Cameras with CT capability Dental X-ray, and Ultrasound. This service shall be performed by ACR Certified Medical Physicist(s).

The contractor shall provide QA on machines initially installed or repaired with issues that could affect the radiation output of the machine.

The physicist shall have the basic ability to operate the equipment with minimal input from VAMCM personnel.

Perform dose estimates form radiation producing machined or radioactive material exposure and provide a report within a minimum of 10 business days.

The contractor shall review the departments radiation safety policies and procedures on an annual basis. This will be in accordance with standards set forth by regulatory authority, as week as recommendations of accreditation bodies. Assistance will be provided in the development of written procedures.

The contractor shall have the ability to have an ACR Certified Medical Physicist on site within 48 hours in cases of emergency to certify newly repaired equipment that is essential to hospital operations. This includes Computerized Tomography (CT), Magnetic Resonance Imaging (MRI). All other equipment will be expected to certify equipment ASAP but no later than 72 hours.

The contractor shall have the capability to provide an ACR Certified Medical Physicist or Qualified Health Physicist to be on site within 1.5 hrs. driving distance of our facility to assist if urgent radiation safety or regulatory matters that may arise.

The contractor shall be familiar with the Radmetix to monitor exposure analysis of CT exams at least quarterly, and report results to the Radiation Safety Committee.

QA performed on radiation producing machines, Nuclear Medicine gamma cameras and PET/CT will be provided to the COR. The documentation will contain the standards set forth by regulatory authority and accreditation bodies.

The contractor shall provide radiation dosimetry devices for all employees designated by VAMCM as radiation workers. The review of dose exposure will be conducted by the contractor upon request of VAMC Martinsburg (VAMCM) or at least quarterly and presented to the Radiation Safety Committee

The contractor will check the integrity of the lead aprons, skirts, vests, thyroid shields, and gloves.

The contractor will provide consultation by telephone of email when needed.

The contractor shall provide an annual schedule of duties that will be performed

EQUIPMENT LIST:

7 Diagnostic x-ray machines

2 CT units

1 MRI unit

6 C-Arms

1 Hybrid X-ray Unit (OR)

1 IR Unit

4 Portable x-ray machines

5 Ultrasound machines (annually)

3 Gamma cameras, one of which is a SPECT/CT

1 DEXA camera

1 PET-CT unit

25 Dental x-ray machines

DIAGNOSTIC RADIOLOGY

The contractor will perform annual Quality Assurance testing of all diagnostic radiation producing machines in accordance with American College of Radiology (ACR), and Joint Commission (JC) standards. This includes major repairs involving x-ray tube replacement, detector assembly replacement, HV generator replacement or software upgrades.

The survey criteria are those of the National Council on Radiation Protection, Report No. 102, "Medical X-ray and Gamma Ray Protection for Energies Up to 50 MeV"; Report No. 105, "Radiation Protection for Medical and Allied Health Personnel"; Report No. 147, "Structural Shielding Design and Evaluation for Medical X-Ray Imaging Facilities, and applicable State regulations.

Evaluation of radiographic equipment will include:

A visual inspection of the room/unit ensuring that applicable warning labels and caution signs are present and a determination of proper function of all radiographic control devices.

SID measurement versus indicated SID distance.

Alignment of the X-ray field versus the visual field.

Measurement of X-ray field versus indicated field.

Measure of alignment between center of the X-ray field and center of image receptor/light field.

Measurement of illuminance of light localizer.

Automatic collimation accuracy determination if applicable.

Evaluation of timer accuracy and reproducibility if applicable.

Evaluation of exposure reproducibility.

kVp evaluation.

Radiation output measurements at kVp ranges used clinically. Bean filtration (Half Value Layer).

Determination of mA station linearity.

Annual update of the Patient Radiation Exposure Monitoring Program in accordance with guidelines established by the U.S. Department of Health and Human Services, Food and Drug Administration (FDA). Our program will satisfy the current Joint Commission standard for monitoring doses from diagnostic radiology procedures.

Additional evaluations specific to direct capture digital radiographic units:

High Contrast Resolution

Low Contrast Resolution

Dynamic range of System

Evaluation of fluoroscopic equipment will include:

A visual inspection of the room/unit ensuring that applicable warning labels and caution signs are present and a determination of proper function of all fluoroscopic control devices.

Beam alignment and collimation.

Evaluation of fluoroscopic interlock system.

Maximum Exposure Rate in all imaging modes.

Displayed air-kerma rate and cumulative air kerma accuracy (when applicable).

High-contrast resolution.

Low-contrast detectability.

Beam filtration (Half Value Layer).

Radiation measurement of primary beam transmission and secondary scatter radiation.

Evaluation of fluoroscopic field size versus visible area.

Measurement of fluoroscopic source to skin distance.

A complete written report will be provided for each machine evaluated. The report will reflect items of both compliance and non-compliance in accordance with applicable requirements of regulatory authority.

COMPUTER TOMOGRAPHY (CT)

The contractor will perform annual Quality Assurance testing of all diagnostic CT in accordance with American College of Radiology (ACR), and Joint Commission (JC) standards. This includes major repairs involving x-ray tube replacement, detector assembly replacement, HV generator replacement or software upgrades.

Annually, a ACR Certified Medical Physicist will perform a performance evaluation of CT scanner. A formal report of these evaluations will be made.

The parameters to be examined during the annual performance evaluation will be consistent with the most current accreditation body standards and/or recommendations, and include the following:

Protocol Review:

Adult Head, Abdomen, and High-Resolution Chest

Brain Perfusion (when applicable)

Phantom & Scanner Alignment

Alignment light accuracy

Scout Prescription accuracy including slice position accuracy

Table travel accuracy

Gantry tilt accuracy

Radiation Beam Width

CT Number Accuracy & Uniformity

Low Contrast Performance (including CNR & Low Contrast Resolution)

Image Uniformity and Noise

Distance Calibration Accuracy

Artifact Evaluation

High Contrast Spatial Resolution

Image Acquisition Display Monitor Evaluation

Patient Dosimetry Measurement of a dosimetry index utilizing the clinical protocol for:

Adult Head & Adult Abdomen,

Dose Index Display Verification

Measured CTDIvol to be within 20% of indicated value)

Review of the routine quality assurance tests being performed by the CT staff.

Review the results of periodic spot checks that are performed in accordance with CT manufacturer recommendations, State regulations and accreditation body standards.

CONE BEAM CT ANNUAL PERFORMANCE EVALUATIONS

Annually, a ACR Certified Medical Physicist will perform a performance evaluation of cone beam CT scanner.

A formal report of these evaluations will be made, and include the following:

Image Quality

Image quality will be evaluated using the manufacturer s recommendations using the manufacturer s QA phantom when applicable.

Dosimetry Measurement of a dosimetry index utilizing the manufacturer s suggested protocols. Dosimetry analysis will include:

Dose Index Comparison to the most recent annual evaluation

Dose Index Display Verification, when applicable

(Measured CTDIvol to be within 20% of indicated value)

NON-DIAGNOSTIC CT (ATTENUATION ONLY) ANNUAL PERFORMANCE EVALUATIONS

Annually, an ACR Certified Medical Physicist will perform a performance evaluation of non-diagnostic CT scanner. (PET-CT, SPECT-CT)

A formal report of these evaluations will be made, and include the following:

Image Quality

Image quality will be evaluated using the manufacturer s recommendations using the manufacturer s QA phantom.

Dosimetry Measurement of a dosimetry index utilizing the manufacturer s suggested protocols.

Dosimetry analysis will include:

Dose Index Comparison to the most recent annual evaluation

Dose Index Display Verification, when applicable

(Measured CTDIvol to be within 20% of indicated value)

CONE BEAM CT ANNUAL PERFORMANCE EVALUATIONS

Annually, an ACR Certified Medical Physicist will perform a performance evaluation of cone beam CT scanner.

A formal report of these evaluations will be made, and include the following:

Image Quality

Image quality will be evaluated using the manufacturer s recommendations using the manufacturer s QA phantom when applicable.

Dosimetry Measurement of a dosimetry index utilizing the manufacturer s suggested protocols. Dosimetry analysis will include:

Dose Index Comparison to the most recent annual evaluation

Dose Index Display Verification, when applicable

(Measured CTDIvol to be within 20% of indicated value)

CT MAJOR REPAIR

Following Major Repair, an ACR Certified Medical Physicist will perform a performance evaluation of CT scanner. A formal report of these evaluations will be made, and include the following:

Image Quality

Image quality will be evaluated by the discretion of the qualified medical physicist.

May include a facility QA review or an ACR QA Phantom evaluations using the facility s Adult Abdomen Protocol.

Patient Dosimetry Measurement a dosimetry index utilizing the clinical protocol for:

Adult Head & Adult Abdomen,

Dose Index Comparison to the most recent annual evaluation

Dose Index Display Verification

(Measured CTDIvol to be within 20% of indicated value)

MAGNETIC RESONANCE IMAGING (MRI)

On an annual basis, conduct equipment performance testing of the number of MRI units. The parameters to be examined on an annual basis will be consistent with accreditation body requirements and will be conducted

At an interval six (6) months after the annual performance testing, conduct spot checks of MRI equipment performance and review and evaluate MRI quality assurance program. Review the results of routine quality control tests as performed in-house and evaluate parameters.

Contractor will instruct the technologist on proper weekly QC testing procedures. These weekly tests should include the following:

Center frequency

Table positioning

Set-up and scanning

Geometric accuracy

High contrast resolution

Low contrast resolution

Artifact analysis

Film quality control (weekly) if applicable

Visual checklist (weekly)

On an annual basis, contractor will perform an on-site evaluation of MRI performance. A formal report of these evaluations will be made. The parameters to be examined on an annual basis will be consistent with ACR and Joint Commission requirements and include the following:

Magnetic Field homogeneity

Alignment Light Accuracy

Geometric or Distance Accuracy

High Contrast Resolution

Low Contrast Resolution

Slice Position Accuracy

Slice Thickness Accuracy

Radio Frequency coil checks (Uniformity & SNR all coils used clinically)

Image Acquisition Display Monitor Evaluation

Artifact Evaluation

ULTRASOUND

On an annual basis, conduct equipment performance testing of ultrasound units. The parameters to be examined on an annual basis will be conducted.

Test criteria are based upon the American College of Radiology Accreditation requirements and will include the following:

Electrical and mechanical safety

Image acquisition display monitor evaluation

The following parameters will be evaluated for the transducers that are in use :

Uniformity and Artifact Survey

Depth of Penetration

Near Field Resolution

Spatial Resolution (Axial and Lateral)

Vertical Distance Calipers

Horizontal Distance Calipers

Visualization of Low Scatter Masses

Visualization of High Scatter Masses

GAMMA CAMERA PERFORMANCE EVALUATION

On an annual basis, contact equipment performance testing of the number of SPECT and planar gamma cameras. The parameters to be examined on an annual basis will be consistent with accreditation body standards and be conducted as outlined:

The parameters to be examined during the annual performance evaluation will be consistent with the most current ACR Program Requirements and The Joint Commission Diagnostic Imaging Standards Elements of Performance requirements, and include the following:

Physical Inspection (including checks of System Interlocks)

Intrinsic Uniformity

System Uniformity (include all commonly used collimators)

Intrinsic or System Spatial (high contrast) Resolution

Energy Resolution (when capable/system dependent)

Count Rate Performance

Sensitivity Performance

SPECT Performance (if applicable)

Uniformity

Artifact Evaluation

Resolution

Contrast Evaluation

Acquisition Display Monitor Performance Evaluation

Dose Calibrator Performance & QA review

Thyroid Uptake and Counting System(s) Performance Evaluation(s)

Review of the technologist quality assurance tests that are performed and documented by the NM staff.

On a semi-annual basis, a qualified medical physicist will complete SPECT Performance testing.

The contractor will provide Deluxe Jaszcsak phantom for SPECT Performance testing

PET SCANNER PERFORMACNE EVALUATION

On an annual basis, conduct equipment performance testing of the number of PET scanners. The parameters to be examined will be consistent with accreditation body standards and/or requirements

At an interval six (6) months after annual performance testing, perform an on-site ACR phantom evaluation of the number of PET scanners

On an annual basis, an ACR Certified Medical Physicist will complete a performance evaluation of PET imaging equipment. A formal report of these evaluations will be made.

The parameters to be examined during the annual performance evaluation will be consistent with the most current ACR Program Requirements and The Joint Commission Diagnostic Imaging Standards Elements of Performance requirements, and include the following:

Physical Inspection

Phantom Performance Evaluation

Uniformity

Artifact Evaluation

Spatial Resolution

Contrast Evaluation

SUV analysis

Acquisition Display Monitor Performance Evaluation

Dose Calibrator Performance & QA review

Counting System(s) Performance Evaluation(s)

Review of the technologist quality assurance tests that are performed and documented by the PET staff.

On a semi-annual basis, a qualified medical physicist will complete PET Phantom Performance Evaluations (if applicable and necessary).

(RAM) AUDIT- NUCLEAR MEDICINE

On a quarterly basis, the contractor shall conduct radiation protection audits in the Nuclear Medicine Department to ensure conformance with the regulatory body license requirements. The audits will include testing for radiation level measurements in areas of typical exposure, review of staff-conducted surveys and other pertinent records.

Attendance at meetings of the Radiation Safety Committee when scheduled to coincide with survey.

Prepare documentation for radioactive material licensure, to include license amendments, renewal applications, etc. Provide responses to and interpretation of regulatory action.

Where applicable, the following services are also provided:

Quarterly linearity determination of the dose calibrator based on data submitted by the staff.

Quarterly inventory and leak test of all sealed sources of radioactive material.

Annual counting system(s) quality assurance testing

Manage the calibration of the number of radiation survey meters, ion chambers and pocket dosimeters, as noted on by a licensed calibration facility each year.

Provide the Annual Radiation Safety Officer Program Audit as required under federal regulations.

Quarterly review of dosimetry reports to ensure that doses do not exceed regulatory limits or limits assigned by the Radiation Safety Committee

RADIOACTIVE MATERIAL (RAM) AUDIT- PET/CT

On a quarterly basis, conduct radiation protection audits in the PET Department to ensure conformance with the current regulatory body license requirements. The audits will include testing for radiation level measurements in areas of typical exposure, review of staff-conducted surveys and other pertinent records.

Attendance at meetings of the Radiation Safety Committee when scheduled to coincide with survey.

Prepare documentation for radioactive material licensure, to include license amendments, renewal applications, etc. Provide responses to and interpretation of regulatory action

The following services are also provided:

Quarterly linearity determination of the dose calibrator based on data submitted by the staff. The site is responsible for maintaining an approved device if they choose to use the attenuation method of evaluation.

Quarterly inventory and leak test of all sealed sources of radioactive material.

Annual counting system(s) quality assurance testing.

Manage the calibration of the number of radiation survey meters, ion chambers and pocket dosimeters, by a licensed calibration facility each year.

DENTAL X-RAY MACHINES

The contractor shall provide QA testing for each machine in accordance with VHA Directives

RADIATION SAFETY (RSO) SERVICES

The contractor shall provide limited RSO services for the administration of the use of radiation producing machine and non-radiation imaging equipment. They will assist the VAMCM RSO with this program in accordance with regulatory and Accreditation bodies. The contractor will be considered the Associate RSO. These services shall include diagnostic Xray, fluoroscopy, CT, CT for attenuation purposes, MRI, Ultrasound and Dental Xray.

The contractor shall be available to consult the RSO providing expertise when needed by the RSO to resolve complex radiation safety issues. This shall be on site or by telephone.

The contractor shall provide VAMCM a schedule for quality assurance testing for all diagnostic equipment that includes due dates for each machine.

The contract or ARSO will perform duties as RSO when the facility RSO is on leave or otherwise unavailable,

The contractor shall attend the quarterly Radiation Safety Committee and be present and designated expert for quarterly EEOC meetings to present a report as it pertains to the radiation safety program.

Ensuring the facility RSO is apprised of any new regulations or recommendations that affect the facility s radiation safety program.

CT PROTOCOL REVIEW

To ensure compliance with accreditation body standards, the contractor shall provide an ACR Certified Medical Physicist (ACMP) to perform a review of all diagnostic CT imaging protocols for the number of CT scanners utilized at the facility.

VAMCM will assure for medical physics review, the diagnostic CT imaging protocols must be sufficiently detailed and be in a printed or digitally acceptable format. The protocols will include all acquisition parameters outlined in the most current accreditation body standards.

The review will occur on a mutually agreed upon method and frequency.

Initial/Acceptance Review(s): The ACR Certified Medical Physicist will complete an initial review of all the CT protocols within 3 months of initiation of the contract.

Protocol Maintenance: An ACMP will be available to meet in person or telephonically with the CT protocol committee established by the facility. The meeting frequency and times will be mutually agreed upon. This shall include four (4) meetings per calendar year.

CT PERFORMANCE IMPROVMENT (PI) AUDITS

The ACMP will assist with the establishment of dose notification and dose alert values for diagnostic CT imaging protocols used at the facility for the number of CT scanners. On a quarterly basis

The ACMP will perform an on-site review of diagnostic CT examinations performed at the facility. The review process will include an analysis and comparison of a representative sample of events where the radiation dose index exceeded expected dose index ranges identified in the imaging protocols and comparison of the data to established external benchmarks.

On a quarterly basis, conduct an on-site CT performance improvement audit to ensure the facility meets all performance standards and best practices recommended by various accrediting bodies.

Radiation Shielding Planning:

The contractor shall provide services of a qualified Health Physicist or ACR Certified Medical Physicist to calculate radiation shielding requirements as needed

Personnel Dosimetry Program:

The contractor shall develop and administer a personnel radiation monitoring program in accordance with current NRC regulations 10 CFR Part 20 Standards for Protection Against Radiation and NRC Regulatory Guide 8.7 Instructions for Recording and Reporting Occupational Radiation Exposure Data.

In accordance with NRC 10 CFR 10.1501, the radiation monitoring service shall be certified by the National Voluntary Laboratory Accreditation Program (NVLAP).

The radiation whole-body personnel dosimetry shall contain optically stimulated luminescence (OSL) radiation detection technology or its equivalent. The equivalent shall have the following characteristics:

Must have a minimal reporting level of 1 mrem

Must be able to differentiate between static (i.e., instantaneous) and dynamic (i.e., normal) exposure

No fade for longer wear frequencies

Tamper resistant

The contractor shall provide extremity monitoring (i.e. ring badges) to all personnel designated by VAMCM who can possibly receive 10% of the annual dose limit to extremities outlined in NRC 10 CFR Part 20.

Exposure reports shall be available electronically to VAMCM authorized personnel.

There are currently approximately 105 employees who are wearing whole body personnel dosimetry and 5 ring badges. The contractor shall take in consideration additional employees due to expansion of services and the inevitability of employees losing badges. Therefore, the bid shall be all inclusive fixed price.

Radiation dosimetry shall be exchanged monthly.

Radiation Safety Consulting:

The contractor shall conduct site visits monthly for the purposes of:

Performing quarterly audits of the radiation safety program that will assist the RSO in his/her duties ensuring compliance with the current requirements of the USNRC, USDOT, USFDA, VHA NHPP, and the recommendations of the ACR and The Joint Commission.

Be available for radiation safety consultation when requested by the RSO.

Conduct quarterly audits of the Nuclear Medicine Radiation Safety Program. The RSO shall be provided with documentation of such audits in accordance with NRC 10 CFR 20.2102. An audit checklist must be provided to the RSO for approval.

Attend the quarterly Radiation Safety Committee meetings to report audit results and provide Health Physics expertise when needed.

Conduct an annual ALARA audit of the radiation safety program.

Provide an annual radiation safety report for both licensed material and x-ray producing machines.

Nuclear Medicine Radiation Safety and Radiation Measurement Equipment Calibration:

The contractor shall provide annual survey meter calibration services in accordance with USNRC regulations.

The contractor shall perform annual accuracy and geometric variation on dose calibrators and well counters in accordance with NRC 10 CFR Part 20 & 35

The contractor shall perform annual quality assurance evaluations for well counters and thyroid probe in accordance with NRC CFR Part 20 & 35.

The contactor shall conduct all QA on gamma cameras the intervals recommended by the ACR.

The contractor shall provide sealed source inventories and leak testing as required by the USNRC and NHPP.

The contractor shall perform semi-annual physics quality assurance for the GE Discovery 710 PET/CT per recommendations from the ACR and JC.

The contactor shall provide health physics support and quarterly audits of the radioactive materials program.

Radiation Safety Training Program:

The contractor shall develop, conduct, and document a training program for the following:

Fluoroscopy Safety Training and certification of Fluoroscopic Equipment users.

Annual Radiation Safety Training for VAMCM employees that frequent areas where radioactive material or radiation producing devices are located. They include, but not limited to, x-ray technologists, nuclear medicine technologists, surgical staff, nursing staff, housekeeping, shipping, and receiving, and security staff. The training shall be commensurate with their job duties.

The contractor shall provide nuclear medicine technologists (NMTs) with HAZMAT training for the shipping of radioactive materials. The training shall be designed to train NMTs in the requirements of DOT 49 CFR Subpart H, and NRC 10 CFR 71.5. After successful completion the NMT shall be certified for a period of 3 years.

HOURS OF OPERATION:

Routine work hours are Monday through Friday, 0800-1630. However, a flexible work schedule may be considered to accommodate the needs of the contractor and VAMCM.VAMCM is closed to observe the following Federal Holidays:

New Years Day

Martin Luther King Day

Presidents Day

Memorial Day

Juneteenth Day

Independence Day

Labor Day

Columbus Day

Veterans Day

Thanksgiving Day

Christmas Day

INVOICES:

Invoices shall be electronically into the IPPS system and paid to the contractor monthly, in arrears, upon submission of a properly prepared invoice for services/ supplies during the period. All invoices will include name of company name and address, point of contact, contract number, dates of services, purchase order number, invoice number, and an itemized listing of charges.

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