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Radiology Department Quality (SPO- Structure, Process, Outcome)
The document outlines the structure, processes, and quality assurance measures for radiology services in a hospital using the Donabedian model. It includes details on equipment specifications, staff roles, patient management, and compliance with legal and safety standards. Additionally, it emphasizes the importance of communication, professional development, and monitoring of service quality through various evaluations and audits.
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Radiology Department Quality (SPO- Structure, Process, Outcome)
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- 3. Structure Safe(Hazard preventive) buildings Equipment Windows Wall thickness of theequipment rooms Positioning of equipment Equipment availability technical equipment Information processing and communication Personal protection equipment Adequate waiting space Organization and staffing Materials available Engineering services
- 4. Medical Superintendent HOD Radiology Administration Office HOD Registration clerks RecordClerks Clinical Head X- Ray I/C Technicians Assistants Attendants Head CT Technicians Assistants Attendants Head Radiotherapy Technicians Assistants Attendants Head Nuclear Medicine Technicians Assistants Attendants Head Nursing Sister I/C Staff Nurses MPWs
- 5. Patient (Walk-in/ appointment) X-RAY CTScan UltrasoundMRI Filling of consent form Patient Preparation Test Done Patient Departure/ back to ward/ IP Generation of report Check and sign by Radiologist
- 6. Functional Area MRI(125-130 sq.mt) COLOR DOPPLER OPG machine Dark Room Mammography (15-20 sq.mt) CT Scan (110- 120 sq.mt) X-RAY machine USG Machine
- 7. Quality of theprocess Display- to facilitate patient with information) • Services, • Charges, • Names of specialists Department Quality Manual • quality policy, • scope of services and • quality assurance measures Documented Protocols (SOPs) • Patient identification • Staff verification • Staff proficiency • Prompt and effective handling of drug reactions Patient Education System • during admission, • before tests, • during process Appointment System
- 8. Continued… 9. Assurance procedurefor • Privacy • Dignity 10. Legal compliance to all acts • PNDT 11. Communication of investigation reports • Standardized time taken for report generation • Time of collection • For inpatients Report collection system Scheduled timings Responsibility for collection specified and known to all staff. To physicians (via online/ directly from radiologist to treating doctor)
- 9. Continued… 12. Report format •Mustcontain name of hospital/ Logo •Date, time of test done •date, time of report generation •Physician's order, name, department, sign •Sealed in envelope (addressed under patient’s name) Continuous professional development program •For staff to acquire skills/ knowledge/ upgraded work pattern •Facility upgradation- induction program Maintenance protocol •Preventive maintenance plan (for a year) •Break down repair (maintain log book) •Periodic calibration (documentation necessary) Periodic Inspection of X-ray installation (by AERB under sec-17 of atomic energy act 1962) Department must be present in safety committee Fire Safety and control plan
- 10. Appointment Booking X- Ray CTScan MRI Sonography Mammography Inventory register for X-RAY films Inventory Register for contrast Inventory Register for Linen Inventory Register for Medicine Dispatch Report Register Form F (Maintain record w.r.t. Pregnant Woman by genetic clinic/ Ultrasound/ Imaging center)
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- 12. Outcome What patients receive? What staff receives? Whathospital receives? What administration receives?
- 13. Indicators for evaluationof quality of services • Patients • Clinicians • Incident Reports pertaining to Radiology Complains Received Film wastage rate • Correlation lack between radiology reports and final diagnosis Medical Committee audit report • non availability of radiologists • equipment breakdown • power failure. Investigations postponed/cancelled due to Response time in emergency cases during non working hours.
- 14. Continued… 6. Turn AroundTime of each Report • radiation safety norms. • PNDT • Other similar applicable regulations 7. Instances of breach/ violation of 8. Documented Interaction (between the radiologist and clinician regarding case diagnosis) 9. Utilization pattern of the equipment 10. Instances of breakdown repairs and downtime thereof. (Log book)
- 15. REGULATORYBODY Radiation protection rule,1971, under Atomic Energy Act 1962. Safety and protection body of the hospital and atomic energy regulatory board Bhaba Atomic Research Center. Disposal of radio waste as per norm. Radio monitoring equipment. Film/TLD badges and monthly monitoring
- 16. REFERENCES 1. Quality inhospital Name of the author SK Joshi. 2. www.slideshare.com/radiology.pptxs/rahulmehta.3208 3. Quality Management powerpoint by NC Das 4. Hospital Planning and Infrastructure Name of Author- G D Kunders