SPRINGLEAF HEALTHCARE PVT. LTD.

60/3, Hosur Rd, next to Andhra Bank, Konappana Agrahara, Electronics City,
Bengaluru, Karnataka 560100

Document Name : AAC 6 POLICY RADIOLOGY SERVICES

Document No. : NABH/SHPL/POLICY/AAC-06/02/10.06.2022

No. of Pages : 5

Date Created : 10/06/2022

Date of Implementation : 15/06/2022

Designation :  Consultant Radiologist

Prepared By : Name : Dr Shreyas P

Signature :
Designation : Managing Director
Approved By : Name : Mrs. Vijaya Sonawane

Signature :

Designation : Quality Manager

Responsibility of Updating :
Name : Ms. Jatoveda Haldar

Signature :
 NABH Policy: RADIOLOGY SERVICES
NABH Standard Reference: AAC.6
Policy/Version No./Issue Date: NABH/SHPL/POLICY/AAC-06/02/10.06.2022
Page No. Page 2 of 5

PURPOSE:
To offer comprehensive radiological testing services to assist in diagnosing disease, monitoring health, and out
patients and inpatients, including emergency and health check clients

SCOPE:

All the imaging services provided by the hospital. (X-ray and ultrasounds)

RESPONSIBILITY:

Radiologist & Radiographer

POLICY

SCOPE OF IMAGING DEPARTMENT AND ITS COMPLIANCES WITH LEGAL REQUIREMENTS

 Compliance to legal and other requirements

Service Legal requirement Compliance

Radiography (X-Ray ) - Get registered with Atomic Energy Registration Done

Regulatory Board

- Carryout quality assurance performance At periodic intervals the quality assurance

test of the X-ray unit test are carried out as perAERB prescribed
format.

- Employ qualified staff Staffs are employed with adequate technical

qualification.(Refer policy HRM . 1 )

- Provide personnel monitoring badges All radiation staff are provided with
for staff members associated with the
AVENNTECH Laboratory operation of X-ray machines Personnel monitoring TLD badge and are
Chennai maintained.

Ultrasound - The pre-natal diagnostic techniques Ultrasound equipments are authorizedand

(regulation and prevention of misuse) licensed by the health welfare department.
ACT, 1994.

STAFF QUALIFICATIONS:

 The radiology department employees are qualified staff (radiologist and radiographer). The minimum
qualification and experience of the staff comply with AERB safety code for medical diagnostic X-ray
equipment and installations. (Refer Radiology Manual)

SCOPE OF THE IMAGING SERVICES

 Scope of the imaging services commensurate to the services provided by the SHPL.(Refer Radiology
manual)

UPDATED BY APPROVED BY ISSUED BY

DR. SHREYAS P MRS.VIJAYA SONAWANE MS JATOVEDA HALDAR

CONSULTANT RADIOLOGIST MANAGING DIRECTOR

QUALITY MANAGER
 NABH Policy: RADIOLOGY SERVICES
NABH Standard Reference: AAC.6
Policy/Version No./Issue Date: NABH/SHPL/POLICY/AAC-06/02/10.06.2022
Page No. Page 3 of 5

INTIMATION OF THE CRITICAL REPORTS TO THE CONCERNED PERSONNEL:

 Critical values followed by the department :

General radiography:

Acute condition.

a. Pneumothorax
b. Infectious pneumonias
c. Pleural effusion
d. Pneumoperitonium
e. Ischemic bowel/ obstruction
 Ultrasound:

a. Acute abdomen Eg: appendicitis calculus disease

b. Ectopic pregnancy
c. Torsions – testis/ovarian
d. Traumatic injuries
Communication of critical values to the concerned
 All the critical values are informed to concerned doctor within 10 minutes.

RADIATION SAFETY PROGRAMME:

The safety committee is responsible for the following:

 To formulate and review policies on radiation safety,

 To monitor radiation safety issues to ensure that they are appropriately addressed by administration,

 To review radiation safety procedures for effectiveness and recommend revisions,

 To conduct investigations into radiation related incidents or accidents,

 To specify the requirement for instruction on radiation safety for staff at all levels,

HANDLING AND DISPOSAL OF RADIO-ACTIVE AND HAZARDOUS MATERIALS:

 We dispose developer in medical liquid waste.

RADIATION SAFETY DEVICES:

 All the staff working in the radiology department are provided with all the necessary radiation safety
device lead Apron.
 It is responsibility of the entire technician to wear radiation safety devices while performing the
procedure.
UPDATED BY APPROVED BY ISSUED BY
DR. SHREYAS P MRS.VIJAYA SONAWANE MS JATOVEDA HALDAR

CONSULTANT RADIOLOGIST MANAGING DIRECTOR

QUALITY MANAGER
 NABH Policy: RADIOLOGY SERVICES
NABH Standard Reference: AAC.6
Policy/Version No./Issue Date: NABH/SHPL/POLICY/AAC-06/02/10.06.2022
Page No. Page 4 of 5

MONITOR TIMELY QUALITY CHECKS OF TLD BADGES AND LEAD APRONS:

 The thermo luminescent dosimeter (TLD) is a device used for personal monitoring to measure the dose
of radiation received by an individual. It also aids in evaluating the effectiveness of radiation controlled
practices in the workplace. The device detects the changes in the radiation levels in the work place and
provides information about accidental exposures too.

 Badges are returned to Avanttec laboratory upon receipt of a new batch promptly. If it is suspected that
a person has received a significant radiation dose, the TLD badge is returned for assessment
immediately.

TESTING OF RADIATION SAFETY DEVICES:

 A quality check for the lead aprons is done once in a year.

 Periodic checks on the lead aprons are carried out under fluoroscopy it look for any cracks / sagging &
the lead sheet within the aprons.

 The damaged lead apron is replaced immediately.

 The list of all badges is collected and updated for all the employees in the hospital who are exposed to
the radiation.

APPROPRIATE DISPLAY OF IMAGING SIGNAGES:

 The department complies with the following requirements of Atomic Energy (Radiation Protection)
Rules, 2004 for radiology and PNDT Act, 1996 for ultrasound facilities.

Radiation symbol or Warning sign: -

The radiation symbol or warning sign shall be conspicuously and prominently displayed at all times

 Outside the X-Ray Room we have display the radiation symbol.

QUALITY ASSURANCE PROGRAMME:

 Quality assurance programme is a planned and systematic actions that provide adequate, consistently
high quality images with minimum exposure of the patient.

 Quality assurance actions include both quality control technique and quality administration procedure.

 Quality assurance test is carried out as per AERB prescribed format.

 It is the responsibility of co-coordinator radiologist and management to ensure that the surveillance is
done within a defined time frame.

UPDATED BY APPROVED BY ISSUED BY

DR. SHREYAS P MRS.VIJAYA SONAWANE MS JATOVEDA HALDAR

CONSULTANT RADIOLOGIST MANAGING DIRECTOR

QUALITY MANAGER
 NABH Policy: RADIOLOGY SERVICES
NABH Standard Reference: AAC.6
Policy/Version No./Issue Date: NABH/SHPL/POLICY/AAC-06/02/10.06.2022
Page No. Page 5 of 5

OUT SOURCE PROCESS:

Quality assurance system for the services out source

The test which are not carried out in-house shall be sent to the referral diagnosis criteria to select referral
diagnosis centre (Refer Radiology manual)

The following are the important parameters for the quality assurance test:-

 Check and verify all electrical and mechanical part of the unit.

 Focal spot test.

 Beam alignment test.

 Congruence test.

 Radiation survey for radiation leakage

ASSOCIATED DOCUMENTS:

RADIOLOGY QUALITY MANUALS

UPDATED BY APPROVED BY ISSUED BY

DR. SHREYAS P MRS.VIJAYA SONAWANE MS JATOVEDA HALDAR

CONSULTANT RADIOLOGIST MANAGING DIRECTOR

QUALITY MANAGER