TATA INSTITUTE OF SOCIAL SCIENCES, MUMBAI

MASTER’S OF HOSPITAL ADMINISTRATION (MHA)

STUDENT NAME: MARUFA FARUQI

ENROLMENT NUMBER: M2021HO021

SUBJECT: HO 2 HOSPITAL INTERNSHIP

INTERNSHIP HOSPITAL:
GCS MEDICAL COLLEGE, HOSPITAL & RESEARCH CENTER,
AHMEDABAD, GUJARAT.
 WEEKLY REPORT 6: 31st October – 5th November 2022

- This week I had covered OT and Radiology Department of the Hospital

- Details for the Radiology project is mentioned below

OPERATION THEATRE DESIGN, LAYOUT AND ADMINISTRATION

This section will briefly deal with the design, layout, work flow and administrative
responsibilities of the Operating Theatre.

There is a separate clean area for storage of clean and sterile instrument, and there is a
demarcated area for used or soiled surgical instruments to be rinsed before sending it to the
CSSD (Central Sterile Services Department).

We have total 14 OTs are following -

OT Number Complex Floor

OT 1, 2, 3, 4 Complex 1 Ground floor
OT 5 Labor OT Ground floor
OT 6, 7 Complex 2 Ground Floor
OT 8 Emergency OT Ground Floor
OT 9, 10, 11 Complex 3 10th Floor
OT 12 Endoscopy 10th Floor
OT 13 CTOT 10th Floor
OT 14 Catha-Lab 10th Floor

1. Layout and Design

Theatre managers, nursing team, infection control team, surgeons and anaesthesiologists are
involved in the planning of the theatre design/layout. The operating theatre suite is a purposely
built independent complex located away from the main flow of traffic but it is in an area easily
accessible to the critical care, surgical and maternity wards and the supporting service
departments, e.g. CSSD, laboratory and diagnostic departments.
The operating theatre should has an independent air handling unit with controlled ventilation
such that the lay-up room and the OT table comes under positive pressure andhas the air
Changes per Hour (ACH) i.e. 20-24 and more than 24 in major OTs where Hepa Filter is
attached.

The traffic within the operating room should be strictly controlled. Only staff, patients and
equipment will be allowed to access in OT from different entrances and exits.

There is buffer zone between the sterile area inside the OT and the unsterile area outside.
Unsterile gown and shoes should not be worn beyond that buffer zone and OT shoes shouldnot
go outside.

• Walls and Ceilings:

All surface materials are hard, non-porous, seamless, stain proof, and easily washable.
The walls and ceiling are used to mount essential devices and equipment to reduce
crowding of the floor area.
There are multiple electric outlets on the walls and on pendulum for purpose of
electronic devices in OT.
• Floors:
The floor surface is suitably hard, nonporous and appropriate for frequent cleaningand
there are no cracks. The floors have a nonslip surface, to prevent staff from slipping
and injuring themselves.

• Doors:
Sliding doors are used in OT complex 3 at 10th floor and swing doors (self-closing)
are used in the remaining OTs. This is essential during an operation because the
microbial count in the air rises every time doors swing open from either direction.

• Lighting:
Most OT lights are white fluorescent as they cast minimal shadow. Lighting is evenly
distributed throughout the room.
Operation theatre has a generator back up in case of power failure. In case one of the
bulbs is not working, it is replaced as soon as possible, to provide sufficient lighting at
all times during an operation.

Ventilation: The ventilating system in the OT is mechanical ventilation, supplied

from an independent air handling unit (AHU) which ensures a controlled, filtered,
clean airsupply. Air changes and circulation provide fresh air.
HEPA filter is present at most of the major OTs (Complex 1, Complex 3 & CTOT)

• Air Flows:
In the OT there is always a positive pressure which enters the OT suite in the
preparation or layup room, to ensure safety of the surgical instruments when the trolleys
are being laid up for surgical procedures. The Layup and OTs have the highest positive
air pressure which flows outwards to the scrub areas, and sub-sterilerooms. Positive
pressure forces air out of the room.

• Temperature and Humidity:

The temperature is maintained at 21 +/- 3 degrees Celsius inside the OT all the time
with corresponding relative humidity between 50 to 60%. Appropriate devices to
monitor and display these conditions inside the OT are installed.

• Zoning:

- Zone 1: Protective Zone included reception area, waiting area, changing

room, store room, and cabins.
- Zone 2: Clean Zone included pre-operative, recovery room, clean utility room
 - Zone 3: Sterile Zone included operating room, scrub room
- Zone 4: Dirty Zone included dirty utility and disposal corridor

2. Administration in the Operating Theatre

• The Operating List
The nurse in charge of the OT has the sole responsibility of managing all the activitiesof
the OT. The activities include among others the theatre lists and communication with the
surgeons in case of changes in the operation list.

The following instructions are followed:

▪ The operation list is sent by doctors before 4 pm from Monday to Friday and before11
am on Saturday before the day of operation.
▪ The OT should be scheduled after getting the following approval
- Anesthesia fitness report
- ABPMJAY approval
- Pre-operative physician fitness report
- RTPCR report.
▪ The operation list is sent through system by unit doctors.
▪ The name of the Doctor and unit who compiled the theatre list is being clearly
indicated.
▪ The surgeon discusses the operation list in co-operation with the OT nursing In-
charge and OT in charge (HOD/professor anesthesia).

Facts that are taken into consideration when operations are booked:
➢ Major cases are always booked at the beginning of the operation list in morning
hours while minor cases are taken at the 2nd half to reduce the chaos in OT.
➢ All the planned surgeries should be completed within 5 PM.
➢ Emergency cases, patient with co-morbid condition, & Pediatrics cases always be
considered as priority.
➢ All known/suspected infected cases and serologically positive cases are taken to theOT
as a last case of the day followed by the cleaning protocol of the OT.

Particulars that Appear on the Operating list:

▪ The time schedule, day, and date when the operation will be performed.
▪ Full names, surname, gender, age as well as the form of address e.g. Mr. Mrs or
Miss.
▪ The name of the ward in which the patient lies, as well as the sex e.g. male or
female.
▪ A clear description of the type of operation to be performed with site marking.
▪ The scheduled sequence for the operations appears on the list. If the surgeon
decides to do a patient earlier or later on the scheduled list or cancel an operation,
the OT nurse is informs the nurse in the particular ward of the changeon the
operating list immediately.
▪ The name of the surgeon appears on the operation list.
▪ It is indicated whether it is major or minor case.

The Registers and Check list used in the Operating Theatres:

Different registers are used in the OT, namely-

a. Operation registers
▪ Every operation done in the OT, whether under general or local anaesthesia,is
 recorded in the operation register. The operating register is a legal document.
It is essential to store the information for at least five years.
▪ All the information and particulars of the patient which appear on the
operating slip are complete and in detail and are recorded in the operating
register
- The patient’s full names and surname
- Registration number and age
- Ward in which the patient is admitted
- Full description of the operation performed
- Initials and surname of anesthesiologist
- Type of anesthesia given
- Name of scrub nurse, as well as the amount of specimens sent to the
laboratory
- Indicate whether the patient is male or female Indicate whether the
patient underwent major or minor surgery
- Duration of the operation
▪ At the end of the day it need to be signed by the in-charge and ANS.
If a patient goes into cardiac arrest in the theatre or dies on the operating
table, this information is recorded in red in the operation register.

b. Anesthesia Register:
▪ Patient identification
▪ Type of anesthesia along with the drug.
▪ Grading of the anesthesia including remarks.

c. Register regarding abortions and pregnancy residues

▪ Register regarding Abortions and Pregnancy Residues Operations like
abortion or the removal of pregnancy residues are separately recorded withthe
particulars of such an operation. There is a special register for the purpose of
abortions and the removal of pregnancy residues.
▪ The register and other relevant documents are kept for at least five years.
▪ The register has the following information:
- Name and surname of patient
- Registration number
- Age/ marital status/ nationality
- Name and surname of the doctor who referred the patient
- Name of the assistant surgeon if applicable
- Description of the operation being performed
- Name and surname of the anesthesiologist
- Type of anesthesia
▪ The special form for the notification of the operation pertaining to an abortion
and the removal of pregnancy residues is completed in duplicate. The original
forms on a monthly basis are sent to the medical superintendent’s office for
cognizance. The duplicate remains in the theatreand are filed.

d. Specimen Register:
▪ For efficient control over specimens, there is a register in which all specimens
are recorded, with the same information as on the label. A space is made
 available for the signature of the person who recorded the specimen into the
register, as well as the signature of the person who received the specimen at the
laboratory.
▪ The specimen is clearly marked with the following information on the table:
- The name and surname of the patient
- The registration number
- The ward in which the patient is placed
- The type of specimen
- The name of the operation
- The date and time when the specimen was taken
- The required laboratory test
- The name of the surgeon
▪ At the end of the day’s operating schedule the nurse checks all specimens
with the entries in the register.
▪ Every specimen carries the correct information to prevent a mix-up of
specimen which may lead to a faulty diagnosis and treatment

For Radiology Department Project:

I. NABH Self-Assessment Checklist

Name Of The Imaging Centre/Hospital Study Hospital

(Imaging
Department):
SELF ASSESSMENT TOOLKIT
Elements Observation & Conclusion
Chapter 1: CONTROL OF SERVICES (CS)
CS.1: Medical Imaging Services shall
address system to ensure delivery of the
service from point of referral to
discharge.
a. Roles and responsibilities of each area
of service delivery are defined.
b. Medical Imaging Services ensure
justification of referrals according to
patients condition, urgency of
diagnosis and radiation risk.
c. Medical Imaging Services ensure that
protocols for imaging pathways and
processes are defined, documented,
implemented and monitored.
d. Medical Imaging Services ensure
appropriate scheduling and
prioritization of referrals
according to patient’s condition and
urgency of diagnosis.
e. Timeframe to manage imaging
pathways
from receiving of referral to discharge
from the Medical Imaging Services is
defined, documented, implemented and
 monitored.
CS.2: Medical Imaging Services ensure
that delivery of services is patient
focused.
a. Roles and responsibilities of staff
managing each area of service to the
patient (information, delivery ofservice
and care, safety, privacy) are
defined.
b. Medical Imaging Services ensure that
the information about specificprocedure
is available to patients and
attendants in relevant format and
language.

c. Medical Imaging Services ensure that

patient and attendants are informed
about expected cost prior to imaging.
d. Medical Imaging Services ensure safety
of patients, attendants and their
belongings while in the facility.
e. Medical Imaging Services ensure safe .
transport of the patients within, to and
from the facility whenever required.
f. Medical Imaging Services ensure
privacy and dignity of the patient
without any discrimination.
g. Medical Imaging Services ensure that
patient’s feedback is utilized to improve
the service delivery system.
h. Medical Imaging Services ensure that
staff is aware about patients rights and
responsibilities.
CS.3: Medical Imaging Services ensure appropriate
management of facility and environment.
a. Roles and responsibilities of
management of each area of facility are
defined
b. Medical Imaging Services ensure
signage in appropriate language and
format to guide the patient and attendant
to and within the facility.
c. Medical Imaging Services ensure that
design and construction of the facility is
in accordance with the legal
requirements pertaining to the equipment
 and the services offered.
d. Medical Imaging Services ensure that
design and construction of the facility
supports specific needs of the patient
population (including children and those
with special needs) and staff.
e. Medical Imaging Services ensure that
access to particular areas is restricted
according to specific needs and risks
with proper barrier and signage.
f. Medical Imaging Services ensure that
water, electricity, ventilation and medical
gases & vacuum installation in all area of
service is maintained with
provision of alternate sources.

Chapter 2: CONTROL OF IMAGING

PROCESSES AND PROCEDURES (CPP)

CPP.1: Medical Imaging Services ensure acquisition

of optimal diagnostic quality images and
performance of diagnostic procedures.
a. Roles and responsibilities of staff for
management of each area of image
acquisition and image quality are
defined.
b. Medical Imaging Services ensure that
protocols for image acquisition for all
examination are developed, defined,
documented, communicated,
implemented and monitored.
c. Medical Imaging Services ensure quality
of diagnostic images and procedures.
d. Medical Imaging Services ensureanalysis
of feedback on images and procedures
through documented process
of internal verification & external
validation.
CPP.2: Medical Imaging Services ensure the quality
of reports (clinical and technical).
a. Roles and responsibilities for staff
reporting the images are defined.
b. Medical Imaging Services ensure that
the structure, content and format of
report are standardized.
c. Medical Imaging Services ensure the
generation, verification and amendments
 of reports are within appropriately
defined timeframe.
d. Medical Imaging Services ensure that all
attempts are made so that the imaging
interpretation is collated with relevant
clinical laboratory and previous imaging
details.
e. Medical Imaging Services ensure
communication of reports to patient
and/or referrer within appropriately
defined timeframe.
f. Medical Imaging Services ensure
appropriate quality of images and reports
for teleradiology services
g. Medical Imaging Services ensureanalysis
of feedback from Referrer/Professional
colleagues on the content and quality of
reports through
defined & documented process.
CPP.3: Medical Imaging Services ensure quality of
diagnostic and therapeutic interventional
procedures.

a. Roles and responsibilities for staff

conducting diagnostic and therapeutic
interventional procedures are defined.
b. Medical Imaging Services ensure that the
risk, the expected outcome andalternative
treatment protocols are explained to the
patient, the attendant and the referrer;
and same is
documented.
c. Medical Imaging Services ensure that
protocols for all diagnostic and
therapeutic interventional procedures are
defined, documented, implemented and
monitored.
d. Medical Imaging Services ensure that
appropriate sedation/anaesthesia, clinical
and emergency support is available
before, during and after the procedure.
e. Medical Imaging Services ensure that the
outcomes of diagnostic and therapeutic
interventional procedures are
monitored.
CPP.4: Medical Imaging Services ensure proper
management of drugs, isotopes, contrast media and
radiopharmaceuticals.
a. CPP.4: Medical Imaging Services ensure
proper management of drugs, isotopes,
contrast media and
radiopharmaceuticals.
b. Medical Imaging Services ensure that
protocols for prescription, purchase,
storage, supply, handling and labeling of
drugs, isotopes, contrast media and
radiopharmaceuticals are defined,
documented, implemented and
monitored.
c. Medical Imaging Services ensure that
protocols for prescription, purchase,
storage, supply, handling and labeling of
drugs, isotopes, contrast media and
radiopharmaceuticals are defined,
documented, implemented and
monitored.
d. Medical Imaging Services ensure that
patients at higher risk of adverse
reactions to specific drugs, isotopes,
contrast media and radiopharmaceuticals
are assessed and
managed.
Chapter 3: CONTROL OF PERSONNEL (CP)

CP.1: Medical Imaging Services ensure that the

staffs are appropriately qualified, competent and
trained, to deliver the service assigned to them.
a. Roles and responsibilities for
maintenance of record and verification
of credentials of the staff are defined.
b. Medical Imaging Services ensure that
policies and procedures for selection,
recruitment, retention and succession
planning of staff are defined,
documented and implemented.
c. Medical Imaging Services ensure that
policies and procedures for selection,
recruitment, retention and succession
planning of staff are defined,
documented and implemented.
d. Medical Imaging Services ensure that
there is a documented personal record
for each staff member.
CP.2: Medical Imaging Services ensure appropriate
Human Resource Planning of staff to deliver the
service.
a. Roles and responsibilities of
management to carry out the processes
of authorization, management and
support to staff to deliver
the services are defined.
b. Medical Imaging Services ensure that
appropriate skill mix and staff
complement exist in accordance with the
scope of services for specific areas of
task.
c. Medical Imaging Services ensure that job
description and job specification for each
category of staff is defined,
documented and communicated.
d. Medical Imaging Services ensure that
students, trainees & volunteers working
in patient care areas have clearly defined
roles and supervision as specified.
e. Medical Imaging Services ensure
induction training and regular ongoing
program for training and development of
the staff.
CP.3: Medical Imaging Services ensure fair and
rational Human Resource Management.
a. Roles and responsibilities of the
management of human resource
pertaining to staff benefits, appraisals,
disciplinary action and grievance
handling are clearly defined.
b. Medical Imaging Services ensure that
there is provision for health checkups;
health and other benefits to the staff.
c. Medical Imaging Services ensure that a
system of regular service appraisals and
personal development reviews exist for
all employees.
d. Medical Imaging Services ensure that
policies and procedures regarding
disciplinary action against any staff is
defined, documented and communicated.
e. Medical Imaging Services ensure that
staff grievance handling procedures
are clearly defined, documented and
communicated.
Chapter 4: CONTROL OF EQUIPMENT (CE)
CE.1: Medical Imaging Services ensure appropriate
procurement and installation of equipment.
a. Medical Imaging Services ensure that the
policies and procedures for the
procurement of all equipment and
consumables are defined, implemented
and monitored in a collaborative manner
between user and management.
b. Medical Imaging Services ensure that the
policies and procedures for theinstallation
of equipment are defined, documented,
implemented andmonitored and record
of same is
maintained.
CE.2: Medical Imaging Services ensure appropriate
operation and working of equipment.
a. Roles and responsibilities for each area
of the operation and working of all
equipment are defined.
b. Medical Imaging Services ensure that the
policies and procedures for operationand
calibration of equipment are defined,
documented, implemented, monitored
and record of the same is maintained.
CE.3: Medical Imaging Services ensure appropriate
maintenance and repair of equipment.
a. Roles and responsibilities for
maintenance, service and repair of the
equipment are defined.
b. Medical Imaging Services ensure that
equipment downtimes are monitored and
managed within defined timeframe.
c. Medical Imaging Services ensure that
policies and procedure for maintenance
and repair of equipment are defined,
documented, implemented and
monitored and record of the same is
maintained.
CE.4: Medical Imaging Services ensure appropriate
replacement of existing equipment & planning for
new equipment for continuation and expansion of
service.
a. Roles & responsibilities for replacement
of existing equipment & planning for new
equipment for expansion of service
are defined.
b. Medical Imaging Services ensure that
equipment replacement and/ or up
gradation is planned and implemented in
accordance with scope of services and
 expansion plan.
Chapter 5: CONTROL OF DOCUMENTS AND
RECORD (CDR)
CDR.1: Medical Imaging Services ensure
appropriate management of all the documents,
images and records pertaining to the patient.
a. Roles and responsibilities for generation,
maintenance, integration, safety,
confidentiality and irretrievability of all
the documents, images and records
pertaining to the patient are defined.
b. Medical Imaging Services ensure that
policies and procedures to identify, and
classify documents, images and records
pertaining to the patient are defined,
preferably in computerized format.
c. Medical Imaging Services ensure that
policies and procedures regarding
retention, confidentiality and
retrievability of all the documents,
images and records pertaining to the
patient are implemented and
monitored.
CDR.2: Medical Imaging Services ensure
generation, revision, retention and dissemination of
information data & documents for staff, patient and
others.
a. Roles and responsibilities for generation,
revision, retention and dissemination of
staff and patient information data (in
designated format and language) are
defined.
b. Medical Imaging Services ensure that
policies and procedures for generation,
revision, retention and dissemination of
staff and patient information &
instruction data in designated format and
language are defined, documented and
implemented.
c. Medical Imaging Services ensure that
feedback from staff; patient and others
are documented and utilized for
continuous improvement of service.
CDR.3: Medical Imaging Services ensure
maintenance of documents of legal and statutory
requirements related to facility, equipment,
personnel and risk monitoring.
a. Roles and responsibilities for
maintenance of documents of legal and
statutory requirements related to facility,
equipment, personnel and risk
monitoring are maintained.
b. Medical Imaging Services ensure that
documents of legal and statutory
requirements related to facility, are
maintained.
c. Medical Imaging Services ensure that
document of legal and statutory
requirements related to equipment are
maintained.
d. Medical Imaging Services ensure that
document of legal and statutory
requirements related to all staff
(including risk monitoring) are
maintained.
CDR.4: Medical Imaging Services ensure
maintenance and updating of all records and
documents pertaining to audit, quality control &
quality improvement of all processes and services.
a. Roles and responsibilities for
maintenance and updating of all records
and documents pertaining to audit, quality
control & quality improvement of all
processes and services are
defined.
b. Medical Imaging Services ensure that
policies and procedures for audit, quality
check, verification and validation are
maintained.
c. Medical Imaging Services ensure that all
documents related to quality
improvement are maintained.
Chapter 6: RISK CONTROL AND SAFETY (RCS)
RCS.1: Medical Imaging Services ensure that the
risk associated with imaging, interventional and
therapeutic procedures are identified, assessed,
managed and minimized.
a. Roles & responsibilities for all levels of
risk management in all areas of imaging
are defined.
b. Medical Imaging Services ensure that the
radiation doses are as low as reasonably
possible for all patients
(ALARA principle) especially for
 children, women of child bearing age,
pregnant women and patients
undergoing repeated exposures.
c. Medical Imaging Services ensure that
there is a system in place to define, asses
and manage risks of occupational
exposure to ionizing radiation and record
for the same is maintained.
d. Medical Imaging Services ensure that
risks of acoustic output and exposure
times are defined, assessed, managed
and minimized.
e. Medical Imaging Services ensured that
risks associated with MRI imaging are
defined, assessed, managed and
minimized.
f. Medical Imaging Services ensure that risk
associated with use of ablative,
therapeutic devices during diagnostic &
interventional procedures are defined,
assessed, managed & minimized.
g. Medical Imaging Services ensure that the
incidents & errors pertaining to risks
associated with all the procedures are
reported, investigated, recorded, acted
upon, analyzed, and used to guide and
plan the future action.
RCS.2: Medical Imaging Services ensure that the
risk of infection to staff, patient and others is
identified, assessed, managed and minimized.
a. Roles and responsibilities regarding
infection control are defined.
b. Medical Imaging Services ensure that
policies and procedures to identify,
assess, manage and minimize the risk of
infection to staff, patient and others are
defined, documented, implemented and
monitored.
c. Medical Imaging Services ensure that
policies and procedures for
decontamination of equipment and
environment are defined, documented,
implemented and monitored.
d. Medical Imaging Services ensure that
protocols and procedures for needle stick
injuries and subsequent post exposure
prophylaxis are defined, documented,
implemented and monitored.
RCS.3: Medical Imaging Services ensure that the
risk associated with hazardous/ Radioactive and Bio-
Medical Waste (BMW) substances and materials to
staff, patient and others are identified, assessed,
managed and minimized.
a. Roles and responsibilities for control of
hazardous/radioactive and Bio- Medical
Waste (BMW) substances and materials
are defined.
b. Medical Imaging Services ensure that
policies and procedures to identify,
assess, manage and minimize the risk
associated with hazardous / radioactive
and Biomedical waste (BMW)
substances and materials to staff, patient
and others are defined, documented,
implemented and monitored.
c. Medical Imaging Services ensure that
appropriate protective equipment
required decontaminating and managing
exposure to hazardous/ radioactive
substances are available and maintained.
d. Medical Imaging Services ensure that the
incidents & errors pertaining to
risks associated with hazardous/
radioactive substances and materials are
reported, investigated, recorded,
analyzed, acted upon and used to andplan
the future action.
RCS.4: Medical Imaging Services ensure that the
risk of violence and aggression to staff, patient and
others are identified, assessed, managed and minimized
a. Roles and responsibilities regarding risk
of violence and aggression are defined.
b. Medical Imaging Services ensure that
policies and procedures to identify,
assess, manage and minimize the risk of
violence and aggression to staff, patient
and others are defined, documented,
implemented and monitored.
c. Medical Imaging Services ensure that
incidents & errors pertaining to risks of
violence and aggression are reported,
investigated, recorded, analyzed, acted
upon and used to guide and plan the
future action.
RCS.5: Medical Imaging Services ensure that the
risk associated with fire, and non fire emergencies to
staff, patient and others and to facility and
environment are identified, assessed, managed and
minimized.
a. Roles and responsibilities regarding risk
associated with fire, and non-fire
emergencies are defined.
b. Medical Imaging Services ensure that
policies and procedures to identify,
assess, manage and minimize the risk
associated with fire, electrocution and
other disaster to staff, patient and others
are defined, documented, implemented
and monitored.
c. Medical Imaging Services ensure that
there is adequate safety equipment
available and that all the staff is aware and
trained in handling them in an
emergency or disaster.

II. Radiology Department Guidelines

GUIDELINES
Standards Study Hospital
1(a) Location: The department should have
Accessibility easy accessibility.
Preferably from the front
/side of the building to bring
in emergency patients. The
department should not
be in the transit route of
other departments.
The department should bein
easy access to the OPD,
casualty, IPD and
ICU.
The department should be
located on ground floor
Around 1.3 sq. meter of
space to be provided per
patient.
A separate registration
counter should be present to
 assist patients (approx.
200Sq)
Separate reception area of
around 100 sq. feet
Should not be in transit of .
other units, to avoid public
exposure to radiation areas
2(a) Layout: Room Minimum 200 sq. feet
size X-ray
2(b) Layout: Room Minimum 180 sq. feet
size USG
2(c) Layout: Room Minimum 300 sq. feet and
size CT control room
minimum 100sq feet.
Minimum 350 sq. feet. Also
zoning should be done
ZONE 1: Unrestricted
[Outside MR suite].
ZONE 2: Restricted to
supervision by MR
personnel[reception,
waiting, Toilets, .
ZONE 3: Highly restricted
area where serious injury
can occur[control room,
computer room]
ZONE 4: Most highly
restricted where all non-MR
personnel must be in direct
visual supervision of Level
2 MR staff at ALL times
[MR scanner room]
2(e) Layout: Room Minimum 110 sq. feet
size Mammography
2(g) Layout: The minimum requirement
Shielding laid down
by AERB is as follows:

a) AERB Type
approved X-ray/
CT/Mammo
b) 23cm thick brick walls-
35cm wall for primary wall
(wall holding chest stand)
shared with residential
Premises in case
of X-ray.
c) 1.7 mm Lead lined doors,
 in case of CT 2mm lead
lined doors
d) Mobile protective barrier
with lead glass viewing
window of 1.7 mm Pb
equivalent
e) Separate control room (
for X-ray Equipment >
125kVp .Also for CT and
MRI separate control room.
In case of MRI antistatic
anti scratch flooring, RF
enclosure is done with
silicon sheets in wood or
copper impregnated.
Windows in the MRI suite
are aluminum impregnated
and there has to be a
cryogen venting facility
available.
2(h) Layout: Natural openings should be
Ventilation and there but with proper
natural openings for shielding measures in place
light. . The USG room should be
dimly lit.
2(i) Layout: Control Control panel should be
panel outside CT, MRI and X ray.
2(j) Layout: Direct Direct viewing of the
viewing of the patient is required.
patient
2(k) Layout: Warning lights and placards
Warning lights to be there with strict policy
of non entering as long as
the lights are on
2(l) Layout: Should be there in the local
Signage’s language and English at all
the places in the hospital.
2(m) Layout: Air There should be air
conditioning conditioning for the MRI
and CT. And necessarily a
separate air handling
unit for MRI. The temp
should be maintained at a
temp of 18 degree
for MRI and between 18 to
21degrees for all other
modality.
2(n) Layout: The corridor should be at
Corridor least 8 feet wide.
2(o) Layout: Dark Should be present and size
room should be minimum of 70
sq. feet.
2(p) Layout: CR Should be present attached
room with the X ray department.
2(q) Layout: Changing room should be
Changing room there along with the X ray
room, CT, Mammography
room, MRI and USG.
2(r) Layout: Toilets Toilet should be present
with the USG
department.
2(s) Layout: Facility of drinking water
Drinking water should be there with the
USG unit.

2(t) Layout: Chiller room should be

Equipment room present
(chiller room ) adjacent to the MRI room
with
cryogen facility.
3.Staff mobility
For a 500 bedded hospital study hospital (all
modalities)
Radiologist 6
Technician 8
Staff nurse 1
Attendants 4
Typist 1
Helper 3
Front desk 1
assistant
Radiation safety 1
officer
Biomedical 1
engineer
4(a) Safety measures Should be present and made
for personnel and patients:
up of 2mm equivalent of
Control booth with
lead in lower half and upper
shielding half is made up of glass lined
with 2mm lead paint.
4(b) Safety measures for Two customized lead apron
personnel and patients: with 0.5 mm lead should be
Lead apron provided in X ray and CT.
4(c) Safety measures TLD batches Should be .
for personnel and patients: provided in all the ionizing
modalities to each radiation
employee and strict policy
on wearing it should be
present.
4(d) Safety measures for Eye glasses with lead
personnel and patients: Eye painted reflective lensshould
glasses be used by radiation
worker
4(e) Safety measures for 0.5mm lead equivalent
personnel and patients: thyroid shield should be
Thyroid shield there
4(f) Safety measures Lead made hand gloves
for personnel and patients: should be provided.
Hand gloves
4(g) Safety measures for This is must for all ionizing
personnel and patients: modalities like X ray, CT,
Warning light Mammo
4(h) Safety This should additionally be
measures for present for
personnel and children coming for
patients: Gonad ionizing modalities.
shield for child
4(i) Safety measures Notice of Strict prohibition
for personnel and for entry of pregnant female
patients: Precaution into the X ray, CT and
for pregnant women Mammo rooms. A policy to
ask for pregnancy in the
above investigations
from young females should
be there.
4(j) Safety measures Dosimeters used for
for personnel and personnel monitoring have
patients: Measures dose measurement
radiation dosimeters limit of 30 mSv per year.
This has to be constantly
monitored every three
months by AERB
Policy and
procedures
Statutory Ideally there should be
requirements policy policy and protocols for the
smooth working of the
department, though
documentation in not
mandatory except for
statutory requirements
 which needs to be updated
from time and time.
b) Policy on contrast
reagents
c)Policy on
radiology personnel
safety
d) Policy on
infection control
e) Policy on equipment
breakdown
f) Policy on quality control
of radiology department
g) Policy on maintenance of
record
f) Policy on
Inventory control
Equipment in numbers
a) X ray
b) USG
c) CT
d) MRI
e) Radiography system
h) PACS

III. Questionnaire

Services and quality of care

Q1.How is the attitude of staff?

Q2.Do you think you are treated with dignity?
Q3.What is your experience with the follow up procedures?
Q4.Are you communicated about the reports within a defined time frame?
Q5.How much efficient did you find the staff?

Information

Q1.Does the staff explain about the consent form that is being asked to fill before any
procedures?
Q2.Does the staff provide information regarding services available in a proper way? Q3.Does
the personnel thoroughly explain about the medical condition of the patient?
Q4.Were you given a chance to ask questions or
make a choice?Q5.Are you informed about the
expected cost prior to imaging?

Hygiene

Q1.How do you find the ambience of the

department? Q2.Do you find the
environment clean and hygienic? Q3.What
do you think about the appearance of the
staff?
Q4.What do you think about the cleanliness of the washrooms?