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: 7th November – 12th November 2022
- 7th November – Had took a leave due to health uneasiness
- Covered the Radiology department in the remaining week
- Details of the department are mentioned below

Location of the Radiology Department

The department of radiology and Imaging services is located on the ground floor. Next toit is
casualty department. On the other side of the radiology department is the OPD for few specialties
which further merges with the registration and billing counters.
The radiology department comprises of CT scan, Ultrasound and General Radiology. Ithas a
separate reception, waiting area and toilet facility.

Timings
The department is functional 24x7 as the hospital is a tertiary care center. The X ray unit works
24*7 whereas the mammography, USG and CT unit work from 8 AM to 4 PM. In addition to it if
there is any emergency the unit can be opened and radiologist /technicianscan be called
immediately.
Organogram
Head of the Department (Radiologist)

Professor

Assistant Professors

Senior Residents

Junior Residents

Senior Technicians

Attendants
Technology
Equipment
1. 4 static X-ray Machine, 1 Dynamic X-Ray Machine
2. 1.5 Tesla MRI by GE
3.32 slice CT by
Siemens4. USG
machine–Phillips

Investigations done in the Radiology department

Routine X – rays includes:
1. Chest
2. Abdomen
3. KUB
4. PND skull
5. Cervical, thoracic and Lumbo sacral spine
6. Pelvis
7. Hand, fingers, wrist and forearm
8. Clavicle, sternum, scapula and shoulder joint
9. Femur, leg, foot, knee and hip

Ultrasonography includes:
1. Abdominal ultrasound
2. Renal ultrasound
3. Ultrasound-guided marking
4. Obstetric ultrasound
5. Pelvic, Transvaginal & Transabdominal
6. Transrectal Scan
7. Ultrasound Scan
8. Chest, Breast ultrasound scan
9. Thyroid scan
10. Ultrasound guided Biopsy

CT scan includes:
1. CT -Brain
2. CT – Guided biopsy
3. C T - Lumbar spine
4. CT – Thorax
5. CT – Neck
6. CT – Extremities
7. CT – Abdomen and Pelvis
8. CT – Angio Abdomen
9. CT – Angio Cranial
10. Cardiac CT/ Coronary CT Angio
 - Skull base CT scan

NAME OF THE EQUIPMENTS IN THE DEPARTMENT

Room No. 73, - CT Scan Siemens, 16 Slice, Emotions CT

Room No. 74,- MRI GE SIGNA EXPLORER 1.5 T MRI
Room No. 80,- Mammography Siemens Mammomat 300
Room No. 46,- USG, Doppler GE WIPRO LOGIQ P5
Room No. 72,- USG, Doppler GE WIPRO LOGIQ P5
Room No. 17,- USG Doppler(OBGY) GE WIPRO LOGIQ P3
Room No.130 - Echo Machine SONOCITE EDGE
Room No.130 - Echo Machine GE Wipro VIVID T8 PRO
Room No.65 - X-RAY WITH IITV Genuine X-ray and Radiology Equipment [Link]
Room No.66 - X-RAY WITH IITV GE WIPRO
Room No.67 - X-RAY UNIT GE Wipro
Room No.70- X-RAY UNIT Meditronics
Room No.118 - X-RAY UNIT Genuine X-ray and Radiological Equipment Pvt. Ltd
Room No.61- X-RAY UNIT Genuine X-ray and Radiological Equipment Pvt. Ltd
Portable X-ray Machine (P.I.C.U) GE Wipro
Portable X-ray Machine (WARD 2A) Diagnox (Meditronics)
Portable X-ray Machine (WARD 4A) Genuine X-ray and Radiological Equipment Pvt. Ltd
Portable X-ray Machine (WARD 6A) L & T (SAKNRAY)
Portable X-ray Machine (WARD 8A) Genuine X-ray and Radiological Equipment Pvt. Ltd
Portable X-ray Machine (10th Floor ICU) Genuine X-ray and Radiological Equipment Pvt. Ltd
Room No.69- CR SYSTEMS 2 CR SYSTEM- FUJIFILM- 2 SYSTEMS
Room No 65 – DSA GENUINE
 Critical Test Results Reporting and Documentation
Sr. no Procedural Responsibility
1. Radiology Technicians shall be vigilant about the Radiology Technician on
films which shows abnormality duty
2. In case any abnormal film is noticed, it has to be Radiology Technician on
immediately informed to the radiologist. In case duty
radiologist is not available order of notification
given above shall be followed directly by
technician
3. Radiologist identifies and confirms critical test Radiology on
result when reported to him. Technicia
nduty/ Radiologist
4. A verbal report is given to the ordering Radiology on
physicianimmediately in person or by phone Technicia
nduty/ Radiologist
5. If the ordering physician is not available, the Radiology on
radiologist immediately contacts the other team Technicia
member. Assistant and a verbal report is given n duty/ Radiologist
in person / phone and then the medical officer /
registrar shall be responsible to inform the same
to the concerned consultant.
6. If the assistant could not be reached, the Radiologist
radiologist will immediately follow the order of
notification.
7. Any delay in intimation of critical result shall Radiologist
berecorded in compliance register with
reason of
the delay
Reporting of Results:
Results are reported in standardized manner. At a minimum report includes name of
hospital, (name of outsourced imaging centre), patient’s name, Reg. No. IP No. (incase
ofinpatient), name & signature of person reporting test result.

Recall/ Amendment in Report:

Due to any reason, incase wrong report is given to patient or sent to IPD area same shall be
corrected by following recall process.
For OPD, new/ amended report is issued to patient and advised to ignorethe earlier one.
For IP patient, new/ amended report is issued to nursing staff handling the patient and informed to
the treating doctor, old report is destroyed to avoid confusion.
Record for same shall be kept with date, time and reason for recall.

1. In-case of equipment failure:

We have sufficient X-rays units so in case of failure the load can be easily manageable.
Urgent cases to be prioritized by the staff. Radiology staff to coordinate the same with the
outsource agency.

2. Manpower
Manpower budgeting is done, by department looking into the need for future one year. The
plan is sanctioned by top management and adequate qualified manpower is recruited to
manage the department functioning as per AERB guidelines
Internal Quality Assurance (Peer Review) of Imaging Protocols and Result

Internal &External review of imaging protocols and result will be done in structuredmanner
by group of radiologists.

Peer review of the imaging will be done on following parameters

• Review of outcome
• Appropriateness of (screening) test
• Appropriateness of procedure/ protocol follow

Frequency & Sample size for the Audit

Sample
Frequency Modality Type of review
Size

Each as per scope Test result, Appropriateness

Quarterly 2%of each of(screening)of test
modality
Only for the CT scan, MRI Appropriateness of procedure/protocol
–contrast procedure follow

Test result, Appropriateness of

Each as per scope
(screening) of test
Quarterly 2%of each
modality Only for the CT scan,
Appropriateness of procedure/protocol
MRI –contrast
follow
procedure
S. No. Key Characteristics Acceptance Norms / Remark
Criteria
3. Timely intimation of Within 15 min
critical results

4. Waiting time for • X ray : 30 mins or less

investigation. (90% cases)
• Ultrasound : 40 min after
preparation (90% cases)

5. Wastage of film because <5%

of repeat process

6. TLD badges Availability and regular

checking to TLD

7. TAT for radiology test 20 min

8. Re-do/error of radiology <4%

test

9. Legal compliance AERB

approvalsTLD
monitoring
Lead apron monitoring
Radiation safety monitoring
S. No. Key Characteristics Acceptance Norms / Remark
Criteria
10. Adherence to safety 100%compliance level
precaution

11. Surveillance activity As per define process

12. Training of staff on Monthly base

radiation safety
Departmental training

13. Quality check of Six monthly at any NABH/

outsource agency NABL accredited center.

14. Quality of X-ray image 90 % of the X-ray shall be 5 – X-ray / Month

ofgood quality shouldbe sent to
NABH
Documentation
Peer review file content following documentation
•
List of samples selected
•
In-house report of both radiologists (on letterhead with signature)
•
Outside (other unit) report of radiologist (on letterhead with signature)
•
Summary sheet with validation of report
•
Documentation of Communication with radiologist in case of any
discrepancy
Minutes of meeting & Attendance sheet of discrepancy meeting.

RADIATION SAFETY POLICIES

a. Policy: Statutory Requirements
The Atomic Energy Regulatory Board (A.E.R.B) is entrusted with the responsibility of
developing and implementing appropriate regulatory measures to ensure radiation safety.
Statutory requirements with regard to radiation safety are as follows:
i. Commissioning and Decommissioning of X-ray Equipment has to be registered
with AERB.
ii. Direct assistance to the patient while being X-rayed has to be avoided. If
assistance is required, appropriate precautions have to be taken by the person
who will assist by making use of appropriate protective material and devices
which are available.
iii. Fetal protection measures to be used.
iv. Image intensifiers to be used for fluoroscopy examination.
v. Periodic inspection of X-ray equipment and shielding features is conducted
regularly.
vi. Personnel monitoring facility be provided to all radiation workers.
vii. Presence of uninvolved staff, patients and persons in any X-ray room must be
avoided.
viii. Regular maintenance and calibration of the unit must be carried out.
ix. Reproductive organs must be particularly shielded.
x. Services of qualified radiologists and X-rays technologists to be used.
xi. Servicing and calibration of X-ray equipment should be undertaken by qualified,
trained and authorized service engineer.
xii. There should be transfer of radiographs and reports to avoid repeated X-rays
examinations.
xiii. X-rays equipment meeting design certification and type approval requirement by
AERB only shall be used.
xiv. X-ray examination of pregnant women and children should be avoided as far
as possible.
xv. Imaging signage are prominently displayed as per AERB norms.

Policy: Personal protective equipment

No person shall operate or permit the operation of certified or uncertified medical
radiographic and fluoroscopic equipment systems unless the following conditions are met:
Only individuals required for the medical procedure, for training or for equipment
maintenance shall be in the radiographic or fluoroscopic room during an exposure.
i. Individuals who are present in a radiographer or fluoroscopic room during any
exposure shall wear protective aprons of at least 0.25 mm lead equivalent during
every exposure.
ii. When a patient must be provided with auxiliary support during a radiation
exposure, the following procedures shall be followed:
iii. The person holding the patient shall be protected with a lead apron of at least
0.25 mm lead equivalent;
iv. Radiographers not to hold the patient during a radiation exposure, except in a
life-threatening situation.
v. No person shall be employed, routinely assigned, or required to hold a patient
during radiographic and fluoroscopic procedures;
vi. If a patient must be held during the x-ray exposure, non-radiation workers such
as nurses or members of the patient’s family may be asked to perform this duty.
vii. Gonad shielding of not less than 0.5 mm lead equivalent shall be used on a
patient during Radiographic and fluoroscopic procedure, except for cases in
which this would interfere with Diagnostic procedure.
viii. The operator shall collimate x-ray beam limitation to ensure that the x-ray field
does not extend beyond the Region of interest.
ix. The Radiographic field shall be restricted to the areas of clinical interest as far as
practical
x. A method to observe the patient during the x-ray exposure (Lead glass) shall be
provided for all units.
xi. During radiographic exposure, the operator shall stand behind the protective
barrier.
xii. The department manager shall provide safety rules to each individual operating
x-ray equipment including any restrictions as to the operating technique required
for the safe operations of the particular x-ray apparatus.

No person shall permit or arrange for the intentional irradiation of a human being
except for the purpose of medical diagnosis or treatment
xiv. No person shall deliberately expose an individual to the useful beam for the sole
purpose of training or demonstration.
xv. No person shall operate an ionizing –radiation-producing machine unless that
person understands and uses the principles of radiation safety to keep radiation
exposure as low as reasonably achievable (ALARA).

c. List of Personal Protective Equipment:

i. Lead aprons
ii. Thyroid Shields (0.50 mm Lead)
iii. Lead Goggles
iv. 2mm Lead Lined Doors in all X-ray Producing unit/lead partition
v. A method to observe the patient during the x-ray exposure (Lead glass)
shall be provided for all units.
vi. Periodic testing of PPEs

d. Policy type: Safety Guidelines

i. All safety guidelines shall be observed.
ii. Report every injury, no matter how slight, to your in charge.
iii. No intoxicating liquor shall be consumed while on duty. Anyone who is found under
the influence of alcohol or drugs will be terminated.
iv. Keep fit for your job, eat properly and get sufficient rest to meet the demands of your
job.
v. Take a special interest in the new or inexperienced persons and help them with the
small details of the job.
vi. Be sure to notify all persons of any dangerous situations that might affect your work
area.
vii. Remember the patient; never leave him/her unattended.
viii. Know all the hospital emergency codes and be sure of your responsibilities.

When dealing with the extremely large patient, be sure to seek help and lift the
patient correctly.
x. Know your fire extinguishers, their locations and the use.
xi. Use good house keeping techniques at all times.
xii. Remember the department security.

Policy: General Radiation Protection

i. A qualified radiographer must only do all radiographic techniques and procedures.
All radiographers must take necessary steps in reducing radiation dose to the patient.
ii. Check the correct patient for correct examination.
iii. Plan your technique to reduce the radiation dose
iv. Close the X-ray room door properly and tightly.
v. Provide the necessary radiation protection.
vi. Collimate the radiation beam to necessary area only.
vii. Give proper and correct instructions.
viii. Select the appropriate exposure factor.
ix. Place the correct ID Number for correct patient
x. Avoid unnecessary repeats.
xi. For female patients check whether they are pregnant.
xii. Limit number of people in the X-ray room while X-ray is being done.
xiii. Mobile X-ray request only if it is necessary.
xiv. All staff must wear radiation-monitoring badge while in the radiology department.
xv. Use only high-speed cassette to reduce exposure.
xvi. Clear all staff from room during Mobile X-ray/Provide Lead apron to the next Bed
patient if he he/she is not able to move.
xvii. Proper training of imaging and ancillary staff on radiation safety norms.

Policy: Departmental Safety

i. Radiation Safety Officer is responsible for maintaining safety standards, developing
safety rules and supervising and training personnel in departmental standards.
ii. Radiation Safety Officer is responsible for notifying the Management in case of any
safety hazard.

All radiology employees shall report defective equipment, unsafe conditions, acts or
safety hazards to Radiation Safety Officer.
iv. Keep electrical cords clear of passage ways. Do not use electrical extension cords
without prior informing the facility department.
v. All equipments and supplies must be properly stored.
vi. Scissors, knives, pins, razors, blades and other sharp instruments must be stored and
used safely.
vii. All electrical machines, with heat producing elements, must be turned off or
unplugged when it is in not use.
viii. Smoking is prohibited, per hospital smoking policy.
ix. Do not permit rubbish to accumulate.
x. Notify the facility department immediately of illumination and Air conditioning effect
Problems.
xi. Furniture and equipment must be placed to allow adequate passage and access to
exits at all times.
xii. Employee who discovers the spill should inform spills, such as blood & biological
fluids spill & chemical spill ,to House keeping team. This shall be done immediately.
xiii. Report faulty equipment to the Biomedical Engineer or vendor, per policy.
xiv. Obey warning signs.
xv. File drawers and cabinet doors shall be closed when not in use.
xvi. Wear suitable clothing, only authorized personnel shall be allowed in X-ray room.

Policy: Role of Radiographers in safety program

i. It is the responsibility of the RADIOGRAPHER to have thorough knowledge and apply
on the job instructions for all personnel regarding safe practices.
ii. Department manager is responsible for the degree to which his/her personnel have
gained the knowledge and skills necessary to perform safely and effectively in their
particular position.
iii. Individual departments will establish and publish safe work rules which reduce
accident probability. Development of these rules should involve:
o A review of all work methods and practices
o A review of all past accident experiences
o Recommendations by supervisory personnel
Patient’s Safety Policy:
i. All patients shall receive the utmost care and attention
ii. No patients shall be left unattended.
iii. Appropriate Personal protective equipment shall be kept available at all times,
personnel shall be trained in their use.
iv. Two staff personnel will attend all trolley patients.
v. When the lift is used for any patient, one staff must be present on the lift.
vi. All wheelchair will have wheel locked when the wheel chair is on the lift and while the
patient is entering or exiting the wheelchair.
vii. When a trolley is used for the transportation of the patient, the side rails will always
be up. Trolley wheel must be locked while trolley is on lift.
viii. Transportation method for out patient will be based on status of the patient when
assessed by the hospital staff prior to x-ray/scanning. An out patient determined to
be ambulatory will be allowed to walk to the unit.
ix. The Bed sheet of [Link] Table shall be changed for each patient where ever
infected patient is there or there is any spill to prevent any kind of cross
Infection/contamination.
x. Any of the hospital employees who knowingly disguard the patients’ safety by
disobeying the aforementioned policies will be subject to disciplinary action by
management.
xi. All X-ray switches shall be in allocation where they cannot be accidentally energized.
xii. TLD shall be worn by all Staffs during working hours in department. Badges will be
processed and recorded Quarterly.
xiii. A routine check shall be made for X-ray equipment before using. Recalibrate when
tubes are changed or machines modified.
xiv. If a patient must be held during x-ray, the assistant holding the patient will wear a
lead-lined apron during the entire procedure.

Policy: Lead Apron inspection/Radiation protective device

i. Lead aprons must be used to protect staffs and patients from unnecessary radiation
exposure from diagnostic radiology procedures.
ii. Health care organization must perform inspections on medical equipment, including
lead aprons, lead protective devices etc.
iii. Inspection Frequency
a. Quarterly: Apron must be placed on the table and checked using the
automatic brightness control (fluoroscopic method)

iv. Aprons must be stored properly in hangers.

v. Do not fold or pile up.
vi. Check for cracks.

Policy: Handling of chemicals

i. Most chemicals are harmful to some degree. Avoid direct contact with any chemical.
ii. Wash thoroughly with water whenever a chemical contacts your skin.
iii. Never taste or smell a chemical.
iv. All container and chemicals must be labeled clearly. Do not use any substance in an
unlabeled container.
v. Always pour concentrated solutions slowly into water or into less concentrated
solution while stirring. Always wear safety spectacles and Plastic apron & Mask while
diluting solutions.
vi. Keep flammable solvents away from heat and sunlight. Do not heat flammable
solvents directly over a naked flame or hot plate.
vii. Discard safely
viii. Wear mask during preparing fresh and filling/ discarding processing solutions.
RECOMMENDATIONS:

Infrastructure and Process

1. Using modular furniture can enlarge the existing space in the reception area.
2. Thyroid shields, eye glasses, gonad shields and lead gloves should be used often in the
department.
3. Strict actions must be taken for enforcing wearing of TLD badges and lead aprons by
the technicians.
4. All the policies and procedures must be documented and should be strictly followed.
5. The hospital should develop a culture of quality and reinforce professional ethics
through continuous professional education.
6. The senior managers, executives should share the information regarding their
achievements, so that the researcher can give some solutions or learn from
their experiences.
7. The quality team can do surprise check in order to monitor the adherence to the
protocols.
8. Standard operating Procedures must be made for every modality of radiology and the
staff must strictly adhere to the standards.
9. The hospital should establish incentives that promote and reinforce the processes. Each
member of the organization from all cadres needs to be motivated to follow these
processes and the ones with good track record should be rewarded with up gradation of
scales or posts.
10. Talent must be retained so that that the organization don’t have to go for the training
process again and again
11. Regular internal audit of the department and findings must be communicated to
the staff.
12. Liaison between radiology department and Quality control team
13. The department can compare their Key Performance Indicators with the
departments insimilar hospitals and can set their benchmarks based on the hospital,
which is performingbest.
14. The department should make use of more and more Radiology Information
Systems (RIS) for documentation instead of paper work, which will save time for
documentationsince the employees don’t have to write same thing repeatedly. It will
also help in comparing department with other hospitals.
15. The department should focus more on team building, reducing the gap between
thehierarchy or no hierarchy, help in reducing the communication gap amongst the
employees
16. Need to create an environment for changing the mindset of hospital
administrators and clinicians to move towards a paperless system.