Our consultancy scope for NABH Medical Imaging
Services (MIS) Accreditation is governed by the 3rd Edition MIS Standards. This
accreditation is essential for diagnostic centers and hospital imaging
departments to demonstrate clinical excellence and radiation safety.
The consultancy scope of service typically
includes:
1.
Statutory Compliance & AERB Licensing
AERB e-LORA Support: Facilitating the
registration of all X-ray, CT, and Mammography equipment on the AERB e-LORA
Portal.
Safety Officer Appointment: Guidance on
the mandatory qualification and appointment of a Radiological Safety Officer
(RSO).
Quality Assurance (QA) Tests: Coordinating
annual QA tests for equipment to ensure they meet dose-limit standards.
2.
Radiation Safety & Infrastructure
Shielding Design: Verifying lead lining in
doors, walls, and viewing windows (typically 2mm lead equivalent) as per NABH
and AERB requirements.
Personnel Monitoring: Implementing the TLD
(Thermoluminescent Dosimeter) badge program and maintaining the "Dose
Records" for all staff.
Signage & Safety Gear: Ensuring
bilingual warning signs, red light indicators outside rooms, and availability
of lead aprons, thyroid shields, and gonadal shields.
3.
Specialized Documentation (MIS Specific)
Standard Operating Procedures (SOPs):
Drafting protocols for specific imaging modalities (MRI, CT, Ultrasound,
Nuclear Medicine).
Teleradiology Protocols: If applicable,
establishing SOPs for data security, turnaround time (TAT), and digital
signature validity.
Contrast Safety Manual: Developing protocols
for managing adverse reactions to contrast media, including the availability of
a fully stocked emergency crash cart.
4.
Technical Quality Control
Dose Optimization: Implementing the ALARA
(As Low As Reasonably Achievable) principle for patient dose management,
especially for pediatric patients.
Image Quality Peer Review: Establishing a
system for "Double Reading" or peer review of a percentage of imaging
reports to ensure diagnostic accuracy.
Equipment Maintenance: Setting up
Preventive Maintenance Schedules (PMS) and tracking "Equipment
Down-time."
5.
Desktop Assessment (DA) Support
Portal Uploads: Managing the NABH Digital
Portal submission, including uploading equipment certificates and RSO
approvals.
Evidence of Calibration: Ensuring all
measuring instruments (like dose meters) have valid calibration certificates
from NABL-accredited labs.
Mock Drills: Conducting training and
documentation for emergency codes, particularly "Code Blue" (cardiac
arrest) and "Code Red" (fire) within the imaging suite.
6.
Quality Indicators for Imaging (2026 Metrics)
Consultants help the center track and
report mandatory indicators such as:
Report Turnaround Time (TAT): For
emergency vs. routine scans.
Re-scan Rate: Monitoring the percentage of
scans repeated due to technical errors.
Patient Identification Errors: Tracking
errors in labeling or site marking.
Critical Value Reporting: Percentage of
life-threatening findings communicated immediately to the referring doctor.
7.
Assessment Readiness
Staff Training: Educating technicians and
nursing staff on patient preparation (e.g., fasting for USG, creatinine checks
for CT).
Mock Assessment: A full simulation of the
NABH audit using the Tracer Methodology to follow a patient from registration
to report delivery.
NC Closure: Assisting in the 15-day window
to close any Non-Conformities raised during the official NABH MIS Assessment.