Chapter 1: Access, Assessment and Care of

Patient (AAC)

 AAC.1: The organization defines and displays the scope of medical imaging services that
it provides.
o Commitment a: The scope of medical imaging services being provided are
clearly defined and prominently displayed.
o Commitment b: Patients are accepted only if the organization can provide the
required medical imaging services.
o Commitment c: The staff is oriented to the medical imaging services.
 AAC.2: The organization has a well-defined registration and admission process.

o Commitment a: The organization uses written guidance for registering the

patient and a unique identification number is generated for each patient at the
end of the registration.
o Commitment b: All attempts are made to ensure that the unique identification
number is maintained for each patient on all subsequent visits.
o Commitment c: The organization has a mechanism to capture all the required
information about the procedure requested, the relevant clinical and lab details,
and information about prior imaging before performing the procedure.
o Commitment d: The organization has a mechanism in place to ensure that the
imaging is appropriate for the patient and the clinical indication.
o Commitment e: The organization has a mechanism in place for scheduling and
prioritization according to the patient's condition and urgency of diagnosis.

 AAC.3: The organization protects patient and family rights and informs them about their
responsibilities during care.

o Commitment a: Patients and families are informed of their rights and

responsibilities in a format and language that they can understand.
o Commitment b: The information about specific procedures are available to
patients and accompanying persons in relevant formats and languages including
the local language.
o Commitment c: The patients and (or) attendants are informed about the
expected costs prior to imaging.
 o Commitment d: Imaging services provided are uniform for a given health
problem in all settings.
o Commitment e: The privacy and dignity of the patient is preserved without any
discrimination.
o Commitment f: Confidentiality of patient information will be maintained.
o Commitment g: The patient and family have a right to seek an additional
opinion.

 AAC.4: The organization has written guidance for obtaining informed consent from the
patients to enable informed decision-making about their care.

o Commitment a: Written guidance incorporates the list of situations where

informed consent is required and the process for taking informed consent.
o Commitment b: Informed consent includes information regarding the
procedure, its risks, benefits, alternatives in a language that the
patient/guardian can understand.
o Commitment c: The written guidance describes who can give consent when the
patient is incapable of independent decision-making.
o Commitment d: Informed consent is taken by the person performing the
procedure or by a staff member of the team.

 AAC.5: Emergency imaging services are guided by applicable laws and regulations and
written guidance.

o Commitment a: The organization shall have written guidance for the

identification of emergencies.
o Commitment b: Written guidance is used for the triaging of patients for
prioritization of imaging.
o Commitment c: Written guidance is used for handling emergency patients in the
premises and during imaging.
o Commitment d: Written guidance is used for handling and management of
medico-legal cases.
o Commitment e: There is an identified area in the organization to receive and
manage emergency patients.

 AAC.6: Patient transportation and ambulance services are guided by applicable laws,
regulations and written guidance.

o Commitment a: Written guidance exists to ensure safe and timely

transportation of patients within,
o Commitment b: There is adequate access and space for the ambulance(s)
and/or patient transport vehicle(s).
 o Commitment c: The ambulance and/or patient transport vehicle(s) adhere to
statutory requirements and are manned by trained personnel as per the existing
laws and regulations.
o Commitment d: The ambulance(s) and/or patient transport vehicle(s) are
appropriately equipped.

 AAC.7: Written guidance exists for the care of patients requiring cardio-pulmonary
resuscitation.

o Commitment a: Written guidance exists for the uniform use of resuscitation

throughout the organization.
o Commitment b: During cardio-pulmonary resuscitation, assigned roles and
responsibilities are complied with.
o Commitment c: Staff providing direct patient care are trained and periodically
updated in emergency life support and cardio-pulmonary resuscitation.
o Commitment d: An appropriately equipped crash cart or a resuscitation tray is
maintained.
o Commitment e: The events during any emergency life support and
cardiopulmonary resuscitation are documented and analyzed.
o Commitment f: The organization has a mechanism for the transfer of patients to
an appropriate acute care facility when required.

 AAC.8: Written guidance exists for the care of patients undergoing anesthesia and
procedural sedation.

o Commitment a: Written guidance exists for the selection of patients for

anesthesia/sedation, its administration and monitoring.
o Commitment b: Informed consent for administration of anesthesia, procedural
sedation is obtained.
o Commitment c: Competent and trained persons administer anesthesia and
sedation.
o Commitment d: The patient is appropriately monitored on predefined
parameters before, during, and after the procedure till the discharge.
o Commitment e: The equipment required for procedural sedation and anesthesia
services is available.
o Commitment f: Equipment and workforce are available to manage patients who
have gone into a deeper level of sedation than initially intended.
Chapter 2: Imaging Procedures and

Interpretations (IPI)

 IPI.1: Written guidance exists for conducting imaging procedures to acquire images of
optimal diagnostic quality.

o Commitment a: Appropriately qualified and trained personnel plan and perform

imaging studies.
o Commitment b: The written guidance for image acquisition for all examinations
is developed based on current best practices.
o Commitment c: The protocols are appropriate for the specific age, gender,
clinical indications, anatomical part, and modality.
o Commitment d: The protocols are implemented, and protocol deviations are
documented.
o Commitment e: The protocols include appropriate post-processing and
quantification as appropriate for the clinical indication.
o Commitment f: The protocols for image acquisition for all examinations are
reviewed at a defined periodicity for improvement and adaptation of the current
best practices and guidelines.
o Commitment g: Written guidance exists to prevent events like wrong patient,
wrong site, wrong side, and wrong imaging procedure.
o Commitment h: Protocols include assessment and monitoring of patients
before, during, and after the imaging procedure.
o Achievement i: The quality of diagnostic images and completeness of the
procedures are checked through written guidance.
o Achievement j: Staff are appropriately oriented and trained for these.

 IPI.2: Written guidance exists for the care of patients undergoing diagnostic and
therapeutic interventional procedures.

o Commitment a: Adequately qualified and trained staff members perform and

assist the procedures.
o Commitment b: The protocols for all diagnostic and therapeutic interventional
procedures are developed and documented.
o Commitment c: Patients undergoing an interventional procedure shall have a
pre-procedural assessment and a provisional diagnosis is documented prior to
the procedure.
 o Commitment d: Informed consent is obtained by a member of the performing
team prior to the procedure and the same is documented.
o Commitment e: Written guidance exists to prevent adverse events like wrong
site, wrong patient and wrong interventional procedure.
o Commitment f: Radiation safety procedures are followed.
o Commitment g: Written guidance for infection prevention and control are
followed.
o Commitment h: Appropriate facilities and equipment, appliances, and
instrumentations are available in the procedure area.
o Commitment i: Appropriate sedation/anaesthesia, clinical and emergency
support is available before, during, and after the interventional procedure.
o Commitment j: A procedure note is documented prior to transfer out of patient
from the facility.
o Commitment k: The outcomes of diagnostic and therapeutic interventional
procedures are monitored.

 IPI.3: The organization has written guidance on the content of the imaging reports and
discharge documents.

o Commitment a: An imaging report or a discharge document are provided to the

patients for each procedure.
o Commitment b: Results are reported in a standardized manner using the current
best practices and guidelines.
o Commitment c: The report contains the patient's demographic details including
unique identification number
o Commitment d: The report contains the details of the procedure performed,
medication and sedation administered, details of any adverse event, and any
other treatment given.
o Achievement e: The report contains findings, diagnosis or differential diagnosis.
o Achievement f: The report ensures that the current clinical indication for the
imaging study is addressed and all attempts are made to collate findings with
the previous imaging findings as well as clinical details.
o Achievement g: The imaging report or discharge document contains advice for
any further investigation, follow-up imaging advice, medication, and other
instructions as appropriate in an understandable manner.
o Commitment h: There is written guidance to address recall/amendment of
reports when required.

 IPI.4: The organization has written guidance for communication of the imaging results
and discharge documents.

o Commitment a: There is written guidance on communication of routine, urgent

and critical imaging findings with a defined turnaround time for each of them.
 o Commitment b: A list of conditions requiring critical and urgent communication
is defined.
o Achievement c: The reports are communicated to the patient and/or referring
clinician within the appropriately defined timeframe based on the clinical
indication and urgency.
o Commitment d: Imaging tests and/or reporting outsourced to other
organization(s) follow the same turnaround time and critical reports
requirements.
o Commitment e: The organization has a mechanism to ensure that the right
report is communicated to the right patient and the right physician at the right
time.

 IPI.5: Teleradiology services address all issues pertaining to reporting and

communication.

o Commitment a: Teleradiology services are provided under a documented

agreement between the provider and consumer of the services.
o Commitment b: All clinical, lab and prior imaging information is available to the
teleradiology services provider.
o Achievement c: Appropriately qualified and trained personnel interpret the
imaging studies.
o Commitment d: Appropriate equipment is used for the acquisition,
communication, display, and storage of images.
o Commitment e: Results are reported in a standardized manner consistent with
the organizational standards.
o Commitment f: Written guidance exists to address recall/amendment of
teleradiology reports when required.

 IPI.6: All research activities and clinical trials are carried out as per written guidance.

o Commitment a: All research activities and clinical trials, in compliance with

regulatory, national, and international guidelines are carried out as per the
written guidance.
o Commitment b: The organization has access to an appropriate ethics committee
or internal review board to oversee all research activities or clinical trials.
o Commitment c: The ethics committee has the power to discontinue a research
activity or clinical trial when risks outweigh the potential benefits.
o Commitment d: Patients' informed consent is obtained before entering them
into research activities/clinical trials in accordance with the prevalent laws and
regulations.
o Commitment e: Patients are informed of their right to withdraw from the
research activity/clinical trial at any stage and also of the consequences (if any)
of such withdrawal.
 o Excellence f: The organization contributes to national and international
research.

Chapter 3: Facility Management Services

(FMS)

 FMS.1: The organization's environment and facilities operate in a planned manner to

ensure operational efficiency and promote environmental friendly measures.

o Commitment a: Facilities are appropriate to the scope of services of the

organization.
o Commitment b: Up-to-date drawings are maintained which detail the site
layout, floor plans, and fire-escape routes.
o Commitment c: The provision of space shall be in accordance with the current
good practices (Indian or international standards) and directives from
government agencies.
o Commitment d: There are appropriate internal and external sign postings in the
organization in a language understood by patient, families, and the community.
o Commitment e: Potable water and electricity are available round the clock.
o Commitment f: Medical gases are procured, handled, stored, distributed, used
and replenished in accordance with written guidance.

 FMS.2: All facilities are appropriately maintained to ensure uninterrupted services.

o Commitment a: There are designated individuals (with appropriate equipment)

responsible for the maintenance of all the facilities.
o Commitment b: Alternative sources for electricity and water are provided as a
backup for any failure/shortage especially for the equipment and the
organization regularly tests these alternative sources.
o Commitment c: There is a maintenance plan for all facilities and furniture.
o Achievement d: Response times are monitored from reporting to inspection and
implementation of corrective and preventive actions.
o Excellence e: The organization takes initiatives towards an energy-efficient and
environmental-friendly facility.

 FMS.3: The organization has a mechanism to provide a safe and secure environment.
 o Commitment a: MIS coordinates the development, implementation, and
monitoring of the facility safety plan.
o Commitment b: Patient-safety devices & infrastructure are installed across the
organization and inspected periodically.
o Commitment c: Operational planning identifies areas which need to have extra
security and describes access to different areas in the organization by staff,
patients, and visitors.
o Commitment d: Written guidance exists for the disposal of waste and scrap
material.
o Commitment e: Facility inspection rounds to ensure safety are conducted.
o Commitment f: Inspection reports are documented and corrective and
preventive measures are undertaken.

 FMS.4: The organization has plans for fire and non-fire emergencies within the facilities.

o Commitment a: The organization has plans and provisions for early detection,
abatement, and containment of fire and non-fire emergencies.
o Commitment b: The organization has a documented safe-exit plan in case of fire
and non-fire emergencies.
o Achievement c: Staff is trained for their role in case of such emergencies.
o Commitment d: Mock drills are held at least twice a year.
o Commitment e: There is a maintenance plan for fire-related equipment and
infrastructure.

Chapter 4: Equipment, Material and

Medications (EMM)
 EMM.1: Written guidance exists for the management of all equipment.

o Commitment a: The organization plans for equipment in accordance with its

services and strategic plan.
o Commitment b: Equipments are inventoried with proper equipment history and
logs.
o Commitment c: The installation of the equipment is safe and commensurate
with the applicable laws.
o Commitment d: The operation of the equipment is safe and compliant with the
applicable laws.
o Commitment e: Appropriate calibration and quality assurance of the equipment
is performed at a defined periodicity.
o Commitment f: Written guidance exists for operational and maintenance
(preventive and breakdown) plan of all equipment.
 o Commitment g: Equipment cleaning and disinfection adheres to transmission-
based precautions at all times.
o Commitment h: The organization identifies and plans for obsolescence,
condemning, and decommissioning of the equipment.
o Commitment i: Qualified and trained personnel inspect, test, and maintain
equipment and utility systems.

 EMM.2: Written guidance exists for the procurement, storage, and usage of medication.

o Commitment a: Written guidance exists for procurement and stocking of

contrast media,
o Commitment b: Written guidance exists for the storage of medication in a clean,
safe and secure environment.
o Achievement c: Sound inventory control practices guide the storage of the
medications.
o Commitment d: Written guidance exists for the usage of multidose formulations
and their discard.

 EMM.3: Written guidance exists for the safe and rational use of contrast media and
medications.

o Commitment a: Written guidance exists for use of contrast media and other
medications, which is commensurate with current best practices.
o Commitment b: Contrast media and other medications are handled and
administered by those who are permitted and trained to do so.
o Commitment c: There is a mechanism to identify patients who are at high risk
for adverse events following the administration of contrast media and other
medications.
o Commitment d: Written guidance exists for monitoring of patients during and
after administration of contrast media and other medications.
o Commitment e: Written guidance exists for managing adverse drug reactions,
and other adverse drug events.

 EMM.4: The organization is governed by written guidance for diagnostic/therapeutic

usage of radiopharmaceuticals.

o Commitment a: Written guidance governs the safe transport, storage,

preparation, handling, distribution, administration, and disposal of
radiopharmaceuticals.
o Commitment b: The written guidance for handling radiopharmaceuticals are in
consonance with laws and regulation.
o Commitment c: This includes the management of radioactive spills and
personnel contamination.
 o Commitment d: The patients at higher risk of adverse reactions to specific
drugs, isotopes, and radiopharmaceuticals are identified, assessed, and
managed.
o Commitment e: Staff, patients, and visitors are educated on safety precautions
and the management of adverse events.
o Commitment f: The protocols followed in the holding area used for nuclear
medicine patients are defined and implemented.
o Commitment g: All patients are provided with a comprehensive discharge
summary.

 EMM.5: Written guidance exists for the use of medical supplies and consumables, stents,
coils, and other implantable and ablative medical devices.

o Commitment a: The use of medical supplies, consumables, and devices is

rational, safe, and commensurate with the current best practices.
o Commitment b: Medical supplies and consumables are stored appropriately and
are available where required.
o Commitment c: Written guidance governs the reuse and re-sterilization of
devices.
o Commitment d: A discharge summary is provided in case of any implant
procedure including the details of the implant.
o Commitment e: Patients and family are educated about the implanted
prosthesis and medical device including their maintenance and precautions.

Chapter 5: Human Resource Management

(HRM)

 HRM.1: Written guidance exists for human resource planning.

o Commitment a: The organization maintains an adequate number and mix of

staff to meet the needs of the organization.
o Commitment b: There is written guidance for the recruitment and selection of
staff.
o Commitment c: Job specification and job description are defined and
documented for each category of staff.
 o Commitment d: The credentials, skills, and training of the staff are verified
wherever possible.
o Commitment e: The organization verifies the antecedents of the potential
employee with regard to criminal/negligent background.
o Commitment f: There is a defined process of privileging for all healthcare
providers for the services assigned to them.
o Commitment g: There are clearly defined roles and supervisory requirements
for the students, trainees and volunteers.

 HRM.2: The organization has a documented training program for the staff.

o Commitment a: Every staff member is made aware of the organization's policies

and procedures through induction training at the time of joining.
o Commitment b: Written guidance for training and development exists for the
staff.
o Commitment c: Retraining occurs at a defined periodicity, and also when job
responsibility changes and/or new equipment is introduced.
o Commitment d: Staff are trained on the risks as applicable to the organization's
environment at a defined periodicity.
o Commitment e: Staff are also trained on occupational safety aspects
o Excellence f: Evaluation of training effectiveness is done by the organization.

 HRM.3: The organization has a documented human resource management process.

o Commitment a: The MIS carries out periodic appraisal and competency

evaluation as per written guidance.
o Commitment b: The organization encourages and promotes competency
development
o Commitment c: The organization has documented disciplinary and grievance
handling policies and procedures.
o Commitment d: There is a provision for appeals in all disciplinary cases.
o Commitment e: There is a provision for health check-ups; health and other
benefits to the staff.

 HRM.4: There is documented personal information for each staff member.

o Commitment a: A personal file is maintained for each staff member.

o Commitment b: The personal files contain information regarding the staff's
qualifications, background, and health status.
o Commitment c: All records of in-service training and education are contained in
the personal files.
o Commitment d: The personal file shall include information on the credentialing
and privileging of staff members for performing all imaging-related procedures.
o Commitment e: Personal files contain the results of all evaluations.
Chapter 6: Management of Quality and

Safety (MQS)

 MQS.1: Roles of management is defined.

o Commitment a: Management defines the organization's vision, mission, and

values.
o Commitment b: Management chooses leaders and establishes an organogram in
the organization.
o Commitment c: Management is aware of current applicable laws and ensures
that the organization adheres to them.
o Commitment d: Management ensures the acquisition of all relevant licenses
and their updation.
o Commitment e: Management ensures ethical management of all patient
services that the organization provides.
o Commitment f: The management ensures that all policies and protocols are
developed and documented to guide the functioning of the organization.

 MQS.2: The organization has a structured quality improvement program.

o Commitment a: A continual quality improvement program is developed,

documented, and implemented throughout the organization.
o Commitment b: The program is periodically reviewed and updated at least once
a year.
o Commitment c: The organization conducts regular audits for timeliness and
efficiency of services.
o Commitment d: The organization identifies and monitors priority key
performance indicators (clinical, managerial, and infrastructural) in the
organization.
o Achievement e: The program includes a system for reporting and analyzing
adverse events and medication errors.
o Commitment f: The program includes a system to obtain feedback from patients
and visitors on all aspects of services.
o Achievement g: There is a system of periodic review to ensure that feedback is
utilized to improve services.
 MQS.3: The organization identifies and monitors the quality of imaging studies and
reports.

o Commitment a: The organization monitors the appropriateness of imaging.

o Commitment b: The organization monitors image quality and completeness of
imaging for a given indication and clinical context.
o Commitment c: The organization monitors re-dos of imaging procedures and
recalls of reports.
o Commitment d: The organization conducts regular audits for the completeness
of reports.
o Achievement e: The program addresses periodic internal/ external peer reviews.
o Achievement f: The program addresses surveillance of imaging results with
clinical correlation and follows up wherever possible.
o Commitment g: The program includes a system to obtain feedback from
referring colleagues.
o Achievement h: There is a system of periodic review to ensure that feedback is
utilized to improve services.

 MQS.4: The management ensures patient and staff safety in the organization.

o Commitment a: A structured patient safety program is developed, documented,

and implemented.
o Commitment b: The program is periodically reviewed and updated at least once
a year.
o Commitment c: The organization conducts regular audits for patient safety
program
o Achievement d: The program addresses the safety of staff, patients and visitors
from violence, aggression, and abuse.
o Commitment e: The organization implements an incident management system.
o Excellence f: The organization shall have a process for informing various
stakeholders in case of a near-miss/adverse event/sentinel event.

 MQS.5: There is an established risk control and safety program in the imaging services.

o Commitment a: The radiation safety program is documented and developed by

the radiation safety committee of the organization.
o Commitment b: This program is implemented and overseen by an appropriately
designated radiation safety officer and is aligned with the organization's safety
program.
o Commitment c: Radiation signages are prominently displayed in all appropriate
locations.
o Commitment d: Patients are appropriately screened for safety/risk prior to
undergoing imaging on a particular modality.
 o Commitment e: Staff personnel and patients are provided with appropriate
radiation protection devices.
o Commitment f: Personal radiation monitoring devices are provided to all the
radiation workers.
o Commitment g: The safety program also addresses the risk associated with MRI.
o Commitment h: The safety program also addresses ultrasound services.
o Commitment i: The safety program also addresses the risk associated with the
use of ablative
o Commitment j: Occupational health hazards are adequately addressed.
o Commitment k: Biomedical and hazardous waste is collected and disposed off in
a safe manner and as per the applicable guidelines.

Chapter 7: Information Management System

(IMS)

 IMS.1: The information needs of the patients, visitors, staff, management, and external
agencies are met using an appropriate information management system.

o Commitment a: The information needs of the organization are identified.

o Commitment b: Information management and technology acquisitions are
commensurate with the identified information needs.
o Commitment c: Written guidance defines the use of remote access to patient
data and images in a safe and secure manner.
o Commitment d: The organization contributes to external databases in
accordance with the law and regulations.
o Excellence e: The organization or its members actively participates in scientific
and educational deliberations.
o Commitment f: The organization has an effective process for document control.
o Commitment g: Written guidance exists for storing and retrieving data.

 IMS.2: The organization has an imaging record for every patient

o Commitment a: Every imaging record includes a unique identifier for each

patient which is maintained for each patient on all subsequent visits.
o Commitment b: Organization policy identifies those authorized to make entries
in imaging records.
 o Commitment c: The mandatory contents of the imaging record are identified
and documented.

 IMS.3: Written guidance exists for maintaining confidentiality, integrity, and security of
records, data, and information.

o Commitment a: Written guidance exists for maintaining confidentiality, security,

and integrity of records, data, and information.
o Commitment b: Written guidance exists for the safeguarding of data/records
against loss, destruction, tampering, and unauthorised use.
o Commitment c: Request for access to information in the medical imaging
records by patients/physicians and other public agencies are addressed
consistently.
o Commitment d: The staff is aware of these.