Introduction to the RAD-AID Radiology-ReadinessTMSurveyWelcome to the Radiology - Readiness Survey. This survey was developed by RAD AID International, a nonprofit nongovernmental organization committed toimproving access and quality of radiology services in resource - limited parts of theworld. The contents of the Radiology - Readiness Survey were modified through acollaboration with the World Health Organization (WHO).This Radiology Readiness Survey is designed to help RAD - AID :1. Understand the healthcare benefit and impact your facility is delivering to the localcommunity2. Identify the potential wider benefit that your institution could provide with radiologyservices, and how augmenting or introducing medical imaging may help achieve yourpatient care goals3. Understand the infrastructural, epidemiological, educational, administrative,logistical, financial and clinical features of your institution in order to optimize radiologyservice delivery to your patientsAll information in the survey will be considered privileged and confidential.The following topics are covered in the survey:1. Community involvement and patient satisfaction2. Disease epidemiology3. Non-radiology clinical resources (including lab testing and referrals)4. Training and continuing medical education5. Engineering, communications, and information technology infrastructures6. Mechanisms for ensuring and evaluating medical image quality and patient safety7. Medical Imaging device inventory, use, maintenance and repair8. Facility finances and economic needs/resources of your patient population
General and Background Information1. Please enter facility name and location.Facility Name:Address 1:Address 2:City/Town:State/Province:Postal code:Country:2. Please provide the names of any other health organizations(national or international) that serve your community.3. Who will be RAD-AID 's primary contact person at your facility?Name:Title:Address 1:Address 2:City/Town:State/Province:Postal code:Country:Email Address:Phone Number:
4. Facility ownership and affiliations. Select all that apply. Public/government University affiliated Privately owned Religious entity or religious charity Corporate Other Non - profitIf Other, please specify5. How would you classify your facility?Please select the single best classification. Tertiary referral center Free - standing imaging center Community or district hospitalCommunity health center orambulatory clinic Small health post or village clinic OtherIf Other, please specify6. What is the approximate size of the population served by your facility?7. Please list the top three challenges faced by your facility in order ofimportance. Please explain the nature of each challenge and why it is particularlyproblematic for your facility.
8. Additional comments?
Community Involvement and Patient Satisfaction1. Facility Name:2. Does your facility support, sponsor, or organize anycommunity service projects ? Yes NoIf Yes, Please describe3. Do you have a strategy for helping your community learn about your facility andthe services it offers? If so, please briefly describe your strategy (brochures,newspaper advertisements, word of mouth, etc.)? Yes NoIf Yes, please describe4. How many of your patients understand a need forpreventative medical imaging in the following areas?Less than10% - 33% 34% - 66% 67% - 99%None10% Breast rasound)Tuberculosisand other lungdisease (chestradiography)All
5. On average, how long must a patient wait before getting the following servicesperformed on an outpatient/ambulatory basis?Within 24NotWithin 1 Within 1 More than2 - 3 dayshoursmonth1 monthavailableweek See a physicianCT Ultrasound MRI Mammography Nuclear Medicine Plain FilmRadiographyInterventionalRadiologyGI Fluoroscopy6. How long do patients typically wait to see a physician for emergent care ? Less than 30 minutes 30 minutes to 1 hour 1 hour to 2 hours 2 hours to 6 hours 6 hours to 10 hours More than 10 hours7. Do you have methods and procedures in place to assess patient satisfaction ? Yes NoA. What methods do you use to assess patient satisfaction ?Please select all that apply. Paper survey or questionnaire filled by patient Computer or web - based survey or questionnaire filled by patient Phone call to patient Email to and from patient In - person discussion with patient OtherIf Other, please specify
8. What are your goals for improving patient service?9. Additional comments?
Disease Epidemiology1. Facility Name:2. How frequently do you treat patients with the following infectious diseases?InfrequentlySometimesFrequentlyNever Diarrheal sisViral Hepatitis Bor C
3. How frequently do you treat patients with the following neglected ver Buruli UlcerChagas disease(Americantrypanosomiasis) Echinococcosis Fascioliasis Leishmaniasis Leprosy Onchocerciasis Rabies Schistosomiasis Trachoma Yaws Podoconiosis Strongyloidiasis nea worm disease)Human AfricantrypanosomiasisLymphaticfilariasisSoil uristrichiura and thehookworms)
4. How frequently do you treat patients with the following PRIMARY cancers?InfrequentlySometimesFrequentlyNever Bladder cancerBreast cancer Leukemia Liver cancer Ovary cancer Pancreas cancer Prostate cancer Stomach cancer Cervical anduterine cancerColon andrectum cancersEsophagealcancerLung, bronchus,trachea cancersLymphomas andmultiplemyelomaMelanoma andother skincancersMouth andoropharynxcancers
5. How frequently do you treat patients with the following chronic,noncommunicable illnesses?InfrequentlySometimesNever Alcohol usedisordersAlzheimer andother dementiaFrequently COPD/Emphysema Diabetes mellitus CerebrovasculardiseaseIschemic orhypertensive heartdiseaseUnipolardepressivedisorders6. How frequently do you treat patients with the following maternal/fetal and traumatic medical conditions?InfrequentlySometimesFrequentlyNever th asphyxiaand birthtraumaPrematurity andlow birth weightTrauma andMusculoskeletalInjuryRoad trafficaccidents
7. Which of the following procedures are available at your facility?Please select all that apply. Cesarean section delivery of pregnancy Image - guided biopsy Surgical biopsy Percutaneous fluid/abscess drainage8. Additional comments?
Patient Demographics, Capacity, and Referral Patterns1. Facility Name:2. What percentage of your patients belong to each of the followingdemographic categories?Less thanNone10%-33% 34%-66% 67% - 99%10% Patients under18 years of agePatients over 50years of ageFemale patientsAll 3. How many inpatient beds are in your facility?4. What is your average inpatient bed occupancy rate at any given time? N/A 10% 10 - 33% 34% - 66% 67% - 90% 90%5. On average, how many outpatients (ambulatory patients)are seen in your facility each day?6. How often do your physicians practice medicine outside their area of residency orfellowship training (for example, internists performing surgeries)? Infrequently Sometimes Frequently
7. Does your facility refer patients to other facilities ? Yes NoIf Yes, please list the hospitals and clinics where you refer your patients.Please also note the distance from your facility to these places.8. Additional comments?
Clinical Tests1. Facility Name:2. Which of the following clinical microbiology testsare available at your facility? Please select all that apply. Fecal culture Urine culture and analysis Mycobacterial culture Acid Fast Bacillus (AFB) stain Tuberculosis PCR Bacterial culture Bacterial antibiotic sensitivity HIV ELISA HIV Western Blot HIV PCR3. Which of the following clinical chemistry testsare available at your facility? Please select all that apply. Electrolytes (Na,K,HCO3,Cl,Ca,Mg,Fe,PO4) Kidney Function Tests (BUN,Cr) Glucose Albumin and Total Protein Liver Function Tests (AST,ALT,GGT,Alk Phos,Bili) Blood gases (O2,CO2)
4. Which of the following clinical hematology testsare available at your facility? Please select all that apply. Hematocrit/Hemoglobin White blood cell count Platelets White cell differential Blood smear INR/PT PTT5. Which of the following clinical pathology resourcesare available at your facility? Please select all that apply. Surgical pathology (microscopic) Cytopathology Autopsy pathology Colposcopy Pap smear6. Additional comments?
Pharmaceutical Agents and other Clinical Consumables1. Facility Name:2. Which of the following general pharmaceuticals and other agentsare available at your facility? Please select all that apply. Intravenous Fluids Disinfectants and antiseptics (e.g. alcohol, iodine, etc.) Oxygen General anesthetics Oral rehydration Local anesthetics Antacids and other antiulcer medicinesSedation for short - term procedures(e.g. midazolam, propofol, fentanyl, etc.) Thyroid hormones and antithyroidmedicines 3. Which of the following antimicrobials are available at your facility?Please select all that apply. Anthelminthics (e.g. Systemic antifungal medicines (e.g. antischistosomals)Fluconazole) Antibacterials (e.g. penicillin)Antituberculosis medicines (e.g.Isoniazid) Antiretrovirals (HIV)Antimalarial medicines (e.g.Mefloquin) 4. Which of the following cardiovascular and pulmonary medicationsare available at your facility? Please select all that apply. Antianginal medicines (e.g. Lipid - lowering agents (e.g. statins) nitroglycerin) Diuretics Antiarrhythmic medicines (e.g.amiodarone) Antiasthmatics and medicines forchronic obstructive pulmonary disease Antihypertensive medicines5. Which of the following anti - inflammatory agentsare available at your facility? Please select all that apply . NSAIDs Corticosteroids
6. Which of the following vaccines are available at your facility?Please select all that apply. Hepatitis B vaccine Live Polio vaccine Human Papilloma Virus vaccine Hepatitis A vaccine Influenza vaccine Diphtheria, Tetanus,Pertussis vaccine Haemophilus influenzatype B vaccine Pneumococcal vaccineInactivated PoliovaccineMeasles, Mumps,Rubella vaccine Rabies vaccine Yellow Fever vaccine Varicella vaccine Typhoid vaccine Meningococcal vaccine Dengue vaccine Rotavirus vaccine Japanese Encephalitisvaccine 7. What method(s) do you use to sterilize and disinfect re usable surgical equipment? Please select all that apply. Steam and high pressure (e.g. autoclave) Dry heat (e.g. oven) Chemical gas sterilization (e.g. ethylene oxide, ozone) Chlorine bleach Aledhydes (e.g. formaldehyde, Ortho - phthalaldehyde, gultaraldehyde) Hydrogen peroxide Acid (e.g. peracetic acid) Ionizing (X-ray) radiation Ultraviolet (UV) radiation8. Additional comments?
Human Resources1. Facility Name:2. Please indicate the number of non - radiology physiciansyou have in your facility in each specialty shown below.None1-45 - 10 Anesthesiology 10 Allergy & Immunology Breast Surgery Cardiology Cardiothorac Surgery Dermatology Emergency Medicine Endocrinology Gastroenterology General Internal Medicine General Surgery Gynecology (non - obstetrical) Hematology Infectious Diseases Intensive Care/ICU Mastology Maxillofacial surgery Neonatology/NICU Nephrology Neurology Neurosurgery Obstetrics Oncology, Medical Oncology, Surgical Ophthalmology Orthopedic Surgery
Otorhinolaryngology (ENT) Pathology Pediatrics Physical Medicine & Rehabilitation Plastic Surgery Podiatric Medicine Psychiatry Pulmonology Radiation therapy Rheumatology Urology Vascular Surgery 3. Please indicate the number of radiology personnelyou have in your facility in each category shown belowNone1-4 Radiologists (all)Specialty/Fellowship trained radiologists(please list in comments section)5 - 10 10 Sonographers Medical Physicists X - ray Technicians/Technologists/RadiographersPlease list radiology specialties here (if any)4. Are radiologists in your facility allowed to work at other non-affiliated facilities (forexample, both a public and a private hospital)? Yes No
5. Please indicate the number of non - physician staffyou have in your facility in each category shown below.None1-4 NursesMidwivesHealth Extension Worker, MedicalAssistant, or other ancillaryclinical personnelPharmacists/pharmacy techniciansInformation technologypersonnel, Computer techniciansNon - radiology Lab TechniciansAdministrators, bookkeepers,accountants, and othermanagerial or business staff5 - 10 10 6. What types of personnel work at your facility? Select all that apply. Full - time or part - time employees Volunteers Resident or fellowship physicians who are in training (just out of medical school) Medical students7. Is your facility currently under - staffed in any of the above positions? If so, select"Yes" and please describe below in "Comments". Yes NoComments
8. Does you facility have high employee turnover in any of the above positions? Ifso, select "Yes" and please describe below in "Comments". Yes NoComments9. Additional comments?
Training and Continuing Education1. Facility Name:2. Please indicate the highest level of training requiredfor each of the following professions.AssociateDegreeIHigh School/ (usuallydon'tVocational2 e/University Sonographer Nurse Radiation safety officer Medical Physicist X - ray Technologist/Technician/Radiographer3. Which of the following careers require career - long participation incontinuing medical education? Please select all that apply. Radiologist Xray Technologist/Technician/Radiographer Sonographer Nurse Radiation safety officer Medical Physicist
4. How accessible are the following forms of continuing medical education toRadiologists at your facility? You may elaborate on the specific reasons for yourselections below under "Comments". Please leave blank if you do not have anyradiologists at your facility.Accessible butAlways orUsuallyRarely or neverin limitednearly alwaysaccessibleaccessiblesupplyaccessible Training (in person)Training (online) Paper Journals Online Journals Local ternationalconferences/meetingsComments
5. How accessible are the following forms of continuing medical education toXray Technologists/Technicians/Radiographers at your facility? You mayelaborate on the specific reasons for your selections below under "Comments".Please leave blank if you do not have any technologists/technicians at yourfacility.Accessible butAlways orUsuallyRarely or neverin limitednearly alwaysaccessibleaccessiblesupplyaccessible Training (in person)Training (online) Paper Journals Online Journals Local ternationalconferences/meetingsComments
6. How accessible are the following forms of continuing medical education toSonographers at your facility? You may elaborate on the specific reasons for yourselections below under "Comments". Please leave blank if you do not have anytechnologists/technicians at your facility.Accessible butAlways orUsuallyRarely or neverin limitednearly alwaysaccessibleaccessiblesupplyaccessible Training (in person)Training (online) Paper Journals Online Journals Local ternationalconferences/meetingsComments7. Do you train radiation safety officers at your facility? Yes No8. Do you train medical physicists at your facility? Yes No
9. Please describe any suggestions you have for future training and developmentprograms you would like at your facility.10. Additional comments?
Structural, Electrical, Climate Control, andTransportation Infrastructure1. Facility Name:2. How reliable is your primary power source ? Power is available 100% of the time Power is available 75 - 99% of the time Power is available 50 - 74% of the time Power is available 50% of the time3. How stable is your primary power source ? Always Stable Sometimes Stable Frequently Unstable4. Are your electronic devices connected to voltage stabilizers ? Yes No5. Do you have a source of back - up power ? Yes NoA. What source(s) of backup power are used at your facility? Select all that apply. Battery Sunlight Diesel or gasoline Hydroelectric Natural gas Geothermal PropaneB. What is the typical working power output of your backup generator/backup energy source (kW)?
6. What is your facility's total floor area in square meters?7. Approximately what percentage of this space is devoted to radiology?8. What material(s) are used in the frame(s) of your building(s)?Select all that apply. Steel frame Wooden frame Stone or brick frame9. What material(s) are used in the walls of your building(s)? Select all that apply. Lead shielding Sheet rock Plaster Wood Brick or stone10. What type(s) of sub - flooring do you have on the lowest level of your building(s)? Select all that apply. Concrete flooring Dirt flooring11. Does your facility have capacity (size and load - bearing limit) to install heavyequipment in excess of two metric tonnes, such as a CT or MRI unit? Yes No Unsure
12. What is your indoor temperature range ?Please enter the yearly low and the yearly high in degrees centigrade.Yearly Indoor Low (degrees centigrade)Yearly Indoor High (degrees centigrade)13. How often are the following available?Always or nearlyMost of the time Some of the time Rarely or neveralways Air conditioning(cooling)Air heating Dehumidification 14. Do you have a problem with water condensation on walls and/or equipment at any time during the year? Yes No15. Do you have a problem with dust accumulating on equipment? Yes No16. Please rate the availability of each of the following at your facility.Usually inUsuallyUnavailableshort supplyavailable Potable water (notnecessarily sterile)Sterile waterAn intact, functionalplumbing system forautomatically distributingwater around your facilityAn intact, functionalsewage system, such as asewer or septic tank, fordisposal of human waste.Alwaysavailable 17. Are most of the roads leading to your facility paved with asphalt or concrete? Yes No
18. How often are the following modes of transportationused by patients to reach your facility?InfrequentlySometimes Helicopter/MedivacMedicalAmbulanceFrequently Boat Bus Motorcycle Train On Foot Car or truck(including taxis)Non - motorizedbicycleAnimal (e.g. mule,donkey, horse, ox)19. Comments?
Communications1. Facility Name:2. Which of the following best describes the availability and reliability of land - linetelephone service at your facility? Mobile telephone services will be addressed later. Available continuously (all day, every day) Available with infrequent to occasional interruptions Available with frequent interruptions Usually to always unavailable3. Is the number of land - line telephone lines adequate to meet your needs? Yes No4. Are you able to easily (financially and logistically) makeinternational calls on your land - line telephones ? Yes No5. Which of the following best describes the availability and reliability of the followingmobile/cellular telephone services at your facility?Available withAvailableAvailable withinfrequent toUsually to /7/365)interruptionsinterruptions VoicetransmissionText messagingDatatransmission 6. Do you have 3G or 4G mobile internet access? Yes No Unsure
7. Is the number of mobile linesamong your staff adequate to meet your facility's needs? Yes No N/A8. Are you able to easily (financially and logistically) makeinternational calls on your mobile telephones ? Yes No9. Which of the following best describes the availability and reliability ofInternet access at your institution? Available continuously (24/7/365) Available with infrequent to occasional interruptions Available with frequent interruptions Usually to always unavailable10. What are the available type(s) of internet connectivityat your institution. Please select all that apply. Dial - up modem DSL Cable T1 or other dedicated, unshared high - speed access line Mobile broadband access (e.g. WiMAX, 3G, 4G) Satellite Internet11. What is your maximum Internet bandwidth (Mbps) ?12. Is your Internet bandwidth adequate to meet your needs? Yes No13. Do you have access to web conferencing technology? Yes No
1. Additional comments?
Information Technology1. Facility Name:2. Do you have general - use computer workstations available for staff? Yes No3. Do you have access to email ? Yes No4. Do you have access to electronic file sharing , such as FTP, Microsoft Sharepoint,group web storage, etc.? Yes No5. Do you have basic word processing capabilities (e.g. Microsoft Word)? Yes No6. Do you have the ability to create basic electronic presentations (e.g. MicrosoftPowerpoint)? Yes No7. Do you use an electronic medical record (EMR) system ? Yes NoIf so, please describe it.
8. Do you use an electronic Radiology Information System that supports suchthings as radiology workflow management, radiology result(s) entry, and radiology report(s) output. Yes NoIf so, please describe it.9. Do you use an electronic Health Management Information System (HMIS or HIS)that helps you keep track of administrative issues like patient registration,appointment scheduling, admission/discharge/transfer, bed management, and billing? Yes NoIf so, please describe it. 10. Are there existing government standards for patient record privacyin your country? Yes No11. How many digital radiology image viewing workstationsdoes your facility have? 0 1-5 6 - 10 11 - 20 2012. Do you have a Picture Archiving and Communication System (PACS) tostore, retrieve, and distribute medical images? Yes NoIf Yes, please specify PACS vendor, software and version
13. Does your facility use teleradiology? Teleradiology is defined as thetransmission of medical images electronically from your facility to another locationfor the purposes of interpretation and/or consultation. Yes No14. Additional comments?
Medical Imaging Capabilities and Limitations1. Facility Name:2. Please indicate for each of the following modalities whether or not your facility usesdigital image acquisition (CR or DR) instead of plain film.We have a firmWe do not haveNo firm plan toAlready digital plan to changethis modalitychange to digitalto digital RadiographyMammographyGeneralFluoroscopyC - armFluoroscopy(e.g.interventionalradiology)Planar NuclearMedicineBoneDensitometry
3. Please indicate for each of the following modalities whether or not your facility usesa PACS (Picture Archiving and Communication System) .We have a firmWe do not have Already using aNo firm plan toplan to install ainstall a PACSthis modalityPACSPACS RadiographyMammography CT MRI PET SPECT GeneralFluoroscopyC - phyPlanar NuclearMedicineBoneDensitometry4. How often is final image interpretation performed by a.Infrequently Sometimes FrequentlyNever Radiologist?Non-radiologistphysician?Non - physician?Always 5. Do you think it is necessary to train physician extenders (physician assistants(PA), radiologist assistants (RA), nurse practitioners (NP), etc.) in medical imageinterpretation? Yes No Maybe
6. Please indicate the average availability of each modality7 days 6 days 5 days 4 days 3 days 2 days 1 day aUnavailablea week a week a week a week a week a week week RadiographyMammography CT MRI PET SPECT GeneralFluoroscopyC - phyPlanar NuclearMedicineBoneDensitometry
7. Please indicate the availability of the following radiology consumables .Unavailable or Usually in shortUsuallyAlways availablenot usedsupplyavailable Iodinated ContrastGadolinium Contrast Barium oral contrast Film Film Cassettes Radiopharmaceuticals Ultrasound jelly Gloves Gauze Water soluble oralcontrastCatheters andsheathsNeedlesUltrasound probesleeves
8. Please indicate how often patients are referred to your facilityto undergo each of the following types of medical imaging.SometimesFrequently to alwaysRarely to never RadiographyMammography CT MRI PET SPECT GeneralFluoroscopyC - phyPlanar NuclearMedicineBoneDensitometry9. If you received a donated piece of medical imaging equipment, would you be willing andable to accept the full respo
This Radiology Readiness Survey is designed to help RAD - AID : 1. Understand the healthcare benefit and impact your facility is delivering to the local community 2. Identify the potential wider benefit that your institution could provide with radiology services, and how augmenting or introducing medical imaging may help achieve your