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SOURCES SOUGHT NOTICE For Medical Physicist Services for Routine Radiographic Equipment Inspection for Aleda E. Lutz, VAMC -Saginaw, MI. This is a Sources Sought Notice. This advertisement is not a so... SOURCES SOUGHT NOTICE For Medical Physicist Services for Routine Radiographic Equipment Inspection for Aleda E. Lutz, VAMC -Saginaw, MI. This is a Sources Sought Notice. This advertisement is not a solicitation for offers, nor is it a request for quotes. A request for quotes may be issued at a later date. This Sources Sought/Market Survey Notice is being conducted by the Network 10 Contracting Office, PO Box 492, Ann Arbor, MI 48106 to identify sources capable of providing Medical Physicist radiological inspection services. There is a need for quarterly review to maintain our compliance with the NHPP license. This includes safety audits, NRC compliance, including updated regulations, and surveys showing exposure to the public in relationship to our department location. Annually, X-ray, Fluoroscopy, CT, Dental, Ultrasound and Nuclear Medicine machines need be tested to meet ACR, AAPM, TJC, NHPP and NRC requirements. Period of Performance: 12 months from date of Award plus four, 12-month option periods. Hours of Service: Monday through Friday, 7:00 am to 3:30 pm. Contractor shall work at least 1 day each quarter. In addition, the contractor will be given seven additional days at eight hours per day, each year for a total of eleven eight hours days per year to complete the following task. Please note that these days and times may vary. Responses should include: (1) Business Name, GSA contract number and Address (if applicable); (2) Point of Contact Name, Phone Number, and E-mail Address; (3) DUNS and NAICS code; (4) Business Size SMALL or LARGE; and (5) Type of Business SERVICE-DISABLED VETERAN OWNED, VETERAN OWNED, 8A, HUB Zone, WOMEN-OWNED etc. All businesses eligible to provide this service are encouraged to reply as this information may be used to determine potential set asides for the above noted service. If this is a service your business can provide, prospective contractors shall respond to this Sources Sought no later than Thursday, August 4, 2022 by 12:00 NOON (EASTERN). Send all replies to Michelle C. Ford at Michelle.Ford2@va.gov. No telephone inquiries shall be accepted or answered. Note: This is a Sources Sought Notice only and is not a request for QUOTES. No reimbursement will be made for any costs associated with providing information in response to this Sources Sought or any follow up information requests. ** PLEASE SEE THE ATTACHED PERFORMANCE WORK STATEMENT** ALEDA E. LUTZ VAMC, SAGINAW, MI for Medical Physics Testing of Diagnostic Imaging Equipment (X-ray, CT, Fluoroscopy, Ultrasound & Nuclear Medicine) INTRODUCTION The contractor shall perform radiological services pertaining to Medical Physicist audits to include physics testing both quarterly and annually of diagnostic imaging equipment (X-ray, CT, Fluoroscopy, Bone Density, Ultrasound & Nuclear Medicine) used at the Aleda E. Lutz Veterans Administration Medical Center, 1500 Weiss Street, Saginaw, MI 48602. The contractor shall provide documentation of an American Board of Radiology (ABR) lead Medical Physicist certified in diagnostic (per ACR definition of Board-Certified Medical Physicist). The lead Medical Physicist shall oversee testing of diagnostic imaging equipment performed under this contract, and sign physics reports documenting the required tests. SCOPE This PWS lists the necessary physics measurements and reporting for. X-Ray equipment, including CT, DEXA and Fluoroscopy tested in accordance with American College of Radiology (ACR). Ultrasound; tested in accordance with ACR. Nuclear Medicine; tested in accordance with ACR. Nuclear Medicine requirements using National Electrical Manufacturers Association (NEMA) protocols. Contractor shall furnish all supervision, labor, travel, equipment, parts and supplies necessary for annual physicist inspections for all radiological equipment and accessories located at Aleda E Lutz VA Medical Center (VAMC), 1500 Weiss Street, Saginaw, Michigan. Services will be provided between 7:00am to 3:30pm, Monday through Friday, excluding Federal holidays. The physicist shall also meet the following requirements. 2.7.1. Be on time for scheduled inspections. Be prepared and actively participate in scheduled quarterly Radiation Safety Committee meetings and any other appropriate, required meetings. Return urgent phone calls within 2 hours Return non-urgent phone calls within 24 hours. Respond to non-urgent fax/email requests within 24 hours if received during normal working hours. Provide notebooks annually with adequately tabbed sections for all required documentation. Follow recommended policies, practices, calibrations and/or procedures of equipment manufacturers. Be knowledgeable with the capacity to explain applicable rules and regulations for the Nuclear Regulatory Commission (NRC), the National Health Physics Program (NHPP) and the State of Michigan. Provide evidence of CEUs (Continuing Education Units) upon request. Will keep Nuclear Medicine Staff informed of any changes or proposed changes in regulations and state laws. Will keep Nuclear Medicine Staff informed of any changes or proposed changes in regulations and State laws. Keep Nuclear Medicine personnel abreast of new practices or procedures. Attend any NRC/regulatory meetings/press conferences as requested. Disclose any NRC or State violations/sanction in the last 5 years. telephone consultation as needed Results of testing shall be documented on a physics report listing the acceptability (e.g., satisfactory/unsatisfactory) of the testing, test results (i.e., measured values), discrepancies, out of tolerance measurements and recommendations. The Medical Physicist shall notify the medical center Radiation Safety Officer and/or Biomedical Engineering of any deficiencies and issues of noncompliance at the time of the physics testing. A written physics report, signed by the lead Medical Physicist, shall be provided to the medical center within 30 days of testing. 2.8.1. Annual inspections will include an overall evaluation of program effectiveness as specified by: 2.8.1.1. Joint Commission (JC) standards 2.8.1.2. VHA Directives 2.8.1.3. The Nuclear Regulatory Commission (NRC) and National Health Physics Program (NHPP) 2.8.1.4 American Association of Physicists in Medicine (AAPM) 2.8.1.5. American College of Radiology (ACR), Accreditation Program Requirements including: 2.8.1.5.1. ACR, Computed Tomography, Quality Control Manual DELIVERABLES Upon contract award the Medical Physicist shall perform physics testing at the Aleda E. Lutz VAMC at 1500 Weiss, Saginaw, MI. Annual physics testing performed on: General Radiographic, Dental (intraoral/panoral/hand-held devices), Fluoroscopy, Computed Tomography (CT), and Bone Density. Ultrasound Nuclear Medicine cameras, Single Photon Emission Computed Tomography (SPECT). Annual physics testing will include an inspection of diagnostic imaging equipment QC and overall program effectiveness in relation to Joint Commission standards, ACR accreditation program requirements (i.e., CT, X-ray, Dental, Fluoroscopy, Ultrasound and Nuclear Medicine), VA Directives and Standard Operating Procedures (SOP), and manufacturer specifications. Additional physics testing shall be performed upon request for newly purchased equipment and following the change of an x-ray tube or major repair/alteration. These physics tests shall be performed within three working days of the time notice is given for the testing. Provide the medical center with a physics report documenting medical physics testing in accordance with this PWS (see specifications). This physics report shall be provided within 30 days of the testing date. The successful contractor is encouraged to provide recommendations which may be used to reduce patient dose, improve image resolution, and diagnostic imaging effectiveness. Upon request the successful contractor shall provide proof of ABR board certification and qualifications for non-board-certified medical physicist. All medical physicist performing duties under this contract shall meet the medical physicist qualifications as stated within ACR accreditation program requirements. 4.0. STATEMENT OF QUALIFICATIONS INCLUDING PROTOCOLS/CALIBRATION/EQUIPMENT/TESTING The successful candidate shall provide a statement of qualifications through CV s (i.e., ABR board certification and medical physicist qualifications), with a brief description of protocols/procedures for performing medical physics testing. This description shall include: 4.1. Calibration statement that instruments used for medical physics testing are calibrated, traceable to the National Institute Standards and Technology (NIST). Fluoroscopy statement of attenuators and/or test phantom (e.g., step wedge for contrast and grid pattern for resolution) used for testing, and criteria for measuring contrast and resolution. CT statement of phantoms used, measurements performed and acceptance criteria (e.g., performed according to ACR CT Quality Control Manual) Bone Density statement of criteria for QA/QC and acceptance (e.g., according to manufacturer specifications). Nuclear Medicine statement of phantoms used, measurements performed and acceptance criteria (e.g., using National Electrical Manufacturers Association (NEMA) protocols). Ultrasound-in accordance with the ACR requirements. Note: Submittal of sample medical physics reports are encouraged for documenting the above criteria. Unique Qualifications The Contractor shall provide a statement of their unique insight, accomplishments, and perspectives on how their services will assist the medical center in providing the best standard-of-care for veterans while reducing patient radiation dose. The contractor shall include a brief description of protocol, phantom, and physics test criteria for testing cone beam computed tomography (CBCT) fluoroscopy. RSO Contingency plan: The contractor will serve as Associate Radiation Safety Officer. Associate RSO includes the following items: serving as Backup RSO during periods of temporary RSO absence such as vacation or medical leave. assisting RSO with preparation of annual RSO summary report to be provided to Administration. reviewing occupational dosimetry reports quarterly and reporting findings to RSC. Assisting with NHPP/NRC licensing actions. Providing in services for ancillary staff upon request when scheduled in conjunction with quarterly inspection visits Permanent assumption of RSO duties will necessitate generation of a new SOW and contract for RSO duties. PHYSICS TESTING SPECIFICATIONS X-Ray Equipment (General Radiographic/Dental/Fluoroscopy/CT/Bone Density/Mammography) General Radiographic Equipment is operating according to the manufacturers intended design including locking, holding, centering and X-ray beam "on" visual/audible indicators (SSRCR, Sec. F.4). Physics Testing. Timer Accuracy in accordance with 21CFR120.31(b) Reproducibility in accordance with 21CFR 120.31(c) Half Value Layer (HVL) in accordance with 21CFR1020.30(m) Linearity in accordance with 21CFR1020.31(d) Field Alignment in accordance with 21CFR1020.31(d)&(e) Positive Beam Limitation in accordance with 21CFR1020.31(g) Dental X-ray Equipment is operating according to the manufacturers intended design including locking, holding, centering and X-ray beam "on" visual/audible indicators (SSRCR, Sec. F.4). Physics Testing. Timer in accordance with 21CFR120.31(a)(2) Exposure Reproducibility in accordance with 21CFR 120.31(b)(1) Kilovolt Peak in accordance with 21CFR 120.31(a)(4) Half Value Layer (HVL) in accordance with 21CFR1020.30(m) Panoramic in accordance with 21CFR 120.31(f) Fluoroscopic Equipment is operating according to the manufacturers intended design including locking, holding, centering and X-ray beam "on" visual/audible indicators (SSRCR, Sec. F.4). Physics Testing. Half value layer (HVL) in accordance within accordance with 21CFR1020.30(m) Field limitation specifications in accordance with 21CFR1020.31(b) Entrance air kerma within limits for adult patient in accordance with 21CFR1020.31(d) Accuracy of air kerma display in accordance with 21CFR1020.31(k) Resolution for high/low contrast in accordance with ACR guidance CT Equipment is operating according to the manufacturers intended design for location (positioning) of patient and safety (SSRCR, Sec. F.4). Physics Testing; performed in accordance with ACR, CT QC Manual Scout Prescription and Alignment Light Accuracy Image Thickness Axial Mode Table Travel Accuracy Radiation Beam Width Low-Contrast Performance Spatial Resolution CT Number Accuracy Artifact Evaluation CT Number Uniformity Dosimetry (CTDIvol) Bone Density: is operating according to the manufacturers intended design including locking, holding, centering and X-ray beam "on" visual/audible indicators (SSRCR, Sec. F.4). Verify QA/QC is performed in accordance with manufacturers specifications. 5.8. All Physics testing shall be performed at the following: 5.8.1. Acceptance testing (assembly evaluation) prior to initial use, and 5.8.2. Annual medical physics testing NUCLEAR MEDICINE Nuclear Medicine equipment is operating according to the manufacturers intended design including system interlocks, holding, centering and visual/audible indicators. SPECT: annual Physics Testing performed in accordance with ACR, Nuclear Medicine Accreditation Program Requirements Intrinsic Uniformity System Uniformity Intrinsic or System Spatial Resolution Relative Sensitivity Energy Resolution Count Rate Parameters Formatter/Video Display Overall System Performance for SPECT Slice-Position Accuracy Slice-Thickness Accuracy Radiofrequency Coil Checks 7.0. LOCATION OF TESTING All equipment listed on the Price Schedule is located at the following addresses: Aleda E. Lutz VAMC 1500 Weiss Street Saginaw, MI 48602 8.0. SCHEDULING OF TESTING All scheduling for testing equipment will be coordinated with the medical center Radiation Safety Officer (RSO) and Contract Officer Representative (COR) 8.1. Special Contract Requirements: The services covered by this contract shall be furnished by the contractor as defined herein. The contractor will not be required, except in case of emergency, to furnish such services during off-duty hours as described below. VA HOURS OF OPERATION/SCHEDULING: Work hours: Monday through Friday, 7:00 am to 3:30 pm. Contractor shall work at least 1 day each quarter. In addition, the contractor will be given seven additional days at eight hours per day, each year for a total of eleven eight hours days per year to complete the following task. Lead apron checks, CT, X-ray equipment and Dental X-ray equipment testing, Nuclear Medicine annual testing, Ultrasound annual testing, Fluoroscopy equipment testing and Dental equipment annual testing. Federal Holidays: The following holidays are observed by the Department of Veterans Affairs: New Year s Day President s Day Martin Luther King s Birthday Memorial Day Juneteenth Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Christmas Any day specifically declared to be a national holiday by the President of the United States. QUALIFICATIONS: Personnel assigned by the Contractor to perform the services covered by this contract shall be licensed in a State, Territory, or Commonwealth of the United States or the District of Columbia. All licenses held by the personnel working on this contract shall be full and unrestricted licenses. The qualifications of such personnel shall also be subject to review by the VA Chief of Staff and approval by the VA Facility Director. PERSONNEL POLICY The contractor shall be responsible for protecting the personnel furnishing services under this contract. To carry out this responsibility, the contractor shall provide the following for these personnel. General liability Workers compensation Professional Liability insurance Health examinations COVID-19-Contractors shall comply with VHA Supplemental Contract Requirements for combatting COVID-19 { This is applicable to all health care workers} Parties agree the Contractor, its employees, agents, and subcontractors shall not be considered VA employees for any purpose. The Contractor shall be liable for, and shall indemnify and hold harmless the Government against, all actions or claims for loss of or damage to property or the injury or death of persons, arising out of or resulting from the fault, negligence, or act or omission of the Contractor, its agents, or employees. REPORTS The Contractor shall be responsible for complying with all reporting requirements established by the Contract. Contractor shall be responsible for assuring the accuracy and completeness of all reports and other documents as well as the timely submission of each. Contractor shall comply with contract requirements regarding the appropriate reporting formats, instructions, submission timetables, and technical assistance as required. What Submit as noted Submit To Copies of any and all board certifications, licenses, to include primary source verification of all licensed and certified staff Upon proposal and upon renewal of licenses and upon renewal of option periods. COR and CO Certification that staff list has been compared to OIG list Upon proposal and upon new hires. CO Proof of Identification and Medical Liability Insurance Upon proposal and upon renewals. COR and CO Certificates of Completion for Cyber Security and Patient Privacy Training Courses Before receiving an account on VA Network and annual training and new hires. COR and CO Medical physicist report evaluating equipment performance for proper working order Quarterly COR Reporting results of dose tracking and Continuous Quality Improvement (CQI) activities to CQI personnel Quarterly COR RECORD KEEPING: The Aleda E. Lutz, VA Medical Center shall establish and maintain a record keeping system that will record the time spent at the facility by the contract employee(s). Contractor's employee(s) shall report to the COR, or designee upon arrival at the Aleda E. Lutz, VA Medical Center. CONTRACT PERFORMANCE MONITORING: The COR shall be the VA official responsible for verifying contract compliance. After contract award, any incidents of contractor noncompliance as evidenced by the monitoring procedures shall be forwarded immediately to the Contracting Officer. KEY PERSONNEL AND TEMPORARY EMERGENCY SUBSTITUTIONS: The Contractor shall assign to this contract the following key personnel: During the first ninety (90) days of performance, the Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death, or termination of employment. The Contractor shall notify the Contracting Officer, in writing, within 15 calendar days after the occurrence of any of these events and provide the information required by paragraph (c) below. After the initial 90-day period of the contract, the Contractor shall submit the information required by paragraph (c) to the Contracting Officer at least 15 days prior to making any permanent substitutions. The Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitutions, complete resumes for the proposed substitutes, and any additional information requested by the Contracting Officer. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The Contracting Officer will notify the Contractor within 15 calendar days after receipt of all required information of the decision on the proposed substitutes. The contract will be modified to reflect any approved changes of key personnel. For temporary substitutions where the key person will not be reporting to work for three (3) consecutive workdays or more, the Contractor will provide a qualified replacement for the key person. This substitute shall have comparable qualifications to the key person. Any period exceeding two weeks will require the procedure as stated above. BILLING Invoice requirements and supporting documentation: Supporting documentation and invoice must be submitted no later than the 20th workday of the month. Subsequent changes or corrections shall be submitted by separate invoice. In addition to information required for submission of a proper invoice in accordance with FAR 52.212-4 (g), all invoices must include: Name and Address of Contractor Invoice Date and Invoice Number Contract Number and Purchase/Task Order Number Date of Service Contract Personnel (Name of Contractor s employee) Number of equipment s that procedures were performed on. Total price Vendor Electronic Invoice Submission Methods Facsimile, e-mail, and scanned documents are not acceptable forms of submission for payment requests. Electronic form means an automated system transmitting information electronically according to the accepted electronic data transmission methods stipulated by the VA Financial Services Center (FSC). See VAAR 852.232-72 for details. The Contractor may contact Tungsten Network Client Services at the phone number or website address listed below with questions about e-invoicing: Phone: 877-489-6135 Website: www.tungsten-network.com/customer-campaigns/veteransaffairs Payment Adjustments/Performance Related Payment Deductions: The contractor shall be paid only for duties performed. Contract providers shall be responsible for accurately reporting of equipment meeting ACR, NRC, and NHPP standards; the COR is responsible for monitoring & verifying Contractor s required duties. The contract shall be adjusted in accordance with actual performance. Payments in full/no billing VA beneficiaries: The Contractor shall accept payment for services rendered under this contract as payment in full. GOVERNMENT RESPONSIBILITIES: VA Support Personnel, Services or Equipment: The Aleda E. Lutz, VAMC will permit the contract Medical Physicists to use VA IT equipment (laptop, docking station and VA-approved USB drive). Contract Administration/Performance Monitoring: After award of contract, all inquiries and correspondence relative to the administration of the contract shall be addressed to: CO Michelle C. Ford | michelle.ford2@va.gov COR Timothy Jackson |timothy.jackson1@va.gov CO RESPONSIBILITIES: The CO is the only person authorized to approve changes or modify any of the requirements of this contract. The Contractor shall communicate with the CO on all matters pertaining to contract administration. Only the CO is authorized to make commitments or issue any modification to include (but not limited to) terms affecting price, quantity, or quality of performance of this contract. The CO shall resolve complaints concerning Contractor s provider relations with the Government employees or patients. The CO is final authority on validating complaints. In the event the Contractor effects any such change at the direction of any person other than the CO without authority, no adjustment shall be made in the contract price to cover an increase in costs incurred as a result thereof. In the event that contracted services do not meet quality and/or safety expectations, the best remedy will be implemented, to include but not limited to a targeted and time limited performance improvement plan; increased monitoring of the contracted services; consultation or training for the contract staff to be provided by the VA; replacement of the contract staff and/or renegotiation of the contract terms or termination of the contract. COR RESPONSIBILITIES: The COR shall be the VA official responsible for verifying contract compliance. After contract award, any incidents of Contractor noncompliance as evidenced by the monitoring procedures shall be forwarded immediately to the Contracting Officer. The COR will be responsible for monitoring the Contractor s performance to ensure all specifications and requirements are fulfilled. Quality Improvement data that will be collected for ongoing monitoring. The COR will maintain a record-keeping system of services. The COR will review this data monthly when invoices are received and certify all invoices for payment by comparing the services documented on the VA record-keeping system and those on the invoices. Any evidence of the Contractor's non-compliance as evidenced by the monitoring procedures shall be forwarded immediately to the Contracting Officer. The COR will review and certify monthly invoices for payment. If in the event the Contractor fails to provide the services in this contract, payments will be adjusted to compensate the Government for the difference. All contract administration functions will be retained by the VA. STANDARDS OF PRACTICE: The Contract Medical Physicist shall provide evidence based on best practices to demonstrate diagnostic imaging meets or exceeds medical physics performance measures applicable to VHA Directives, TJC standards, ACR guidance and AAPM. VHA Directives https://www.va.gov/vhapublications/publications.cfm?Pub=1 TJC standards http://www.jointcommission.org/standards_information/hap_requirements.aspx The ACR QC manuals for modalities with ACR accreditation: https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical- Standards/Practice-Parameters-by-Subspecialty; https://www.acr.org/Clinical- Resources/Practice-Parameters-and-Technical-Standards/Technical-Standards The requirements contained in this PWS MEDICAL RECORDS Authorities: Medical Physicist providing healthcare services to Aleda E. Lutz, VAMC shall be considered as part of the Department Healthcare Activity and shall comply with the U.S.C.551a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records), Title 5 U.S.C. § 522a (Records Maintained on Individuals) as well as 45 C.F.R. Parts 160, 162, and 164 (HIPAA). HIPAA: This contract and its requirements meet exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health Information to: a health care provider for treatment. Based on this exception, a BAA is not required for this contract. Treatment and administrative patient records generated by this contract or provided to the Contractors by the VA are covered by the VA system of records entitled Patient Medical Records-VA (24VA19). Contractor generated VA Patient records are the property of the VA and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations. Contractor shall ensure that all records pertaining to medical care and services are available for immediate transmission when requested by the VA. Records identified for review, audit, or evaluation by VA representatives and authorized federal and state officials, shall be accessed on-site during normal business hours or mailed by the Contractor at his expense. Contractor shall deliver all final patient records, correspondence, and notes to the VA within twenty-one (21) calendar days after the contract expiration date. Disclosure: Medical Physicist may have access to patient medical records: however, Contractor shall obtain permission from the VA before disclosing any patient information. Subject to applicable federal confidentiality or privacy laws, the Contractor, or their designated representatives, and designated representatives of federal regulatory agencies having jurisdiction over Contractors, may have access to VA s records, at VA s place of business on request during normal business hours, to inspect and review and make copies of such records. The VA will provide the Contractor with a copy of VHA Handbook 1907.1, Health Information management and Health Records and VHA Handbook 1605.1, Privacy and Release of Information. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the Contractor. Professional Standards for Documenting Care: Care shall be appropriately documented in medical records in accordance with standard commercial practice and guidelines established by VHA Handbook 1907.01 Health Information Management and Health Records: https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 and all guidelines provided by the Aleda E. Lutz, VAMC. Release of Information: The VA shall maintain control of releasing any patient medical information and will follow policies and standards as defined, but not limited to Privacy Act requirements. The Contractor may respond to requests for records contained in their non- VA record system, but all requests for VA records will be forwarded to Portland VA Health Care System Release of Information Office (ROI) for response. The ROI office may be contacted via phone at 503-220-8262 extension 55196, and fax at 503-721-1054. ADMINISTRATIVE: Contractor s Medical Physicist will not perform administrative oversight of Federal employees. Attend Meetings including CQI, staff meetings as required by the VA Chief, Radiology, Nuclear Medicine and COS. The Contract Medical Physicist shall communicate with the COR on this requirement and report any conflicts that may interfere with compliance with this requirement. Performance Standards, Quality Assurance Program (QAP) and Continuous Quality Improvement (CQI): The Government may evaluate the quality of professional and administrative services provided in accordance with VHA Directives and standards (TJC, ACR and AAPM) as outlined in this document, but retains no control over the medical, professional aspects of services rendered (e.g., professional judgments, diagnosis for specific medical treatment), in accordance with Federal Acquisition Regulation (FAR) 37.401(b). The following measures represent the performance standards required to be met and will be included on the government s Quality Assurance Surveillance Plan: Measure: Qualifications of Key Personnel. Performance Requirement: Medical Physicist shall be ABR board certified in accordance with ACR Standards. Standard: (100%) Medical Physicist shall be ABR board certified in accordance with ACR Standards. Acceptable Quality Level: No deviations from the standard (100%) Surveillance Method: Periodic Sampling of certification. Frequency: Quarterly. Measure: Physics reports documenting TJC requirements for physics testing of diagnostic imaging equipment. Performance Requirement: Diagnostic imaging equipment is tested with physics reports documenting equipment meets requirements of TJC standards. Standard: All (100%) of diagnostic imaging equipment is tested with physics reports documenting requirements of TJC standards. All (100%) of diagnostic imaging equipment reports are documented and reviewed annually. Acceptable Quality Level: Almost all (95%) physics testing, reports and TJC requirements are met. Surveillance Method: Periodic inspection of physics reports and TJC requirements. Frequency: Annually. Measure: Policies and Standard Operating Procedures (SOP) for each ACR accredited modalities. Performance Requirement: Policies and SOPs for each diagnostic imaging modality with ACR accreditation as required by ACR QC manuals. Standard: All (100%) diagnostic imaging modalities f, such as CT, MRI, PET, Nuclear Medicine, and mammography, etc., have written Policies & SOPs meeting requirements of ACR QC manuals. All (100%) of Policies & SOPs are reviewed and updated annually. Acceptable Quality Level: Almost all (90%) of requirements in ACR QC manuals are documented in policies and SOPs. Surveillance Method: Periodic inspection of policy & SOPs for each modality with ACR accreditation. Frequency: Annually. Measure: Quarterly CQI reports for each modality with ACR accredited. Performance Requirement: Implement requirements of ACR QC manuals for each modality with ACR accreditation documented in quarterly reports provided to CQI committees. Standard: All (100%) ACR QC manual requirements are documented and reported to CQ...