Spotlight On Franklin Square Hospital
Baltimore, MD

A LABORATORY ACCREDITED BY THE ICANL
IN NUCLEAR CARDIOLOGY, NUCLEAR MEDICINE, AND PET IMAGING

submitted by Gabriel Soudry, MD
Director, Nuclear Medicine Section
Franklin Square Hospital

from the August 2005 issue

At Franklin Square Hospital, our motivation for seeking ICANL accreditation was threefold. We wanted to demonstrate to referring physicians and to hospital administration that we provide very high quality nuclear imaging services, encompassing general Nuclear Medicine, Nuclear Cardiology, and PET. We wanted to use this demonstrated excellence to help distinguish us from the many providers of imaging services available to outpatients. Finally, we wanted to demonstrate to the hospital that we are enhancing its reputation by virtue of our efforts and that we are deserving of the support that we need to continue to offer state-of-the-art services.

Reflecting on our goals, now as an accredited laboratory, we find that ICANL did indeed meet our expectations. The facility was provided with an objective, independent measure of the quality of our services. The accreditation allows us to document that we meet national standards in Nuclear Medicine, Nuclear Cardiology, and PET, becoming only the eighth such laboratory within the United States and Canada to have done so, so far. Our accomplishment was announced at meetings amongst the medical staff and the hospital administration and was included in the hospital's newsletter. On an ongoing basis, we proudly highlight our accreditation in our marketing efforts geared toward both referring physicians and patients. Reflecting on the process of preparing for ICANL accreditation, one of the key benefits we experienced continues to positively affect our laboratory on a day-to-day basis: the organization and review of each one of our policies and procedures.

We decided to keep master copies of all of our manuals and procedures on a hospital server that is backed up daily and that is available from workstations throughout the department. This action ensured that the most recent versions are always readily available in a single location. We were thus able to avoid having multiple, printed copies of the various manuals and having to make sure that no outdated copies were still in circulation. We used uniform formats for all of the manuals, making sure that the written instructions for the staff reflected our current practice and equipment, and avoiding the common problem of "the manual says this, but what we really do is that."

Among the manuals that were put online were the procedure manual, the computer acquisition and processing protocols, our custom designed Nuclear Medicine Department patient history sheets, patient preparation sheets, patient information sheets, therapy instruction and documentation sheets, nursing instructions, QC procedures, consent forms, the Radiation Safety manual, and hospital administrative protocols. In addition, all credentialing documentation was gathered in a central location. We are no longer dependent upon the memory of individuals who may not always be available. Supporting information for patients, nurses, and referring physicians can easily be printed our and distributed, as needed. We are confident that we are ready for state or JCAHO inspections with full documentation of how our department operates. We can now be sure that all personnel will act in a consistent manner to provide the highest quality care for our patients and referring physicians.

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