Initial Assessment/Change in Service Information Form

Initial Assessment/Change in Service Information Form

Pulmonary Function Testing - Hospital Based Services

Completing this form:

This form is to be completed and submitted to the DAP in the following situations. Please indicate the situation that applies:

This is a new service to be provided in a hospital

This is an existing accredited hospital based pulmonary function laboratory that has had a significant change in service:

There is a change in scope of testing provided

New equipment is in use

There is a change in the physician(s) who are providing the service

There is a change in the technical staff who are performing the testing

There is a change in the physical location of the service

Hospital Name:
Health Authority:
Pulmonary Function Laboratory Name:
Address:
Pulmonary Function Laboratory Phone No:
Pulmonary Function Laboratory Information
Organization – Please provide the Pulmonary Function Laboratory service organization chart:
Leadership / Name / Title / Location
Regional Pulmonary Function Laboratory Administrative Leader:
Regional Pulmonary Function Laboratory Medical Leader:
Health Service Area, Pulmonary Function Laboratory Administrative Leader:
Health Service Area, Pulmonary Function Laboratory Medical Leader:
Medical Leader of Pulmonary Function Laboratory:
Administrative Leader of Pulmonary Function Laboratory:
Technical Leader of Pulmonary Function Laboratory: (e.g. Chief Technologist)
Other Individuals appointed to leadership positions: (e.g. Professional Practice Leader)
Hospital COO/Administrator:
Pulmonary Function Laboratory Contact Person for Accreditation Activities:
Name: / Title:
Address:
City: / Postal:
Phone No: / Fax No:
Cellular No: / Email:
Scope of Pulmonary Function Laboratory Testing
Category IIA
Simple screening spirometry without bronchodilators
Spirometry - before and after bronchodilators
Peak expiratory flow rate / Category IIB
Simple screening spirometry without bronchodilators
Spirometry - before and after bronchodilators
Peak expiratory flow rate
Spirometry - forced expiratory - without bronchodilators
Spirometry - forced expiratory - before and after bronchodilators
Category III
Overnight home oximetry
Simple screening of spirometry without bronchodilators
Spirometry - before and after bronchodilators
Peak expiratory flow rate
Lung volumes
Spirometry - forced expiratory - without bronchodilators
Spirometry - forced expiratory - before and after bronchodilators
Diffusion studies with carbon monoxide / Category IV
IVA Flow volume loops without bronchodilators
IVA Flow volume loops before and after bronchodilators
IVB Progressive exercise test
IVB Ventilation at rest/exercise with blood gases
IVB Exercise in a steady state
IVB Exercise in a steady state - AA gradients
IVC Exercise induced asthma
IVD Inhalation challenge
IVE CO2/O2 responsive of respiratory centres
IVF Plethysomography
IVH Preciptin tests
IVI Oximetry at rest, with or without oxygen
IVI Oximetry at rest and exercise, with or without oxygen
IVK Inspiratory and expiratory muscle strength
Are pediatric studies performed? / Yes No
Interpreting Physicians
First Name / Last Name / CPSBC # / Category Interpreting / Location of Physician
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
II A / II B / III / IV A
IV B / IV C / IV D / IV E
IV F / IV H / IV I / IV K
Have all physicians been credentialed by the College of Physicians and Surgeons of BC? / Yes No
Is there an interpreting physician present on-site during testing? / Yes No
Pulmonary Function Testing
Days and hours of operation:
Number of technical staff (FTE) in the Pulmonary Function Laboratory:
All technical staff: (mark all those that apply)
Are Canadian Society of Respiratory Therapists registered
Have additional training and experience in pulmonary function testing
Have special age-specific training when pediatric testing is undertaken
If none of the above are marked, please provide name and qualifications of technical staff below:
Name / Qualifications
Number of clerical staff (FTE) in the Pulmonary Function Laboratory:
Number of staff working each shift:
·  Technical:
·  Other:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated staff or rotate through the area? / Dedicated Rotate
Are there Pulmonary Function tests that are only performed by specialized technical staff? / Yes No
When is an interpreting physician on-site to interpret studies:
All the time
Only certain days (e.g. Monday to Wednesday):
Never, explain:
Are studies transferred to other facilities for interpretation?
If yes, please indicate the name of each interpreting physician, location and method of distribution (e.g. Dr. John Doe, ABC Hospital, Courier): / Yes No
Name / Location / Method of Distribution
Are studies received from other facilities for interpretation?
If yes, please indicate the location and method of distribution (e.g. XYZ Hospital/Health Center, Courier): / Yes No
Location / Method of Distribution
Is blood gases testing done within the Pulmonary Function Laboratory? / Yes No
Equipment List
Please list all testing equipment
Description of equipment (e.g. spirometer) / Make / Model/Serial Number / Year / Location

For all questions below, electronically check or manually indicate the appropriate responses. Please provide narrative response, where appropriate.

Human Resources / DAP Use Only
1.1  A current organization chart is available
Yes No, explain: / Yes No
Comment:
1.2  Job descriptions are available for all positions
Yes No, explain: / Yes No
Comment:
1.3  The senior medical leader responsible for the quality of clinical practice has a valid medical license from the College of Physicians and Surgeons of BC. (Please provide C.V.’s)
Yes No, explain: / Yes No
Comment:
1.4  Medical supervision by:
A respirologist
A physician with a special interest and experience in respiratory disease
This physician is:
On site
Off site / Comment:
1.5 The Pulmonary Function service provides orientation, training and continuing education for the safe provision of services
Yes No, explain: / Yes No
Comment:
1.6 The Pulmonary Function service has a staff performance management system to improve the quality of service
Yes No, explain: / Yes No
Comment:
Information Management
(refers to both paper based and electronic systems) / DAP Use Only
2.1  There are policies and procedures to protect the confidentiality, security and integrity of data and information
Yes No, explain: / Yes No
Comment:
2.2  Processes are in place to allow the release of data and information, and are consistent with organization policy and relevant legislation
Yes No, explain: / Yes No
Comment:
2.3  Patient information and test records are stored and can be easily accessed when needed
Yes No, explain: / Yes No
Comment:
2.4  The information system generates management reports that assist in planning and implementing operational changes
Yes No, explain: / Yes No
Comment:
Safety / DAP Use Only
3.1  A safety committee or other active mechanism to deal with safety related issues is in place
Yes No, explain: / Yes No
Comment:
3.2  First aid resources are available on site
Yes No, explain: / Yes No
Comment:
3.3  Facilities have been inspected by external authorities (e.g. Fire Marshall, WCB etc.)
Yes No, explain: / Yes No
Comment:
3.4  The design and layout of the physical space allows service delivery to be safe, efficient and accessible
Yes No, explain: / Yes No
Comment:
3.5  The physical environment meets patient needs and allows for privacy and confidentiality
Yes No, explain: / Yes No
Comment:
3.6  Documentation such as a Safety Manual and WHMIS information are available for staff
Yes No, explain: / Yes No
Comment:
Safety / DAP Use Only
3.7  Adequate, appropriate safety equipment is in place (eye washes, sharps containers etc. as appropriate)
Yes No, explain: / Yes No
Comment:
3.8  Adequate, personal protective equipment is available and used appropriately (gloves, gowns, face shields, masks etc)
Yes No, explain: / Yes No
Comment:
3.9  There are policies and procedures for the prevention and follow-up of blood and body fluid exposure
Yes No, explain: / Yes No
Comment:
3.10  A current disaster and emergency response plan is in place
Yes No, explain: / Yes No
Comment:
Test Performance and Documentation / DAP Use Only
4.1  Test performance is according to current best practices as laid out in the ATS standards
Yes No, explain: / Yes No
Comment:
4.2  Written or electronic documentation is available to staff performing procedures
Yes No, explain: / Yes No
Comment:
4.3  There is a process to review and update policies and procedures as needed
Yes No, explain: / Yes No
Comment:
Quality Control / DAP Use Only
5.1  Testing is performed on an appropriate number of healthy controls to ensure results are reproducible and within the accepted, predicted range
Yes No, explain: / Yes No
Comment:
5.2  Protected time is allotted for quality control on a monthly basis
Yes No, explain: / Yes No
Comment:
5.3  There is a quality assurance program that ensures all aspects of testing, reporting and interpretation are adequately performed and reviewed
Yes No, explain: / Yes No
Comment:
5.4  There are regular reviews of quality control by supervisors and the medical leader
Yes No, explain: / Yes No
Comment:
5.5  Turnaround times are monitored and meet clinical needs
Yes No, explain: / Yes No
Comment:
Instrumentation / DAP Use Only
6.1  Instruments are appropriately maintained and monitored
Yes No, explain: / Yes No
Comment:
6.2  Instruments and analytical processes are operated in suitable environments
Yes No, explain: / Yes No
Comment:
6.3  Temperatures and barometric pressures are monitored and documented
Yes No, explain: / Yes No
Comment:
Reagents, Chemicals and Supplies / DAP Use Only
7.1  There is a defined process for the selection and evaluation of suppliers (e.g. gases, ECG materials, methacholine)
Yes No, explain: / Yes No
Comment:
7.2  An inventory control system is in place
Yes No, explain: / Yes No
Comment:
Reports / DAP Use Only
8.1  Reports are comprehensive and include appropriate information
Yes No, explain: / Yes No
Comment:
8.2  There are policies and procedures to deal with corrected reports
Yes No, explain: / Yes No
Comment:
8.3  There are policies and procedures to deal with critical results
Yes No, explain: / Yes No
Comment:
Name and title of the person completing this form:
Comments:
Date:

Please mail, fax or scan/email form to

College of Physicians and Surgeons of British Columbia

Diagnostic Accreditation Program

300-669 Howe Street

Vancouver BC V6H 0B4

Fax: 604.733.3503

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Revised: January 12, 2012