Requirements of the Responsible Physician
Effective Aug 10, 2018Mass. Register #1371MGL c. 111, §§ 3 and 5N through 5QDepartment of Public Health
- (A) Responsible Physician Qualifications A physician shall be qualified to be designated as a Responsible Physician if he or she holds a current Massachusetts license issued by the Board of Registration in Medicine and is in compliance with applicable regulations issued by the Board of Registration in Medicine, including 243 CMR 2.07(24)(g).
(B) Responsible Physician Duties The Responsible Physician shall be responsible for:
- (1) Establishing and maintaining an ongoing quality assurance program in accordance with 105 CMR 127.018;
- (2) Establishing a Quality Assurance Procedures Manual as specified in 105 CMR 127.018(B);
- (3) Conducting and documenting an annual review of the Quality Assurance Procedures Manual;
- (4) Ensuring that test equipment and materials as specified in the Quality Assurance Procedures Manual are available to perform quality control tests and to record and interpret results;
- (5) Ensuring that staffing and scheduling are arranged so that adequate time is available to perform quality assurance tests and to record and interpret results;
- (6) Ensuring that a designated individual oversees the radiation protection program for employees, patients, and other individuals in the surrounding area;
- (7) Ensuring that records concerning employee qualifications, mammography technique and procedures, quality assurance, safety, and protection are properly maintained and updated in the Quality Assurance Procedures Manual;
- (8) Evaluating the Mammography Radiologic Technologist's performance during the first three months of employment and annually thereafter;
(9) Ensuring that:
- (a) Mammography Radiologic Technologists meet mammography training and continuing education standards as defined in 105 CMR 127.012; and,
- (b) A Mammography Radiologic Technologist is selected to be the quality assurance technologist, who is personally responsible for maintaining mammography quality and performing the quality assurance tests defined in 105 CMR 127.019(C)(1) through (4), and (10), the results of which are reviewed at least quarterly by the Responsible Physician;
(10) Ensuring that:
- (a) All Medical Physicists meet mammography training and education standards of 105 CMR 127.013;
- (b) A designated Medical Physicist establishes and evaluates the equipment quality assurance program; and
- (c) All Medical Physicist's reports and results are reviewed by the Responsible Physician within a reasonable time of completion of the tests however in any case no longer than 30 days of completion of the tests;
- (11) Ensuring that the Responsible Physician and Interpreting Physician meet mammography training and education standards outlined in 105 CMR 127.011 and 127.014;
- (12) Ensuring that an ongoing program to assess the quality of mammographic interpretation is implemented; and
- (13) Ensuring that the Interpreting Physician is complying with the reporting requirements of 105 CMR 127.020(B).