The Joint Commission’s New Imaging Standards


NMullens_eleakis201565-05By Neomi Mullens

February 2014—The topic of radiation safety and radiation dose monitoring has moved from state-specific regulations to a national trend with The Joint Commission’s (TJCs) recent announcement of their “New and Revised Diagnostic Imaging Standards.” The call for dose management and tracking has graduated from being advised to being mandated – from both a legal perspective and from within the world of healthcare’s patient safety foundation. The question that many organizations find themselves asking is “Where does this leave me?” and “Are we prepared for compliance?”

The race to implement reform and effective solutions around radiation dose safety was brought to the forefront when some states took a very progressive initial stance regarding patient safety and quality by creating control measures to govern certain radiology procedures that utilize radiation dose as part of an exam. By creating legislation that mandated the monitoring of radiation dose and reporting of any radiation dose incidents, states such as California and Texas left healthcare providers with no option but to comply with new laws and enhance their radiation safety initiatives. But being compliant doesn’t always equate to a clinically proficient, ”patient first” radiation safety program.

Following the legal reforms, numerous hospitals and healthcare organizations outside of these states quickly embraced the call for radiation dose safety changes by beginning to build more robust radiation safety programs and re-evaluating internal radiation safety practices. Many of these organizations are top tier healthcare providers who are often looked to for setting standards and trends within the healthcare industry. The restructuring of their radiation safety  initiatives included enhancing current practices around CT protocol reviews, the development of incident management policies and procedures, procurement of new technologies and software to track and monitor radiation dose, and  the revision of general workflows and daily practices for performing radiology exams. Several entities have adopted radiation safety initiatives such as these in an effort to become compliant according to their own organizational standards and goals. With these self-initiated efforts underway, many organizations are ahead of the game, but where will the standardization among efforts come into play?

The answer and call to action came this past December when TJC released their “New and Revised Diagnostic Imaging Standards.” The announcement of TJCs revised imaging standards blankets all TJC accredited hospitals, critical access hospitals and ambulatory health care organizations that provide diagnostic imaging services effective July 1, 2014, with additional requirements to be phased in by 2015. The only question that remains is, “Are you prepared for the integration of and compliance with these new standards?”

In assessing your organization’s preparedness to efficiently and effectively comply with the upcoming standards and regulations, it may be helpful to understand where you stand in forming internal radiation safety policies and whether you are on the path to success or need to drive initiatives harder in order to deliver responsible healthcare.

Organizations not prepared for compliance with TJC standards:

  • Lack of organizational radiation safety committee and regular radiation safety meetings
  • Radiology exams being performed by unregistered and uncertified technologists
  • Inability to track patient radiation dose history or exam history within patient records
  • Outdated and sub-standard CT protocol use
  • No policies or procedures regarding radiation dose tracking or incident management

Organizations on the path to compliance:

  • Organized radiation safety committee that conducts regular standards reviews
  • Open communication with clinical staff regarding radiation safety best practices
  • Development of a dynamic radiation safety program
  • Defined radiation safety incidents and incident management policies and procedures
  • Exploration of technical solutions to monitor and capture patient radiation dose

Organizations prepared to comply with and embrace new radiation standards:

  • Implementation of a robust and dynamic radiation safety program
  • Engaged radiation safety committee and physicist who regulate radiation safety practices and initiatives on a regular basis
  • Annual performance evaluations of imaging equipment by a medical physicist
  • Registration and certification of all radiology technologists
  • Updated protocols for all imaging procedures including the pediatric population
  • Method for collecting and storing patient dose data within the patient’s clinical record
  • Collection of data on incidents where pre-identified radiation dose limits have been exceeded

With new radiation management spreading throughout the industry, the expectation and demand for optimized radiation safety practices will drive healthcare organizations to implement new methodologies and programs to keep up with highly competitive industry-wide initiatives.


Neomi Mullens is a Project Manager at Ascendian Healthcare Consulting and a frequent and published contributor to the subject of Enterprise Dose Management and Tracking. You may contact her directly at nmullens@ascendian.com or visit the Ascendian website for more information at www.ascendian.com.

Comments
2 Responses to “The Joint Commission’s New Imaging Standards”
  1. Donald G Wood says:

    Excellent and timely information.

    Like

  2. Tobias Gilk says:

    It is worth noting that the new Joint Commission DI standards aren’t exclusively about ionizing radiation. A major component of the new standards is MRI safety, including staff training requirements, access control and supervision (a la the ACR 4-Zone… though TJC doesn’t dare call it that), and – perhaps most significantly – recording of near-miss and injury incidents with ferromagnetic objects and burn events.

    While TJC isn’t prescriptive about the preventative steps for MRI burns & projectiles (which make up the majority of MRI injuries), the fact that providers *must* record these events essentially means that providers are building their own paper-trail if they fail to implement effective preventions for these types of injuries.

    Like

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