Are You Joint Commission Ready?


By W. Geoffrey West, PhD, DABR, CHPGeoff-West-ed

Effective July 1, 2015, the Joint Commission (JC) implemented their long-awaited new imaging standards. The standards, consisting of 25 new or revised Elements of Performance, contain a multitude of new requirements that affect JC accredited facilities performing MRI, CT, or NM/PET services. Specifically, the new standards address the following areas: annual equipment physics testing, ongoing equipment quality control, medical physicist qualifications, technologist training, x-ray shielding design and verification, personnel dosimetry (ALARA) review, patient dose incident tracking and analysis, CT protocol documentation and review, and MRI safety. The JC had previously delayed implementation of the standards by one year (from an original effective date of July 1, 2014) to allow accredited facilities additional time to budget and prepare staff for the proposed changes. The additional time extension allowed most imaging facilities and their staff to be well prepared for the much-anticipated arrival of JC surveyors into the radiology department, surveying against the new standards.

Since many of the new standards involve support from the medical physicist, the staff at West Physics and I have been very busy in the last year assisting imaging departments in implementing the new requirements. The most common requests we have received and supported thus far have been (i) performing annual MRI, CT, NM, and PET annual physics evaluations; (ii) establishing CT dose index ranges, optimizing protocols, and analyzing and benchmarking CT doses; (iii) training technologists in MRI safety and CT radiation dose reduction; and (iv) performing x-ray shielding designs and radiation protection surveys.

By far, the most challenging standards for imaging departments have been in the area of CT dose management. This is an area that is completely new and foreign for most healthcare providers, since it involves areas of expertise that have not been addressed by management, technologists, radiologists, and even many medical physicists to date. The physicists specializing in CT dose management at West Physics learned early on in the dose management process that a commercial CT dose tracking and analysis software solution is imperative in order to properly assess the initial data and provide ongoing surveillance of the imaging department’s CT scanners, protocols, and technologist scanning techniques. Yet software alone is not enough. An experienced and involved dose team, consisting of the medical physicist, chief CT technologist, and radiologist, is essential for turning that data into understandable and actionable information, and then using it wisely.

Please join me at the AHRA Annual Meeting in Nashville for my session, “One Year After the JC Imaging Standards Changes – What Have We Learned and What’s Coming Next.” I will describe the positive impact the standards have had on patient care and CT radiation dose reduction, as well as some of the challenges in implementation experienced to date by both the JC and by the accredited facilities. I will also be speaking about what is next on the horizon at the JC as far as new imaging standards.


W. Geoffrey West, PhD, DABR, CHP is the president and chief medical physicist at West Physics Consulting in Atlanta, GA. He can be reached at geoff@westphysics.com.

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