The Joint Commission has made changes to its standards for accredited hospitals, critical access hospitals, and ambulatory healthcare organizations that provide diagnostic imaging services, including ambulatory organizations that have achieved Advanced Diagnostic Imaging certification. The changes, effective July 1, 2014, with additional requirements to be phased in by 2015, relate to either quality and safety issues that more fully address the evolution of healthcare delivery practices, or expand the current requirements, such as those related to magnetic resonance imaging. Phase one focuses on computed tomography (CT), nuclear medicine (NM), positron emission tomography (PET), and magnetic resonance imaging (MRI) services. Phase two, to be implemented in 2015, will focus on fluoroscopy, minimum qualifications for clinicians who perform imaging exams, and cone beam CT used in dental offices and oral-maxillary surgery practices. Areas addressed in the new and revised standards include:
- Minimum competency for radiology technologists, including registration and certification by July 1, 2015
- Annual performance evaluations of imaging equipment by a medical physicist
- Documentation of CT radiation dose in the patient’s clinical record
- Meeting the needs of the pediatric population through imaging protocols and considering patient size or body habitus when establishing imaging protocols
- Management of safety risks in the MRI environment
- Collection of data on incidents where pre-identified radiation dose limits have been exceeded
The revisions incorporate recommendations from diagnostic imaging experts, professional associations, and accredited organizations. The new and revised elements of performance are available on The Joint Commission’s website. The requirements will be published in the spring 2014 E-dition® Update and the 2014 Ambulatory Care, Critical Access Hospital and Hospital Comprehensive Accreditation Manuals scheduled for publication in March 2014. If you have questions about the changes, complete thestandards online question form or call the Standards Interpretation Group at 630-792-5900.