On Infection Prevention & Control

Experiences, case studies and news about infection prevention and control.

Deferring Performance Evaluation Requirements of Medical Imaging Equipment


Robert Campbell, PharmD, director, clinical standards interpretation for hospital/ambulatory programs 

Editor’s Note: This blog post is part of The Joint Commission’s daily communication on issues relevant to organizations managing the COVID-19 pandemic. The full list of FAQs is available here. All examples are for illustrative purposes only.

During a national emergency, can organizations defer completing the annual performance evaluation requirements for medical imaging equipment, such as computed tomography (CT) and magnetic resonance imaging (MRI) equipment outlined in Joint Commission Environment of Care standards EC.02.04.03, elements of performance (EP 20-25, and 34)?

Yes. During the COVID-19 pandemic, when a state of emergency has been declared and the organization has activated their emergency operations plan, organizations may defer completing the performance evaluations for diagnostic imaging equipment, such as:

  • CT
  • MRI
  • nuclear medicine (NM)
  • positron emission tomography (PET)
  • fluoroscopy equipment and acquisition monitors for these modalities

After the state of emergency ends (national, federal, or local level depending upon which allows the most time to address), organizations have 60 days to complete these requirements.

Please note: 
This response applies only to the requirements found in the EC chapter of the applicable accreditation manuals at EC.02.04.03 EPs 20 –25, 34. This requirement does not apply to mammography equipment.

Robert Campbell, PharmD, is director, Clinical Standards Interpretation Hospital/Ambulatory Programs and director, Medication Management. Prior to these roles, he served as the pharmacist for Clinical Standards Interpretation in the Division of Healthcare Improvement at The Joint Commission. Campbell also surveys as a field representative for The Joint Commission in the Hospital Accreditation and Critical Access Hospital Accreditation Programs and is a reviewer in the Medication Compounding Certification Program. Prior to joining The Joint Commission, Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control, medical staff services, as well as inpatient and outpatient pharmacy services.