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On June 25, 2018, The Joint Commission published updated imaging standards for accredited hospitals, critical access hospitals, ambulatory care centers, and office-based surgery centers providing fluoroscopy services. Five new standards, which impact facilities performing general and interventional fluoroscopy services, took effect on January 1, 2019 in addition to two more standards that were revised on July 1, 2018, and mandate a broad range of quality and safety activities and practices. Joint Commission accredited facilities will be expected to comply with these new standards in addition to any other applicable state or federal regulations, or applicable ACR or IAC accreditation standards.

The two revised 2018 Elements of Performance (EPs) address the Environment of Care (EC) area. These are:

• EC.02.02.01 – Organization manages risks related to hazardous materials and waste
• • EP 7. The organization minimizes risks associated with the selection and use of hazardous energy sources, including x-ray equipment. This EP now includes shielding for fluoroscopy.
  • EP 17. The results of staff dosimetry monitoring are reviewed at least quarterly by the radiation safety officer, a diagnostic medical physicist, or a health physicist. This EP now includes dosimetry from fluoroscopy services.

The five new 2019 Elements of Performance (EPs) that came into effect January 1, 2019 are:

• EC.02.04.03 – Organization inspects, tests, and maintains medical equipment
• • EP 34. A diagnostic medical physicist conducts an annual performance evaluation of fluoroscopic imaging equipment.

• HR.01.05.03 – Staff participate in ongoing education and training
• • EP 15. Accredited organization verifies and documents that individuals (including physicians, non-physicians, and ancillary personnel) who use fluoroscopic equipment participate in ongoing annual radiation safety education.

• PC.01.02.15 – Organization provides for diagnostic testing
• • EP 13. The accredited organization ensures the cumulative-air kerma or kerma area product is documented in a retrievable format, or if the equipment is incapable of recording those metrics, fluoroscopy time and number of images.

• PC.02.01.01 – Organization provides care, treatment, and services for each patient
• • EP 30. The accredited organization identifies radiation exposure and skin dose threshold levels.

• PI.02.01.01 – Organization complies and analyzes data
• • EP 20. The accredited organization reviews and analyzes instances where the radiation exposure and skin threshold levels identified by the organization are exceeded.

Additionally, if a facility has not previously been required to appoint a Radiation Safety Officer, the following new EP in the Leadership (LD) category also applies:

• LD.04.01.05 – Organization effectively manages its programs. services, or sites
• • EP 25. The organization designates an individual to serve as the radiation safety officer, who is responsible for making certain that radiologic services are provided in accordance with law, regulation, and organizational policy.

West Physics has unique expertise and experience to help facilities comply with ALL of these new standards and we have developed a set of services for individual facilities as well as networks to efficiently and quickly address the standards. Whether you require assistance with only those new requirements that specifically require a medical physicist, or you prefer a turn-key integrated solution (to include all required equipment testing, staff training, establishing dose thresholds, RSO services, etc.), West Physics is capable of meeting your needs.

Ensure complete success during your next Joint Commission accreditation survey by selecting a medical and health physics provider that not only has a reputation as the premier provider of medical and health physics services in the nation, but also has intimate knowledge of the new standards and how to effectively and efficiently comply with them. Our physicists look forward to helping you meet the new standards in a simple, stress-free and cost-effective manner.

Please contact us today for a no-obligation quote.

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