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
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- 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
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- 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
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- 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
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- 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
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- EP 30. The accredited organization identifies radiation exposure and skin dose threshold levels.
- PI.02.01.01 – Organization complies and analyzes data
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- 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
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- 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.
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Whether to meet Joint Commission, ACR, IAC or State regulatory requirements, diagnostic imaging equipment requires periodic (in most cases annual) performance testing by a qualified physicist. West Physics provides these quality assurance services in a prompt, expert, and convenient manner. Our clients, located throughout the United States, know that they can count on our team of professionals to perform this testing expediently and to all applicable standards. Whether your needs are in MRI, CT, PET, SPECT, mammography, ultrasound, radiography, or fluoroscopy, we employ state-of-the-art test equipment and highly-trained graduate-degreed physicists to assure you total compliance and maximum value.
All of West Physics’ annual services include:
- on-site refresher training for technologists (with ASRT Category A credits available),
- quality control records review and consultation,
- a turn-key Quality Control / Policies and Procedures Binder (for ACR-accredited equipment),
- unlimited telephone consulting for as long as you remain a client, and
- flexible scheduling options, including weekend service (subject to availability).
We pride ourselves on not only ensuring your facility’s regulatory compliance, but also on making substantive improvements to your image quality. Our physicists are trained to communicate test results clearly and understandably, and work with your service personnel to resolve problems rapidly. This is why some of the most prestigious imaging centers and networks in the nation have chosen West Physics. Let us show you the West Physics difference!
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- LUTATHERA (lutetium Lu-77) experienced radiation safety physicists available on-staff, to help you navigate the unique radiation safety and regulatory management requirements to ensure your radiation safety & compliance
- West Physics is able to provide a full range of RSO support for medical and non-medical facilities throughout the United States
- Our physicists currently serve as active and involved RSO’s for numerous medical and
non-medical facilities utilizing radiation emitting devices or radioactive byproducts
- All of our physicists meet the training and experience requirements implemented by the NRC and the Agreement States and includes multiple former state and federal regulators
- We can prepare all of your Radioactive Materials “RAM” license applications, amendments and renewals, and our expertise can prevent months of delays negotiating license conditions with regulators
- We will ensure that your RAM license does not commit your facility to any unnecessary, expensive, and time-consuming compliance activities
- We have extensive experience with multi-state operations, SPECT and PET/CT mobile operations, and other radiation producing modalities. These modalities demand special knowledge and experience and we have it
- Our physicists will manage the personnel dosimetry review program to ensure ALARA principles are supported to minimize personnel radiation exposures to the safest levels
- We can act as statutory or non-statutory RSO on your RAM License
- Our RSO Service includes 24/7/365 technical and regulatory support
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West Physics offers a full range of professional regulatory consulting services to represent clients in a wide range of situations. From serving as Radiation Safety Officers (RSO) for hospitals and clinics, to assisting health care facilities with obtaining or amending federal or state radioactive materials (RAM) licenses, West Physics has the depth of experience few if any firms can offer. Among our regulatory services are the following:
- RAM License Application and Amendment Preparation
- RSO services for nuclear medicine and all other types of RAM holders
- Representation of licensees before enforcement proceedings
- Nuclear medicine program startup and change consulting
- Nuclear medicine program quarterly audits
- Design of dosimetry monitoring programs
- Provision of standards-compliant Policies and Procedures
All of our regulatory consulting services are provided by a world-class staff of experts who have expertise and experience with a multitude of program types and scenarios. In particular, the staff is intimately familiar with the unique needs of emerging modalities such as positron emission tomography (PET). West Physics’ President & Chief Medical Physicist, Dr. Geoffrey West, has special expertise in the regulatory consulting arena due to his status as a former nuclear materials inspector for the U.S. Nuclear Regulatory Commission, as well as to his possession of board certifications in both health physics and medical physics. West Physics has provided highly successful RSO services for a number of large-scale RAM operations and our staff specializes in unique situations and complex needs.
Please contact us today to discuss your specific needs.