On January 9, 2015, the Joint Commission published significantly updated imaging standards for accredited hospitals, critical access hospitals, and ambulatory care centers. These new standards, which primarily impact facilities performing MRI, CT and NM/PET services, take effect on July 1, 2015 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 new standards consist of 25 new Elements of Performance (EP’s) that address the following general areas:
- Imaging equipment quality control and maintenance
- Medical physicist credentialing
- Technologist continuing education
- Patient radiation exposure
- Staff radiation exposure
- MRI safety
Among the numerous specific requirements in the new standards are the following:
- Annual measurement of CT radiation dose by a medical physicist
- Annual performance evaluation of CT, MRI, and NM/PET units by a medical physicist
- Performance of lead shielding designs by a qualified physicist upon equipment installation, upgrade or renovation
- Performance of radiation protection surveys by a qualified physicist after such activity
- Annual radiation dose optimization training for CT technologists
- Annual MRI safety training for MRI technologists
- Recording of patient CT radiation doses on every diagnostic CT study in the medical record and in the interpretive report
- Consideration of patient age and recent imaging exams when deciding on the most appropriate type of imaging exam
- Consideration of clinical indication, contrast administration, age, patient size and body habitus, and expected dose range in establishing CT protocols
- Periodic review of CT imaging protocols with the radiologist, technologist and medical physicist
- Compilation and analysis of patient CT dose incidents in comparison to dose benchmarks
- MRI access control, incident tracking, supervision and signage
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 staff training, policies and procedures, dose tracking program setup, etc.), West Physics is willing and able to meet your needs.
Ensure complete success during your next Joint Commission accreditation inspection by selecting a medical physics provider that not only has a reputation as the premier provider of medical 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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With accreditation bodies, regulatory bodies, members of the public, facility staff and others worried more and more every day about radiation doses from medical imaging procedures, it is essential that your hospital, imaging center or private practice look at this issue seriously and ensure that it is reducing doses as much as possible. But how do you know if the radiation dose from your CT, fluoroscopy or radiography protocols is as low as possible while still providing excellent diagnostic images? How do members of the public know that they are protected properly and that they can trust your site with themselves or their children? What can you do to ensure that you meet the latest guidelines, regulations and standards?
Optimizing radiation dose is a complex process. To do it properly requires training of technologists, image quality consultation with radiologists, investigation of new hardware and software options and equipment, review and improvement of policies and procedures, and a host of other steps. Plus, how do you properly measure your progress, compare it to industry standards, and articulate your success to your clients, referring physicians and accreditation bodies?
While the process is complex, the answer is simple. Hire a radiation expert to set you on the right course and keep you there. Our diagnostic medical physicists are trained to evaluate the starting dose situation at a facility, draw up a multi-element plan to improve it, and then properly verify and communicate the end result. It is not enough to involve the OEM, technologist and radiologist. You need a professional who is trained in radiation dosimetry, intimately familiar with all of the relevant standards (Joint Commission, ACR, IAC, State, Federal, Image Gently, Image Wisely, California SB 1237, etc.), and can ensure that your investment in time and money to address this important issue is spent wisely. To reduce dose, you have to consider numerous questions: Should you upgrade your scanners with new dose reduction features? Would it be better to invest in dose monitoring software? Are all of your protocols optimized and if not, how exactly do you ensure that they are? Are all your staff trained in dose optimization?
West Physics leads the medical physics industry in providing turn-key CT, fluoroscopy and radiography Dose Reduction Programs to facilities that measure doses, lower doses, help you make optimal decisions about new equipment or software, train staff, and provide information to your patients and staff about what has been done to keep them safe. In many cases, expensive scanner upgrades are NOT what is needed to reduce your doses – what is needed is proper patient dose tracking and analysis, protocol optimization and staff training. Let us help you put all the pieces together.
Our Dose Reduction Programs include the following elements:
- Dose and Image Quality Testing
- Protocol Optimization
- Dose Action Level Setup
- Dose-related Policies and Procedures (P&P) Review and Feedback
- Participation in JC- and State-required Protocol Review Committees
- Technologist and Radiologist Dose Awareness and Reduction Training
- Dose Strategy Consultation
- Dose Reduction Certificate
- Patient Dose Reduction Brochure
- Staff Q&A Session and Training Checkups
- Annual Dose and Image Quality Retesting
- Annual Dose Reduction Review
- Ongoing Protocol Refinement and Dose Action Level Checkups
- Ongoing consultation
Special Note: As part of our dose reduction programs, we are also pleased to provide expert setup, maintenance and oversight of customer dose tracking software packages. Our staff is experienced at working with Bayer Radimetrics, GE DoseWatch, PACSHealth DoseMonitor, and many more! Let a radiation safety professional help you manage your dose tracking and reduction program optimally, and in full compliance with the latest Joint Commission and ACR guidelines.
All of these elements add up to a simple, turn-key comprehensive Dose Reduction Program that will put your facility on solid footing with respect to dose reduction and ensure that you are taking the right steps to lower doses.
Please contact us today for more information about the individual elements of this service and for a no-obligation quote!
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.
Please contact us today for a no-obligation quote.
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West Physics is the premier solutions provider for facilities wishing to pursue the prestigious American College of Radiology (ACR) or Intersocietal Accreditation Commission (IAC) accreditations. We can help you with MRI, CT, PET, PET/CT, SPECT, mammography, and ultrasound accreditations. Our visits include phantom scanning (and clinical scanning for MRI if requested), staff training, and assistance throughout the entire process. Our staff has unparalleled training and experience in helping clients successfully apply for and properly maintain their ACR and IAC accreditations.
In the MRI arena, whether you have a 0.2T open system or a 3.0T high-field, our physicists DO NOT GIVE UP on you or your magnet. Even after well over 1,000 accreditations, we have a 99.8% success rate in getting our client’s machines to pass the process. This is why we are one of the only physics service providers in existence to offer a full guarantee on our services and your results. Click here for more information on our exceptional suite of ACR MRI services.
In the CT space, our physicists understand the complex intricacies of proper ACR application preparation as well as the scanning of the ACR phantom. For IAC accreditations, West Physics assisted in the accreditation of one of the very first IAC CT pilot sites in 2007 and we have a very mature technical and administrative assistance package. We employ the very finest Swedish-made (Unfors) CT dosimetry testing equipment to ensure that the accuracy of your CT radiation dose calculations are beyond question. With West Physics, you get the highest possible level of expertise and service, provided at an attractive price.
For PET (or PET/CT) and SPECT accreditation, West Physics was among the very first consulting firms to develop expertise in the ACR process, and we also can provide application assistance for IAC Nuclear/PET accreditation applications. And, of course, in mammography, you can rest assured that your accreditation and ongoing support will be provided by a board-certified and FDA-approved senior medical physicist.
Simply put, no other medical physics consulting firm in existence has both the breadth and depth to support your ACR and IAC accreditation needs. Let us show you why even major equipment vendors recommend West Physics to their customers for ACR and IAC services – they know it will be done right the very first time.
Please contact us today for a no-obligation quote.