Following public comment received in the fall of 2013, The Joint Commission has released new accreditation standards for diagnostic imaging services. Nearly all of these new standard elements of performance (EP) are slated to become effective in a half-year.
The new TJC accreditation requirements are catching up with industry best practice standards. Accredited providers, if they are not already doing so, will need to begin the following by July 1, 2014:
- Actively managing risks in the MRI environment, including ferromagnetic materials (inside and outside of patients), emergent patients, and acoustic noise.
- Providing access controls, direct supervision, and warnings about hazards in the MRI environment.
- Keep staff ionizing radiation exposure as low as reasonably achievable (ALARA) and review exposure at least quarterly.
- Develop a QC plan for all imaging modalities which includes frequency of evaluation.
- For CT, verify accuracy of system displayed dose at least annually.
- Annual medical physicist evaluations of CT, PET, nuclear camera and MRI scanners (and clinical displays).
- For new equipment installations, medical physicist to design, and provide post-installation testing of ionizing radiation shielding.
- Observe specific educational / credential requirements for medical physicists serving CT scanners.
- Ongoing annual safety training for CT and MRI technologists.
- Verify dose for any isotope administered for a nuclear medicine exam.
- Record CT dose on the study (for CT scanners that have the capability of reporting dose).
- For CT, follow industry standards of practice for dose reduction.
- For CT, review imaging protocols periodically for adherence to industry standards.
- Collect information on MRI adverse events, including burns, projectile events, and screening oversights when ferromagnetic objects were permitted into the MRI scanner room.
- Review CT radiation dose data and compare with industry benchmarks.
- The one new EP with a delayed implementation date is a call for credentialing of technologists performing CT exams:
- By July 1, 2015, Technologists performing CT exams will need to be registered and certified by ARRT or NMTCB
- Much of the new standards follow closely the field review draft document published earlier this year.
It is highly recommended that Joint Commission accredited providers of any imaging services review the new standards themselves. The new EPs for diagnostic imaging are available in PDF format from the Joint Commission's website.
Many of the elements of TJC's updated imaging standards are simply requiring elements that have been a part of existing best practices, or, as with the case with CT dose recording, are state requirements. Many forward-looking imaging providers are expected to find that their existing practices already comply with the new TJC standards, or require only very modest modifications. Please closely review your existing practices against the new EPs to help assure compliance with the new expectations.
Sources within The Joint Commission have indicated that these diagnostic imaging standards represent a first installment, which will be followed by standards updates that will address interventional imaging, nuclear medicine and radiation therapy.
For more information: www.jointcommission.org
April 24, 2024 
