1. Gregg C. Daversa Director, Business Development West Physics
The New Joint Commission Imaging Requirements – How to Ensure That Your Facility is Ready
Gregg C. Daversa
Director, Business Development
West Physics

2. Objectives
Identify which JC-accredited facilities will be impacted by the 2014 standard changes, and the dates for full compliance
Identify which imaging modalities will be affected
Discuss why the JC made the changes in imaging standards
Review each standard and identify how it will impact image quality, patient care, and patient/personnel safety
Review each standard and identify how the JC-accredited organization will be expected to meet the revised standards
Understand how your facility can prepare for the changes and be completely ready for your next JC survey

3. JC Accreditation Facts
JC released the new imaging standards in “pre-publication” form on December 20, 2013
Effective date for the new standards will be July 1, 2014
New JC imaging standards will impact hospitals, critical access hospitals, and ambulatory care centers
Modalities impacted will be MRI, CT, NM & PET (including hybrid modalities)
Dental Cone Beam CT (CBCT) used for maxillofacial region for diagnosis or treatment planning is excluded from the standard changes
Standards sections impacted are Environment of Care, Human Resources, Medication Management, Provision of Care, Treatment, Services, and Performance Improvement

4. What Prompted These Changes to the Standards Specific to Imaging?
Progression of JC Sentinel Event Alert, Issue 47 to more formal standards
Progression of historical JC National Patient & Safety Goals to more formal standards
Patient and payer (e.g., CMS) expectations for higher patient safety and quality standards
Need for greater parity with other imaging industry standards such as those of the ACR and IAC accreditation programs
Various highly publicized imaging-related medical events

5. Environment of Care (EC)

6. EC.02.01.01 – Organization Manages Safety And Security Risks
(14) For facilities that provide MRI services: The facility manages safety risks in the MRI environment associated with the following:
Patients who may experience claustrophobia, anxiety, or emotional distress
Patients who may require urgent or emergent medical care
Patients with medical implants, devices, or imbedded foreign objects (e.g. shrapnel, etc.)
Ferromagnetic objects entering the MRI environment
Acoustic noise

7. EC.02.01.01 – Organization Manages Safety And Security Risks
(16) For facilities that provide MRI Services: The facility manages safety risks by doing the following:
Restricting access of everyone not trained in MRI safety or screened by MRI-trained staff from the scanner room and the area that immediately precedes the entrance to the MRI scanner room
Making sure that these restricted areas are controlled by and under the direct supervision of MRI-trained staff
Posting signage at the entrance of the MRI scanner that conveys the risk of the dangers of the magnetic field.
Signage to also indicate that the magnet is always on with the exception of those that can be routinely turned off by the operator

8. EC.02.02.01 – Organization Manages Risks Related To Hazardous Materials And Waste
(17) Facilities that provide CT, PET or NM services will have staff dosimetry results reviewed by the RSO or a diagnostic medical physicist at least quarterly to assess whether staff radiation exposures are ALARA and below regulatory limits

9. EC.02.04.01 – Organization Manages Medical Equipment Risks
(7) The facility identifies quality control and maintenance activities to maintain the quality of diagnostic images produced. The organization identifies how often these activities should be conducted.

10. EC.02.04.03 – Organization Inspects, Tests, And Maintains Medical Equipment
(15) The facility maintains the quality of the diagnostic images produced.
(17) CT scanners are tested at least annually by a diagnostic medical physicist:
Measure radiation dose in the form of CTDIvol
Adult brain
Adult abdomen
Pediatric brain
Pediatric abdomen
Substitute procedures can be used if the above are not commonly performed at the facility

11. EC.02.04.03 – Organization Inspects, Tests, And Maintains Medical Equipment
(17) Cont.
Verify that the radiation dose in form of CTDIvol displayed by the CT system for each tested protocol is within 20% of the CTDIvol measured by the physicist. The dates, results, and verifications of these measurement results are documented
This EP is only applicable to CT systems capable of displaying radiation dose in the form of CTDIvol

12. EC.02.04.03 – Organization Inspects, Tests, And Maintains Medical Equipment
(19) At least annually, a diagnostic medical physicist conducts a performance evaluation of all CT imaging equipment. Evaluation includes use of phantoms to assess:
Image (CT Number) uniformity
Slice thickness accuracy
Slice position accuracy (when prescribed from a scout image)
Alignment light accuracy
Table travel accuracy
Radiation beam width
High-contrast resolution
Low-contrast resolution
Geometric or distance accuracy
CT number accuracy
Artifact evaluation

13. EC.02.04.03 – Organization Inspects, Tests, And Maintains Medical Equipment
(20) At least annually, a diagnostic medical physicist or MRI scientist conducts a performance evaluation of all MRI imaging equipment. Evaluation includes the use of phantoms to assess:
Image uniformity for all RF coils used clinically
SNR for all coils used clinically
Slice thickness accuracy
Slice position accuracy
Alignment light accuracy
High-contrast resolution
Low-contrast resolution (or CNR)
Geometric or distance accuracy
Magnetic field homogeneity
Artifact evaluation

14. EC.02.04.03 – Organization Inspects, Tests, And Maintains Medical Equipment
(21) At least annually, a diagnostic medical physicist conducts a performance evaluation of all NM imaging equipment. Evaluation includes the use of phantoms to assess:
Image uniformity/system uniformity
High-contrast resolution/system spatial resolution
Low-contrast resolution or detectability (N/A for planar acquisitions)
Sensitivity
Energy resolution
Count-rate performance
Artifact evaluation

15. EC.02.04.03 – Organization Inspects, Tests, And Maintains Medical Equipment
(22) At least annually, a diagnostic medical physicist conducts a performance evaluation of all PET imaging equipment. Evaluation includes the use of phantoms to assess:
Image uniformity/system uniformity
High-contrast resolution/system spatial resolution
Low-contrast resolution or detectability (N/A for planar acquisitions)
Artifact evaluation
Tests recommended but not required:
Sensitivity
Energy resolution
Count-rate performance

16. EC.02.04.03 – Organization Inspects, Tests, And Maintains Medical Equipment
(23) Annual performance evaluation by a diagnostic medical physicist of image acquisition display monitors connected to MRI, CT, PET & NM systems to assess:
Maximum and minimum luminance
Luminance uniformity
Resolution
Spatial accuracy

17. EC – Organization Manages Its Environment During Demolition, Renovation, Or New Construction To Reduce Risk To Those In The Organization
(4) Facilities that provide CT, PET or NM services will have a structural shielding design conducted by a medical physicist:
Prior to installation of new imaging equipment
Prior to replacement of existing imaging equipment
Prior to modification to rooms where ionizing radiation will be emitted or radioactive materials will be stored (e.g., scan rooms or hot labs)

18. EC – Organization Manages Its Environment During Demolition, Renovation, Or New Construction To Reduce Risk To Those In The Organization
(6) Facilities that provide CT, PET or NM services will have a radiation protection survey conducted by a medical physicist after installation of imaging equipment or construction in rooms where ionizing radiation will be emitted or radioactive materials will be stored. This survey will verify the adequacy of installed shielding. This survey is conducted prior to clinical use of the room.

19. Human Resources (HR)

20. HR.01.02.05 – Organization Verifies Staff Qualifications
(19) The facility verifies and documents that radiologic technologists who perform CT exams meet the following requirements by July 1, 2015:
American Registry of Radiologic Technologists (ARRT) (R) or
Nuclear Medicine Technology Certification Board (NMTCB) and
Trained and experienced in the operation of CT equipment
WPC Note: Best practice is to conduct primary source verification

21. HR.01.02.05 – Organization Verifies Staff Qualifications
(20) The facility verifies and documents that medical physicists that support CT services have board certification in:
Diagnostic Radiologic Physics by the American Board of Radiology (ABR) or
Diagnostic Imaging Physics by the American Board of Medical Physics or
Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine or
A graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university, and
Formal graduate-level coursework in the biological sciences with at least 1 course in biology or radiation biology and 1 course in anatomy, physiology, or a similar topic related to the practice of medical physics, and
Documented experience in a clinical CT environment conducting at least 10 CT performance evaluations under the direct supervision of a board-certified medical physicist.

22. HR.01.05.03 – Staff Participate In Ongoing Education And Training
(14) The facility verifies and documents that radiologic technologists who perform CT exams participate in ongoing education that includes annual training on radiation dose reduction techniques (e.g., Image Gently and Image Wisely).

23. HR.01.05.03 – Staff Participate In Ongoing Education And Training
(25) The facility verifies and documents that MRI technologists participate in ongoing education that includes MRI safety training:
Patient screening for ferromagnetic items, medical implants, NSF
Patient positioning to avoid RF burns
Equipment and supplies acceptable to be safely used in MRI environment
Safety response procedures for patients who need emergent medical care
MRI equipment emergency shutdown procedures (e.g., magnet quench)
Patient hearing protection
Patient claustrophobia, anxiety, emotional distress

24. Medication Management (MM)

25. MM.06.01.01 – Organization Safely Administers Medications
(13) For NM & PET, before administration of a radioactive pharmaceutical for diagnostic purposes, staff verify that the dose to be administered is within 20% of the prescribed dose, or, if the dose is prescribed as a range, staff verify that the dose to be administered is within the prescribed range.

26. Provision of Care, Treatment, and Services (PC)

27. PC.01.02.15 – Organization Provides For Diagnostic Testing
(5) For CT, the facility documents in the patient’s medical record the radiation dose measured in CTDIvol or DLP for every study produced during a CT examination:
Only applicable to CT systems capable of providing a CTDIvol or DLP measurement
Does not apply to radiation therapy treatment planning (SIM CT) or attenuation correction-only CT

28. PC.01.02.15 – Organization Provides For Diagnostic Testing
(6) For facilities that provide diagnostic CT, the interpretive report of the CT study includes the patient’s CTDIvol or DLP radiation dose. The dose is either recorded in the patient’s interpretive report or included on the protocol page.
Best practice will be patient’s radiation dose value to be included in the physician interpretative diagnostic report
Applicable to only CT scanners capable of calculating and displaying radiation dose values

29. PC.01.02.15 – Organization Provides For Diagnostic Testing
(10) Prior to conducting a diagnostic imaging study, the facility verifies the following:
Correct patient
Correct imaging site
Correct patient positioning
CT only: Correct imaging protocol
CT only: Correct scanner parameters

30. PC.01.02.15 – Organization Provides For Diagnostic Testing
(12) The facility considers the patient’s age and recent imaging exams when deciding on the most appropriate type of imaging exam:
To prevent unnecessary duplication of exams (reduce radiation exposure)
WPC Notes: Utilize EMR or RIS to support decision process. Reference ACR appropriateness criteria

31. PC.01.03.01 – Organization Provides For Diagnostic Testing
(25) For CT, the facility establishes imaging protocols based on current standards of practice, which address key criteria including:
Clinical indication
Contrast administration
Age (pediatric or adult)
Patient size and body habitus
Expected radiation dose range

32. PC.01.03.01 – Organization Provides For Diagnostic Testing
(26) For CT, imaging protocols are reviewed and kept current with input from an:
Interpreting radiologist
Medical physicist
Lead imaging technologist
To make certain that they adhere to current standards of practice and account for changes in CT imaging equipment. These reviews are conducted at time frames identified by the organization.
WPC Note: Reference standard of practice:
AAPM
Adult Brain, Brain perfusion, Chest, ABD, Pelvis
Physicist
Technologist
Radiologist

33. Performance Improvement (PI)

34. PI.01.01.01 – Organization Collects Data To Monitor Its Performance
(46) For MRI, the facility collects data on patient burns that occur during MRI exams.
(47) For MRI, the facility collects data on:
Incidents where ferromagnetic items entered the MRI scanner room
Injuries resulting from the presence of ferromagnetic items in the MRI scanner room

35. PI.02.01.01 – Organization Compiles And Analyzes Data
(6) For CT, the facility compiles and analyzes data on patient CT radiation doses and compares it with external benchmarks, when such benchmarks are available.
Best practice will involve dose tracking and analysis software technology
ACR Dose Index Registry, NEXT and other external benchmarks.

36. PI.02.01.01 – Organization Compiles And Analyzes Data
ACR
National Radiology Data Registry (2008)
Dose Index Registry “DIR” (2011)
5 million CT studies from 600 participating facilities. Most studies from a single index in the world
Cost to participate: $ one time entry fee
Annual fee ranges from $ to $10,000 depending of number of radiologists working at facility and number of distinct locations within the organization

37. PI.02.01.01 – Organization Compiles And Analyzes Data
CT dose tracking software solutions:
RaySafe S1 (Fluke)
Dose Watch (GE)
Dose Monitor(PACSHealth)
Radimetrics (Bayer)
imalogiX (Medlnt)
DoseTrack (Sectra)
AccuRad (Aware)
Scannerside (RightDose)
Radiance (UPenn)

38. Benefits Of CT Dose Tracking Software
Accurate dose reporting and myriad analysis capabilities
Identify studies that fall above or below median threshold dose values and allow corrective actions
Proves success of dose reduction efforts
Vehicle to transfer dose value to medical record
Archive for patient dose values
Compare dose values to other databases
Reads DICOM format and/or utilizes OCR
Reduce patient radiation dose!

39. Factors To Address Before Purchase of CT Dose Tracking Software
Full license purchase (outright purchase) or
Subscription model (pay for each study)
Age, make, and model of CT scanner (structured report)
Single or multi-site installation
Network bandwidth
Manage dose values through PACS, RIS, EHR
Compatibility with dictation vendor and version
Manage patients with different unique identifier numbers in same network
IT dept. must be part of the dose tracking implementation
Finally – who will actually manage it?

40. 8 Key Important Take Home Points
July 1, 2014 effective date for standards to be implemented (except CT tech credentialing, which is July 1, 2015)
Annual equipment testing required by medical physicist for MRI, CT, NM, PET
Radiation structural shielding design for CT, NM & PET by medical physicist
Radiation protection survey for CT, NM & PET by medical physicist
Minimum credentialing requirements for technologists and medical physicists
Record, track and analyze patient CT radiation dose
Analyze and benchmark CT and MRI safety data
Annual dose reduction and MRI safety training required

41. QUESTIONS
Gregg c. daversa Phone: WEST (9378)