Compliance Checklist: Joint Commission’s Imaging Standards
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality: Magnetic Resonance Imaging (MRI)Requirement:EC.02.01.01 EP 14(Applies only to MRI)EC.02.01.01 EP 16(Applies only to MRI)Areas to assess:Processes are in place to address thefollowing MRI safety risks (staff candescribe processes for):- patients with claustrophobia, anxiety,emotional distress-urgent/emergent patient care needs-patients with medical implants, devices,embedded metallic objects-preventing entry of ferromagnetic objectsinto MRI are a (only MRI-safe equipmente.g. fire extinguishers)*-protecting patients from acoustic noiseIdentifies activities and frequencies inwriting for maintaining, inspecting andtesting all medical equipment on inventoryEC.02.04.01 EP 10Equipment quality control andmaintenance activities are identifiedTimeframes are established for how oftenthey are to be doneEC.02.04.03 EP 18(Applies to CT, PET,NM, and MRI)EC.02.04.03 EP 22(Applies only to MRI)NoCommentInitialsAccess to the MRI area is restricted.*-all staff and patients are screened prior toentering the MRI area.*-there are controls in place to preventunauthorized access to the MRI area*-warning signage is posted at the entranceto the MRI scanner*-signage is posted indicating that themagnet is always on (as applicable)*EC.02.04.01 EP 4(Applies to CT, PET,NM, MRI, x-ray andfluoroscopy)(Applies to CT, PET,NM, MRI andfluoroscopy)YesEquipment quality control andmaintenance activities are doneQC logs are complete*A performance evaluation is performedannually by an MRI scientist, and includesall required tests.Evaluation/ testing results andrecommendations are documented.1* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality: Magnetic Resonance Imaging (MRI)Requirement:Areas to assess:EC.02.04.03 EP 25A performance evaluation thatincludes all required tests andparameters is performed on eachimage acquisition monitor annually bya medical physicist or MRI scientist (forMRI only)(Applies to CT, PET,NM, and MRI)HR.01.05.03 EP 25(Applies only to MRI)PI.01.01.01 EP 34(Applies only to MRI)PI.01.01.01 EP 35(Applies only to MRI)YesNoCommentInitialsDocumentation of staff annual trainingand ongoing education on all requiredtopics is availableData is collected on any MRI-relatedpatient thermal injuriesData is collected on:-incidents where have unintentionallyentered the MRI scanner room-injuries resulting from the presence offerromagnetic objects in the MRIscanner room2* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality: Computed Tomography (CT)Requirement:Areas to assess:EC.02.02.01 EP 17(Applies to CT, NM,PET, Fluoroscopy)Dosimetry monitoring results reviewedquarterly by radiation safety officer,diagnostic medical physicist, healthphysicist; assess ALARAEC.02.02.01 EP 18(Applies to CT, NM,PET, Fluoroscopy, x-ray)Radiation workers checkedperiodically for amount of radiationexposureEC.02.04.01 EP 4(Applies to CT, PET,NM, MRI, x-ray andfluoroscopy)Identifies activities and frequencies inwriting for maintaining, inspecting andtesting all medical equipment oninventoryEC.02.04.01 EP 5(Applies to CT, PET,NM, MRI, x-ray andfluoroscopy)Deemed: Maintenance, inspectiontesting in accordance withmanufacturer’s recommendationsEC.02.04.01 EP 10Equipment quality control andmaintenance activities are identifiedTimeframes are established for howoften they are to be done(Applies to CT, PET, NM,MRI and fluoroscopy)EC.02.04.03 EP 18(Applies to CT, PET, NM,and MRI)EC.02.04.03 EP 20(Applies only to CT)YesNoCommentInitialsEquipment quality control andmaintenance activities are doneQC logs are complete*At least annually:- the CTDI is measured for adult brain,adult abdomen, pediatric brain, andpediatric abdomen, or othercommonly used protocols and- the radiation dose for each protocolis verified to be within 20% of dosedisplayed-the measurements and doseverifications are done by a medicalphysicist3* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality: Computed Tomography (CT)RequirementAreas to assess:EC.02.04.03 EP 21A performance evaluation isperformed annually by a medicalphysicist and includes all requiredtests. Evaluation/ testing results andrecommendations are documented.(Applies only to CT)EC.02.04.03 EP 25(Applies to CT, PET,NM, and MRI)EC.02.06.05 EP 4(Applies to CT, PET,and NM)EC.02.06.05 EP 6(Applies to CT, PET,and NM)YesCommentInitialsA performance evaluation thatincludes all required tests andparameters is performed on eachimage acquisition monitor annually bya medical physicist or MRI scientist (forMRI only)A structural radiation shielding designassessment is conducted prior toimaging equipment installation orroom modificationThe survey is conducted by a medicalphysicist or health physicistA radiation protection survey isconducted after installation of imagingequipment or constructionThe survey is done prior to clinical useof the room and is conducted by amedical physicist or health physicistHR.01.01.01 EP 32(Applies only to CT)Documentation is available forverification of specified qualificationsfor each technologist who performsdiagnostic CT examsHR.01.01.01 EP 33Documentation is available ofverification of specified qualificationsfor each medical physicist supportingCT services(Applies only to CT)No4* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality Computed Tomography (CT)RequirementAreas to assess:HR.01.05.03 EP 14Documentation of staff annual trainingand ongoing education is available.The training includes:-radiation dose optimizationtechniques-safe operation of CT equipment theywill use(Applies only to CT)YesPC.01.02.15 EP 5(Applies only to CT)Radiation dose index is documentedfor on every CT exam.The dose index is exam specific,summarized by series or anatomicarea and retrievablePC.01.02.15 EP 12(Applies to CT, PET,NM, MRI)Appropriateness of exam (patient age,recent imaging exams, exam type)PC.01.03.01 EP 26Imaging protocols are reviewed, keptcurrent. Input is provided by aninterpreting MD, medical physicist,and imaging technologist.*Protocols are reviewed per establishedtimeframes(Applies only to CT)PI.02.01.01 EP 6(Applies only to CT)NoCommentInitialsIncidents where radiation dose indicesexceeded expected dose index rangeare reviewed and analyzed. Theseincidents are compared to externalbenchmarks5* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality: Nuclear Medicine (NM) & Positron Emission Tomography (PET)Requirement:Areas to assess:YesEC.02.02.01 EP 6(Applies to NM, PET)Minimizes risk associated withselecting, handling, storing,transporting, using and disposing ofradioactive materialsEC.02.02.01 EP 17(Applies to CT, NM,PET, Fluoroscopy)Dosimetry monitoring results reviewedquarterly by radiation safety officer,diagnostic medical physicist, healthphysicist; assess ALARAEC.02.02.01 EP 18(Applies to deemed:CT, NM, PET,fluoroscopy, x-ray)Radiation workers checked periodicallyfor amount of radiation exposureEC.02.04.01 EP 4(Applies to CT, PET,NM, MRI, x-ray andfluoroscopy)Identifies activities and frequencies inwriting for maintaining, inspecting andtesting all medical equipment oninventoryEC.02.04.01 EP 5(Applies to CT, PET,NM, MRI, x-ray andfluoroscopy)Deemed: Maintenance, inspectiontesting in accordance withmanufacturer’s recommendationsEC.02.04.01 EP 10(Applies to CT, PET,NM, MRI andfluoroscopy)Equipment quality control andmaintenance activities are identifiedTimeframes are established for howoften they are to be doneEC.02.04.03 EP 18(Applies to CT, PET,NM, and MRI)Equipment quality control andmaintenance activities are doneQC logs are complete*EC.02.04.03 EP 1(Applies to MRI, CT,NM,PET, x-ray,Fluoroscopy,Performs safety, operational,functional checksNon-deemed: before initial use.Deemed: Before initial use and aftermajor repairs or upgradesNoCommentInitials6* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality: Nuclear Medicine (NM) & Positron Emission Tomography (PET)Requirement:Areas to assess:EC.02.04.03 EP 16(Applies to NM, PET)Qualified staff inspect, test andcalibrate NM equipment annually.Results, completion datesdocumented.EC.02.04.03 EP 23A performance evaluation isperformed annually by a medicalphysicist or nuclear medicine physicistand includes all required tests.Evaluation/ testing results andrecommendations are documented.(Applies only to NM)EC.02.04.03 EP 24(Applies only to PET)EC.02.04.03 EP 25(Applies to CT, PET,NM, and MRI)YesNoCommentInitialsA performance evaluation thatincludes all required tests is performedannually by a medical physicistEvaluation/testing results andrecommendations are documented.A performance evaluation thatincludes all required tests andparameters is performed on eachimage acquisition monitor annually bya medical physicist or MRI scientist(for MRI only)EC.02.06.05 EP 4(Applies to CT, PET,NM)Structural shielding assessment priorto installation of new/replacement ofexisting imaging equipment; roomswhere ionizing radiation emitted orradioactive material stored, medical orhealth physicistEC.02.06.05 EP 6(Applies to CT, PET,NM)Radiation protection survey to verifyadequacy of shielding after installationof imaging equipment or constructionby medical or health physicistMM.06.01.01 EP 13(Applies to NuclearMedicine)Verified dose is within 20% prescribeddose or range7* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality: Nuclear Medicine (NM) & Positron Emission Tomography (PET)Requirement:Areas to assess:YesMS.03.01.01 EP 16(Applies to CT, NM.PET, x-ray,fluoroscopy)Deemed: Medical staff determinesqualifications radiology staff who useequipment & administer proceduresMS.03.01.01 EP 17(Applies to NM, PET)Deemed: Approves nuclear servicesdoctor qualifications, training,functions, responsibilities NM staffNoCommentInitials8* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging StandardsUse this tool to assess your organization’s compliance with The Joint Commission’s requirements that relateto the provision of imaging services.Modality: FluoroscopyRequirement:Areas to assess:EC.02.04.01 EP 5(Applies to CT, PET,NM, MRI, x-ray andfluoroscopy)Deemed: Maintenance, inspectiontesting in accordance withmanufacturer’s recommendationsEC.02.04.01 EP 10Equipment quality control andmaintenance activities are identifiedTimeframes are established for howoften they are to be done(Applies to CT, PET,NM, MRI andfluoroscopy)EC.02.04.03 EP 34(Applies tofluoroscopic units)A performance evaluation thatincludes all required tests is performedannually by a diagnostic medicalphysicist. Evaluation/testing resultsare documentedPC.01.02.15 EP 13(Applies tofluoroscopy)Cumulative air kerma, kerma areaproduct (fluoroscopy time, number ofspot films) documented in nitialsMiscellaneousRequirementAreas to assess:LD.04.01.05 EP 25(applies if anyradiologic servicesare provided)Designated radiation safety officerwith authority and responsibilities asdescribed9* Frequent area of noncomplianceUpdated April 2020
Compliance Checklist: Joint Commission’s Imaging Standards Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services. 1 * Frequent area of noncompliance Updated
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