Imaging checklist.pdf

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.

* = Frequent area of noncompliance Updated April 2020

Modality: Magnetic Resonance Imaging (MRI) Requirement: Areas to assess: Yes No Comment Initials

EC.02.01.01 EP 14

(Applies only to MRI)

Processes are in place to address the following MRI safety risks (staff can describe 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 objects into MRI are a (only MRI-safe equipment e.g. fire extinguishers)* -protecting patients from acoustic noise

EC.02.01.01 EP 16

Access to the MRI area is restricted.* -all staff and patients are screened prior to entering the MRI area.* -there are controls in place to prevent unauthorized access to the MRI area* -warning signage is posted at the entrance to the MRI scanner* -signage is posted indicating that the magnet is always on (as applicable)*

EC.02.04.01 EP 4

(Applies to CT, PET, NM, MRI, x-ray and fluoroscopy)

Identifies activities and frequencies in writing for maintaining, inspecting and testing all medical equipment on inventory

EC.02.04.01 EP 10

NM, MRI and fluoroscopy)

Equipment quality control and maintenance activities are identified Timeframes are established for how often they are to be done

EC.02.04.03 EP 18

NM, and MRI)

Equipment quality control and maintenance activities are done QC logs are complete*

EC.02.04.03 EP 22

A performance evaluation is performed annually by an MRI scientist, and includes all required tests.

Evaluation/ testing results and recommendations are documented.

Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services.

* = Frequent area of noncompliance Updated April 2020

Modality: Magnetic Resonance Imaging (MRI)

Requirement: Areas to assess: Yes No Comment Initials

EC.02.04.03 EP 25

(Applies to CT, PET, NM, and MRI)

A performance evaluation that includes all required tests and parameters is performed on each image acquisition monitor annually by a medical physicist or MRI scientist (for MRI only)

HR.01.05.03 EP 25

Documentation of staff annual training and ongoing education on all required topics is available

PI.01.01.01 EP 34

Data is collected on any MRI-related patient thermal injuries

PI.01.01.01 EP 35

Data is collected on:

-incidents where have unintentionally entered the MRI scanner room -injuries resulting from the presence of ferromagnetic objects in the MRI scanner room

Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services.

* = Frequent area of noncompliance Updated April 2020

Modality: Computed Tomography (CT)

EC.02.02.01 EP 17

(Applies to CT, NM, PET, Fluoroscopy)

Dosimetry monitoring results reviewed quarterly by radiation safety officer, diagnostic medical physicist, health physicist; assess ALARA

EC.02.02.01 EP 18

PET, Fluoroscopy, x-ray)

Radiation workers checked periodically for amount of radiation exposure

NM, MRI, x-ray and fluoroscopy)

Identifies activities and frequencies in writing for maintaining, inspecting and testing all medical equipment on inventory

EC.02.04.01 EP 5

NM, MRI, x-ray and fluoroscopy)

Deemed: Maintenance, inspection testing in accordance with manufacturer’s recommendations

(Applies to CT, PET, NM, MRI and fluoroscopy)

Equipment quality control and maintenance activities are identified Timeframes are established for how often they are to be done

(Applies to CT, PET, NM, and MRI)

Equipment quality control and

EC.02.04.03 EP 20

(Applies only to CT)

At least annually:

- the CTDI is measured for adult brain, adult abdomen, pediatric brain, and pediatric abdomen, or other commonly used protocols and

- the radiation dose for each protocol is verified to be within 20% of dose displayed -the measurements and dose verifications are done by a medical physicist

Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services.

* = Frequent area of noncompliance Updated April 2020

Modality: Computed Tomography (CT)

Requirement Areas to assess: Yes No Comment Initials

EC.02.04.03 EP 21

A performance evaluation is performed annually by a medical physicist and includes all required tests. Evaluation/ testing results and

NM, and MRI)

A performance evaluation that includes all required tests and parameters is performed on each image acquisition monitor annually by a medical physicist or MRI scientist (for MRI only)

EC.02.06.05 EP 4

and NM)

A structural radiation shielding design assessment is conducted prior to imaging equipment installation or room modification The survey is conducted by a medical physicist or health physicist

EC.02.06.05 EP 6

and NM)

A radiation protection survey is conducted after installation of imaging equipment or construction The survey is done prior to clinical use of the room and is conducted by a medical physicist or health physicist

HR.01.01.01 EP 32

Documentation is available for verification of specified qualifications for each technologist who performs diagnostic CT exams

HR.01.01.01 EP 33

Documentation is available of verification of specified qualifications for each medical physicist supporting CT services

Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services.

* = Frequent area of noncompliance Updated April 2020

Modality Computed Tomography (CT)

Requirement Areas to assess: Yes No Comment Initials

HR.01.05.03 EP 14

Documentation of staff annual training and ongoing education is available.

The training includes:

-radiation dose optimization techniques -safe operation of CT equipment they will use

PC.01.02.15 EP 5

Radiation dose index is documented for on every CT exam.

The dose index is exam specific, summarized by series or anatomic area and retrievable

PC.01.02.15 EP 12

NM, MRI)

Appropriateness of exam (patient age, recent imaging exams, exam type)

PC.01.03.01 EP 26

Imaging protocols are reviewed, kept current. Input is provided by an interpreting MD, medical physicist, and imaging technologist.* Protocols are reviewed per established timeframes

PI.02.01.01 EP 6

Incidents where radiation dose indices exceeded expected dose index range are reviewed and analyzed. These incidents are compared to external benchmarks

Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services.

* = Frequent area of noncompliance Updated April 2020

Modality: Nuclear Medicine (NM) & Positron Emission Tomography (PET)

Requirement: Areas to assess: Yes No Comment Initials

EC.02.02.01 EP 6

(Applies to NM, PET)

Minimizes risk associated with selecting, handling, storing, transporting, using and disposing of radioactive materials

EC.02.02.01 EP 17

PET, Fluoroscopy)

Dosimetry monitoring results reviewed quarterly by radiation safety officer, diagnostic medical physicist, health physicist; assess ALARA

EC.02.02.01 EP 18

(Applies to deemed:

CT, NM, PET,

fluoroscopy, x-ray)

Radiation workers checked periodically for amount of radiation exposure

NM, MRI, x-ray and fluoroscopy)

Identifies activities and frequencies in writing for maintaining, inspecting and testing all medical equipment on inventory

NM, MRI, x-ray and fluoroscopy)

Deemed: Maintenance, inspection

NM, MRI and fluoroscopy)

Equipment quality control and maintenance activities are identified

NM, and MRI)

Equipment quality control and

EC.02.04.03 EP 1

(Applies to MRI, CT, NM,PET, x-ray, Fluoroscopy, Performs safety, operational, functional checks Non-deemed: before initial use.

Deemed: Before initial use and after major repairs or upgrades

Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services.

Modality: Nuclear Medicine (NM) & Positron Emission Tomography (PET)

EC.02.04.03 EP 16

(Applies to NM, PET)

Qualified staff inspect, test and calibrate NM equipment annually.

Results, completion dates documented.

EC.02.04.03 EP 23

(Applies only to NM)

A performance evaluation is performed annually by a medical physicist or nuclear medicine physicist and includes all required tests.

Evaluation/ testing results and

EC.02.04.03 EP 24

(Applies only to PET)

A performance evaluation that includes all required tests is performed annually by a medical physicist Evaluation/testing results and

NM, and MRI)

A performance evaluation that includes all required tests and parameters is performed on each image acquisition monitor annually by a medical physicist or MRI scientist (for MRI only)

EC.02.06.05 EP 4

NM)

Structural shielding assessment prior to installation of new/replacement of existing imaging equipment; rooms where ionizing radiation emitted or radioactive material stored, medical or health physicist

EC.02.06.05 EP 6

NM)

Radiation protection survey to verify adequacy of shielding after installation of imaging equipment or construction by medical or health physicist

MM.06.01.01 EP 13

(Applies to Nuclear Medicine)

Verified dose is within 20% prescribed dose or range

Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services.

Modality: Nuclear Medicine (NM) & Positron Emission Tomography (PET)

MS.03.01.01 EP 16

(Applies to CT, NM.

PET, x-ray, fluoroscopy)

Deemed: Medical staff determines qualifications radiology staff who use equipment & administer procedures

MS.03.01.01 EP 17

(Applies to NM, PET)

Deemed: Approves nuclear services doctor qualifications, training, functions, responsibilities NM staff

Use this tool to assess your organization’s compliance with The Joint Commission’s requirements that relate to the provision of imaging services.

Modality: Fluoroscopy

NM, MRI, x-ray and fluoroscopy)

Deemed: Maintenance, inspection

NM, MRI and fluoroscopy)

Equipment quality control and maintenance activities are identified

EC.02.04.03 EP 34

(Applies to fluoroscopic units)

A performance evaluation that includes all required tests is performed annually by a diagnostic medical physicist. Evaluation/testing results are documented

PC.01.02.15 EP 13

(Applies to fluoroscopy)

Cumulative air kerma, kerma area product (fluoroscopy time, number of spot films) documented in retrievable format

Miscellaneous

Requirement Areas to assess: Yes No Comment Initials

LD.04.01.05 EP 25

(applies if any radiologic services are provided)

Designated radiation safety officer with authority and responsibilities as described