Inpatient Facility Coding & Compliance Alert

Weigh in with your feedback to Joint Commission by Oct. 24.

If you missed the Sept. 16 news, Joint Commission posted the long-awaited revisions to diagnostic imaging standards for feedback from hospitals, clinicians and radiology staff. Read on to learn more about the proposed changes and how you can voice your opinion.

Background: Earlier this year, Joint Commission postponed the implementation of new and revised diagnostic imaging requirements for accredited hospitals, critical access hospitals, and ambulatory care organizations that provide diagnostic imaging services. The group’s reasoning was that further research was needed to adequately ensure quality and relevance of the standards. Now, in an endeavor to uphold and evolve further the quality and safety standards, Joint Commission has come up with changes that address the following areas:

• Minimum qualifications for radiologic and nuclear medicine technologists that perform computed tomography (CT) exams. 
• Orientation of technologists on safe practices related to the provision of diagnostic imaging
• Documentation of CT radiation dose.

Absorb the Impact of the Change

So how are the hospitals currently responding to this big news? “The impact of these changes will vary considerably depending upon the hospital’s current policies and procedures in this area,” says Duane C. Abbey, Ph.D., president of Abbey and Abbey Consultants Inc., in Ames, IA.  “Some hospitals will need to make slight modifications to their policies and procedures, while others will need to develop additional P&Ps.  For some hospitals, implementing these changes will be expensive,” he adds.  “If there is a way to generate interest in commenting, it would be from the financial impact of implementing the new requirements. While there is only a hint relative to archiving images and/or tests, this is an area that needs to be addressed. “

Sneak a Quick Look: What’s In and What’s Not

Proposed changes focus on highly technical areas of radiation safety. Here is a summary of the Joint Commission’s proposed revisions for diagnostic imaging standards for accredited hospitals. Highlights include: 

1. Minimum qualification for technologists performing stand-alone diagnostic CT exams stands revised as follows:

a) The technologist is no longer required to be registered and certified in radiography by the American Registry of Radiologic Technologists (ARRT). Credentialing is acceptable, but he can else have the valid state licensure that permits him to perform stand-alone diagnostic CT exams. 

b) Advanced-level certification by ARRT in computed tomography is not mandatory, although it would meet the intent of this element of performance. 

2. The new requirement states that technologists who perform positron emission tomography (PET) or single photon emission computerized tomography (SPECT) combined CT should have at least one of the following qualifications:

a. State licensure that permits them to perform multimodality or fusion imaging exams 

b. Registered and certified in radiography by the ARRT and with additional training in nuclear medicine

c. Certified as a nuclear medicine technologist by the Nuclear Medicine Technology 

Certification Board (NMTCB) with additional training on CT

3. The revision puts the onus on hospitals to orient radiologic technologists who perform CT with ongoing education and annual training that include radiation dose reduction techniques following industry accepted standards. 

4. On the same lines, hospitals must orient the technologists who perform magnetic resonance imaging (MRI) on safe MRI practices. The Joint commission revised standards specifically add that hospitals should orient the staff about “MRI system quench and cryogen safety procedures” as a part of “MRI system emergency shutdown procedures.”  (http://www.astm.org)

5. In the section on diagnostic testing, the Joint Commission revision adds that “The CT radiation dose must be exam-specific, summarized by series or anatomic area, and documented in a retrievable format.” It also cautions that “While the CTDIvol and DLP are useful indicators for monitoring radiation doses emitted by the CT machine, they do not represent the patient’s radiation dose.”

6. The erstwhile requirement for hospitals in California to keep electronic archives of the CT study and protocols page stands deleted now.

7. Information regarding data analysis and compilation has a new clause that requires the hospital to keep a record, review and analyze incidents when the radiation dose during diagnostic CT exceeded the expected dose ranges as per the protocol.

Read the Changes and Submit Feedback

The Joint Commission solicits feedback from clinicians and radiology staff with expertise in diagnostic imaging.  The Joint Commission website also includes separate documents in its standards field review related to: 

- Ambulatory Care proposed revisions for diagnostic imaging 

- Critical Access Hospitals proposed revisions for diagnostic imaging

- Hospitals proposed revisions for diagnostic imaging. 

The revisions in the above documents are presented in strikethrough and underlined bold text within a grey box for easy identification.

You can read the revised documents; submit your comments via an online survey by Oct. 24 or even send a conventional mail by post. You have all the links available at:

www.jointcommission.org/standards_information/field_reviews.aspx?StandardsFieldReviewId=C9K2vcyLB3mFHMTk7hiBm7aLRzbz3AxdZHBivEICNzc=.