Inpatient Facility Coding & Compliance Alert

Changes to be implemented in two phases beginning July 2014.

Diagnostic imaging standards for accredited hospitals, critical access hospitals, and other facilities will be changing in 2014, according to a mid-December announcement from The Joint Commission. Every hospital needs to be aware of the changes that become effective July 1, 2014, with additional requirements planned to be phased in by 2015.

Quality and Safety Are Primary Focuses

The standards changes relate to either quality and safety issues that were needed to more fully address the evolution of health care delivery practices, or expanding upon the current Joint Commission requirements, such as those related to magnetic resonance imaging (MRI). A Joint Commission press release stated that the revisions incorporate recommendations from diagnostic imaging experts, professional associations, and accredited organizations regarding areas that affect the safe delivery of diagnostic imaging services.

“With these updates, The Joint Commission’s goal is to ensure that our imaging standards remain up-to-date and sufficiently address quality and safety,” said Margaret VanAmringe, MHS, executive vice president of public policy and government relations for The Joint Commission. “These rigorous imaging standards address overall patient safety, oversight of imaging services, staff competency, radiation safety procedures, equipment maintenance and quality control. This system evaluation seeks to ensure that organizations providing imaging services have the requisite infrastructure and safety culture to minimize radiation exposure to patients and staff and provide safe and effective care.”

Be Aware of Necessary Changes

Your first step in preparing for the new standards is to assess where your facility currently stands in the affected areas. The Joint Commission says the new and revised standards will include:

• Minimum competency for radiology technologists, including registration and certification by July 1, 2015
• Annual performance evaluations of imaging equipment by a medical physicist
• Documentation of CT radiation dose in the patient’s clinical record
• Meeting the needs of the pediatric population through imaging protocols and considering patient size or body habitus when establishing imaging protocols
• Management of safety risks in the MRI environment
• Collection of data on incidents where pre-identified radiation dose limits have been exceeded.

Time line: Because of the scope of this work, standards changes will be addressed using a phased approach. These initial standards changes represent phase one, which focus on computed tomography (CT), nuclear medicine (NM), positron emission tomography (PET), and magnetic resonance imaging (MRI) services. Phase two, which will be implemented in 2015, will focus on fluoroscopy, minimum qualifications for clinicians who perform imaging exams, and cone beam CT used in dental offices and oral-maxillary surgery practices.

Resource: The new and revised elements of performance are available on the Joint Commission’s website. (www.jointcommission.org; click on “Standards,” then “Prepublication Standards” to access detailed information). The requirements will be published in the 2014 Ambulatory Care, Critical Access Hospital, and Hospital Comprehensive Accreditation Manuals scheduled for publication in March 2014 and in the spring 2014 E-dition^® update.