Inpatient Facility Coding & Compliance Alert

Wield your imaging edge by gauging your preparations

Joint Commission (JCAHO) announced in December 2013 that revised safety requirements for facilities providing diagnostic imaging services to be implemented July 1, 2014, with further changes to be phased in during 2015. The changes will still come to every facility offering diagnostic imaging services, but now you have some extra time before implementation. 

Refresher: According to press releases from Joint Commission, the 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 JCAHO requirements, such as those related to magnetic resonance imaging (MRI). 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.”

Current status: In its endeavor to uphold and advance the quality and safety standards, JCAHO analyzed the feedback from key stakeholders and concluded that some issues related to quality, safety and evolution of health care delivery practices require further evaluation and research.

To ensure that the new standards comprehensively promote the safety and quality, the implementation has been delayed for a year.

The revised standards will now be released en bloc in 2015, rather than as a partial roll out in 2014 and 2015.However, experts predict that most of the 2014 proposed requirements would be implemented verbatim. The first phase was to focus on CT, nuclear medicine, PET and MRI. The second phase will focus on minimum qualifications for clinicians to carry out the imaging procedures, fluoroscopy, and cone beam CT used in dental practices and maxillofacial surgery facilities.

The final version will be posted on the JCAHO website for six months until the identified implementation date. Critical safety areas being addressed include radiation dosage documentation, equipment performance evaluation, entry level qualifications of technologist performing CT.

See for yourself: To learn more, visit http://www.jointcommission.org/standards_information/prepublication_standards.aspx. The site includes the following information on the standards update: 

In order to finalize a single set of standards in 2015, we are collecting additional information about several critical areas of radiation safety. The critical areas include:

• Documentation of the radiation dose.
• Annual equipment performance evaluations by a medical physicist or Magnetic Resonance scientist.
• Minimum qualifications for radiologic technologists who perform computerized tomography (CT) exams.  These requirements were to have become effective July 1, 2015.  Since this subject is covered in the now postponed revised requirements, this date is also no longer effective.
• Requirements that align with the State of California’s CT law.

Send feedback at imagesafety@jointcommision.org.