New Joint Commission Fluoroscopy Requirements for January 2019 - Bio-Med Associates Medical Physics Consulting

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New Joint Commission Fluoroscopy Requirements for January 2019

Bio-Med Associates is capable of providing annual medical physics coverage for the performance of Joint Commission-required testing.

As of January 2019, Joint Commission will require, for hospitals that provide fluoroscopic services:

At least annually, a diagnostic medical physicist conducts a performance evaluation of fluoroscopic imaging equipment. The evaluation results, along with recommendations for correcting any problems identified, are documented. The evaluation includes an assessment of the following:

Beam alignment and collimation
Tube potential/kilovolt peak (kV/kVp) accuracy
Beam filtration (half-value layer)
High-contrast resolution
Low-contrast detectability
Maximum exposure rate in all imaging modes
Displayed air-kerma rate and cumulative-air kerma accuracy (when applicable)

Joint Commission will also require that the hospital designates an individual to serve as the radiation safety officer who is responsible for making certain that radiologic services are provided in accordance with law, regulation, and organizational policy. This individual has the necessary authority and leadership support to do the following:

Monitor and verify compliance with established radiation safety practices (including oversight of dosimetry monitoring)
Provide recommendations for improved radiation safety
Intervene as needed to stop unsafe practices
Implement corrective action

We offer to serve as the Radiation Safety Officer for Radiologic Services. Bio-Med personnel can be onsite to oversee the entire radiologic program to ensure total compliance with new Joint Commission standards.

As of January 2019, Joint Commission will require, for hospitals that provide fluoroscopic services: The cumulative-air kerma or kerma area product are documented in a retrievable format. For fluoroscopy equipment that cannot display or provide cumulative-air kerma or kerma-area product, fluoroscopy time and number of images acquired are documented in a retrievable format, such as a picture archiving and communication system.

Note: This element of performance does not apply to fluoroscopy equipment used for therapeutic radiation treatment planning or delivery.

Bio-Med's state-of-the-art equipment can measure and evaluate the displayed fluoro doses to ensure safety during procedures.

As of January 2019, Joint Commission will require, for hospitals that provide fluoroscopic services: The hospital identifies radiation exposure and skin dose threshold levels, that if exceeded, trigger further review and/or patient evaluation to assess for adverse radiation effects.

Note 1: Information on radiation exposure thresholds can be found in the National Council on Radiation Protection (NCRP)’s report number 168 and on the Food and Drug Administration’s (FDA) Center for Devices for Radiological Health (CDRH) website.

Note 2: Radiation exposure thresholds may be established based on metrics such as reference-air kerma, cumulative-air kerma, kerma-area product, or fluoroscopy time. (See also PI.02.01.01, EP 20)

For hospitals that provide fluoroscopic services: The hospital reviews and analyzes instances where the radiation exposure and skin dose threshold levels identified by the organization are exceeded.

Note: Radiation exposure thresholds may be established based on metrics such as reference-air kerma, cumulative-air kerma, kerma-area product, or fluoroscopy time. (See also PC.02.01.01, EP 30)

Bio-Med Associates' highly skilled physicists can assist in implementing dose threshold levels and patient dose calculations when necessary. All in accordance with national references.