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Joint Commission Confirms Facilities Need an Expected Dose Range for All CT Protocols; Note to Self: XR-29 Does NOT Equal TJC Compliance

The following question was submitted to the Joint Commission:

Must we establish an expected dose range for every imaging protocol or can we pick and choose the protocols for which we establish expected dose ranges and monitor only those? I interpret [PI.02.01.01.A.6.] to require monitoring of every protocol we use, not just some portion of them.

The Joint Commission response:

All protocols need to have an expected dose index range included. For protocols that are of similar anatomical areas, I have suggested that a general range (like the AAPM alert levels or ACR Pass/Fail levels) be used. As data is collected, analyzed and benchmarked then the expected dose index range can be refined.

Associate Director Standards Interpretation Group, Standards Interpretation Division of Healthcare Improvement Group The Joint Commission


Dose Registry Support Services Discussion: The reason we asked this question is to confirm my suspicion that XR-29, by itself, does not meet TJC’s dose incident identification requirement UNLESS facilities enter a dose range for every protocol they use, AND THEN have the ability to check the dose threshold UPON COMPLETION of the exam, which is much different than the XR-29 which often only test a subset of protocols and issues pre-scan alerts or notifications. Additionally, most XR-29 solutions do not establish a lower threshold in the system.  By definition, a “range” requires both an upper and lower threshold.  This was also confirmed with TJC during RSNA.  In summary, be very careful if you plan to depend solely on your scanner’s XR-29 capabilities to meet TJC’s Dose Incident Identification requirements.  It may not be set up to test doses on every protocol you use.

We have developed an effective, low cost solution for establishing both an upper and lower threshold dose range as well as identifying “dose Incidents” in which an exam exceeded the threshold.  The only requirement:  Participation in the ACR’s Dose Index Registry.  Contact us to learn more.