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Joint Commission Annual Fluoro Training Requirements May Be Rescinded Soon

Thought you might find this interesting.  This was sent to me earlier today.  Looks like TJC will soon announce they are rescinding the annual fluoroscopy education requirements. Stay tuned!

Michael Bohl
Dose Registry Support Services


Sent: Thursday, June 13, 2019 12:48 PM
To: Michael Bohl

Subject: TJC fluoro training

From a recent release:

(To be published in the August 2019 Perspectives)

Effective immediately, The Joint Commission is deleting Standard HR.01.05.03, element of performance (EP) 15 from the Ambulatory Care, Critical Access Hospital, Hospital, and Office-Based Surgery programs.

For reference, the text of the deleted EP is as follows:

Standard HR.01.05.03, EP 15: The  verifies and documents that individuals (including physicians, non-physicians, and ancillary personnel) who use fluoroscopic equipment participate in ongoing education that includes annual training on the following: 
 – Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® and Image Wisely® campaigns 
 – Safe procedures for operation of the types of fluoroscopy equipment they will use 
 Note 1: Information on the Image Gently and Image Wisely initiatives can be found online at http://www.imagegently.organd
 Note 2: This element of performance does not apply to fluoroscopy equipment used for therapeutic radiation treatment planning or delivery.

Since the launch of HR.01.05.03, EP 15 on January 1, 2019, The Joint Commission has determined through stakeholder and customer feedback that this requirement is redundant to other accreditation requirements and would be burdensome to conform with annually. Therefore, an annual training requirement will not be required, and an  assessment of staff and physician competency to provide fluoroscopy services will continue to be assessed during the on-site survey using accreditation standards that currently exist in the “Human Resources” and “Medical Staff” chapters.

This deletion will be posted on The Joint Commission website at It will no longer be part of the Comprehensive Accreditation Manuals for the above programs as of the January 2020 E-dition® update and January 2020 hard copy publications.  

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