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TJC Dose Monitoring Requirements: XR-29 Dose Notifications Don’t Meet Them

When the facility I was working with was exploring using their scanners’ XR-29 Notifications to meet PI 02.01.01.A6 Dose Incident Identification requirements we reviewed the technical elements underpinning XR-29’s Dose Check feature.  After reading them we grew very concerned that XR-29’s dose notifications would not meet TJC’s requirement.  The facility submitted a question to TJC asking about this specific issue.  We were correct to be concerned; TJC’s response indicated XR-29 Dose Notifications don’t meet the requirements.  Here is a copy of their response:


TJC requires facilities establish the expected total dose ranges (CTDIvol, DLP, or SSDE) for each protocol and then test the actual total dose imparted after the exam has been completed to the protocol’s expected total.  The total is across all irradiation events;  this includes the sum of the pre-monitoring, bolus tracking, and then actual scan series dose values.  In the image below that equates to the Total DLP at the top of the image or the sum of the doses listed in the CTDIvol values column. 

Dose Page

There are several ways of complying with TJC’s dose incident identification requirements, some expensive, some free or nearly so. 

You may get lucky and have TJC auditors that don’t yet understand the technical aspects of dose monitoring.  However, this facility did not want to take that chance.  Dose Registry Support Services can provide facilities with a very low-cost, fully TJC compliant program using your DIR data and avoid the expense of purchasing and then operating a third-party software solution. 


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Dose Index Registry Exam Name Mapping Made Easy – On Sale

Reviewing existing exam name RPID mapping assignments is one of the most important Dose Index Registry® (DIR) maintenance tasks facilities should routinely perform. IncorrecBookcovertly mapped studies can result in misleading and/or incorrect Aggregate and Standardized Dose Reports. This guide is written to provide the reader with an easy method of validating your RPID mappings and identifying potentially incorrectly mapped studies for correction using the DIR’s bulk editing feature.  Includes step by step instructions.

The paperback is on sale at for $7.27.

Click here for more information.

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Announcing the Dose Index Registry® Support Services LinkedIn Group

I am renaming and repurposing my LinkedIn radiology management group to concentrate on supporting use of the ACR’s Dose Index Registry ® rather than a general radiology business forum. The new group is named “Dose Index Registry Support Services.” 

If you are a LinkedIn member and would like to join the new group enter Dose Registry Support Services in the search box.  You should see the group listed in the search query. 

Dose Registry Support Services is committed to providing the most cost efficient support available supporting facilities monitor and reduce their CT doses.  In many cases we can save facilities $60,000 to $100,000 or more each year, compared to some other third party-solutions.  

If you are struggling to implement an effective dose monitoring and dose reduction solution, please contact Dose Registry Support Services.   

Michael Bohl

Dose Registry Support Services

* Please note that the Dose Index Registry® Support Services LinkedIn group is not affiliated with or moderated by the American College of Radiology. Dose Index Registry® is a registered trademark of the American College of Radiology.

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CTDIvol vs DLP – a simple explanation

What do they represent? CTDIvol is based on measurements obtained when scanning either a 16cm or 32 cm phantom.   Essentially, it represents scanner output.  DLP is derived from CTDIvol, but incorporates a scan length component.  Both function as reasonable proxies for absorbed dose but do not represent the actual patient dose.  In other words, if your CTDIvol and/or DLP is twice as high as it could be, then the doses you are imparting will be about twice as high as they could be.

Can CTDIvol and DLP results tell me two different things?     Yes.  CTDIvol represents the output when scanning a phantom, while DLP takes into account the scan length.  We’ve seen instances where CTIDvol is considered well within a “normal” range but DLP was unexpectedly high.  We found the scan settings were appropriate for the study, but the exam length  was longer than what others were using.

For example, a Chest CT could be started too high into the neck and end too far into the abdomen.  If this is the case CTDIvol (basic scanner settings) could be just fine, but because scans extended more than necessary above and/or below the requested area, the DLP could easily be too high.


The following information, obtained from, is a more technical discussion of CTDIvol and DLP for those interested.

The following is taken from an article posted on

CT Dose Index Volume (CTDIvol) The CTDIvol can be calculated as: CTDIvol = [(N x T)/I] x CTDIw where CTDIw = weighted or average CTDI given across the field of view N = number of simultaneous axial scans er x-ray source rotation T = thickness of one axial scan (mm) I = table increment per axial scan (mm)

In helical CT the ratio of the I to (N x T) is the pitch; therefore in helical mode:  CTDIvol = (1/pitch) x CTDIw

CTDIvol (or CTDI volume) represents the dose for a specific scan protocol which takes into account gaps and overlaps between the radiation dose profile from consecutive rotations of the x-ray source. Therefore CTDIw represents the average radiation dose over the x and y direction whereas CTDIvol represents the average radiation dose over the x, y and z directions.

Dose Length Product The dose length product (DLP) is the measure of ionizing radiation exposure during the entire acquisition of images.

Therefore, DLP (mGy-cm) = CTDIvol (mGy) x irradiated length (cm) (irradiated length is usually longer than imaged length in helical scanning)

CTDIw and CTDIvol are independent of scan length for determining the total energy absorbed whereas DLP is proportional to scan length.

Need help getting more from your participation in the ACR’s Dose Index Registry® ?  Let Dose Registry Support Services tailor a program designed specifically to help your department succeed.  Contact Dose Registry Support Services to see how we can help.

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DoseID helps facilities identify duplicate and superfluous scanner protocols

One of the more interesting and unique benefits Dose Registry Support Services’ DoseID Program has for facilities is its ability to shed light on duplicate and superfluous protocols in use at their facilities.  DuplicatedProtocols

The table to the right shows how one facility had 7 different protocols being used on a single scanner during a recent 3 month period.  As you can see, all protocols are purportedly for a CT Abdomen/Pelvis without contrast exam, yet they are used with significantly varying frequency.  One is used by staff 714 (79%) of the 903 without contrast studies performed, yet 2 were used just under 40 times and 3 were used five or fewer times.  One has to question why these protocols exist and on what basis is staff choosing the infrequently used protocols.

This creates several issues, from hanging protocols in PACS to patient safety issues.  For example, when it is time to alter the protocol will whomever is updating the scanner parameters really change all 7 protocols?  This is important as facilities review their Dose reports and begin to make protocols changes to lower patient doses.

This is a widely recognized issue within the industry.  In its 2016-2017 development cycle Integrating the Healthcare Enterprise (IHE) is developing a new profile titled Enterprise Scanner Protocol Management to address this very issue.  Click here for more information on IHE’s initiative.

The good news is that because of the information contained in our reports, we are able to help them identify and eliminate duplicate and superfluous scanner protocols.

Need help getting more from your participation in the ACR’s Dose Index Registry® ?  Let Dose Registry Support Services tailor a program designed specifically to help your department succeed.  Contact Dose Registry Support Services to see how we can help.



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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.