From the Joint Commission in response to a question related to PI.02.01.01
The ACR DIR provides benchmark data. The intent of PI.02.01.01 is to ensure that the organization is committed to dose optimization and stays current with standard of practice. Since the frequency of data collection and analysis is under the organization’s purview, participation in the ACR DIR would meet compliance with PI.02.01.01.
- This is a general statement about compliance, and is not a guarantee of “no finding” at PI.02.01.01 on an individual survey.
- There are other ways to comply with PI.02.01.01.
http://www.acr.org/Quality-Safety/National-Radiology-Data-Registry/Dose-Index-Registry (Retrieved October 18, 2015)
It is important to point out the DIR satisfies TJC’s requirement to compare dose incidents against and external benchmark. However, the DIR does not natively identify individual dose incidents (i.e., studies which exceeded their expected dose range). Facilities still need to develop a process to establish expected dose ranges for their CT studies and then identify any study that exceed its expected range.