Joint Commission’s 2015 Diagnostic Imaging Requirements

The Joint Commission (TJC) released its updated Diagnostic Imaging Requirements on August 10, 2015. The new guidelines address several issues related to patient and staff safety, staff education, and CT Dose monitoring.  A copy of the requirements can be obtained here.

While many of the new requirements are process oriented (i.e., documenting staff training) other elements require new capabilities and/or skills, formal protocol review by radiologists, physicists, and lead imaging staff, as well as the incorporation of the new XR-29 standards for dose monitoring for XR-29 compliant equipment.

Dose monitoring can be classified as two types:  pre-exam alerts and post-exam “incident” identification.  XR-29 standards primarily address the pre-exam alert requirement.  However, XR-29 compliant scanners do little towards meeting the Joint Commission’s Element of Performance PI.02.01.01 A6 which requires post-exam identification of high dose exams. PI.02.01.01 A6 requires organizations to:

  1. Review and analyze incidents where the radiation dose index from diagnostic CT examinations exceeds expected dose index ranges established for your protocols; and then,
  2. Compare these incidents to external benchmarks.

How do you plan to identify high dose incidents?


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