For organizations performing fluoroscopy services, there are new requirements effective July 1, 2018.
We don’t believe you will find the requirements challenging. But, since the article combines changes to the ambulatory care, critical access hospital, hospital and office based surgery accreditation programs, it is a bit confusing.
Fluoroscopy Services Requirements Defined
The change for the hospital program is in the “catch all” EP for radiation safety, under EC.02.02.01, EP 7. So, why do we use the term “catch all?” Because this EP requires the hospital to minimize risks associated with using hazardous sources of radiation. In fact, the EP covers many different issues including failure to:
- Monitor lead shield integrity
- Wear a dosimetry badge
- Check badge use
TJC added a Note 2. It states, “This includes the use of proper shielding during fluoroscopic procedures.” Since it is a “catch all” EP, we assumed it already covered fluoroscopy.
Nevertheless, share this article with your radiology staff to ensure they are know the requirement.
Do you need Joint Commission compliance assistance? Give us a call at 888-742-4621 to discuss your needs or contact us to learn more.