New Fluoroscopy Requirements

For organizations providing fluoroscopy services, there are revised standards. Although an article details the new fluoroscopy requirements, they are not published in Perspectives. Instead, go to the Joint Commission website and download them from the standards prepublication page.

New Fluoroscopy Requirements

The first revised fluoroscopy services standard is EC.02.04.03, EP 21. Strangely, it does not discuss fluoroscopy, but rather CT. EP 21 currently requires 11 physicist-performed annual tests. It covers the proper functioning of CT equipment using 11 unique terms. These terms are frequently difficult to identify in the physicist’s annual report.

In fact, in 2019 TJC will eliminate the requirements for “slice thickness accuracy and slice position accuracy.” Scout prescription accuracy will replace this term. Share this prepublication list with your employed or contracted physicist. And, ask them to use the terminology in the EP or provide you with a cross walk table between the TJC term and the terms they use instead.

There is also a new EP 34 which is like the CT requirement. It requires another physicist report on the fluoroscopy equipment detailing seven specific performance characteristics. And, they must be evaluated and described in the physicist’s report.

This EP also has two notes associated with it. First, it authorizes the physicist to use supportive personnel in conducting the evaluation, providing these personnel have the training and skills required by the physicist. Bear in mind, if you use such support personnel, the surveyor will want to see the training requirements. Plus, the need evidence that the individual has met those requirements.

The second note indicates that this new EP does not apply to fluoroscopy equipment used for therapeutic radiation treatment planning.

Another CT Services Revision

There is a revised HR.01.05.03, EP 14, again referencing CT services. This EP discusses the Image Gently and Image Wisely low dose training requirement. There is a simple change removing the term technologists and replacing it with “individuals.” Then the new EP 15 establishes a requirement for “individuals” who perform fluoroscopy services. They must acquire knowledge obtained from the Image Gently, Image Wisely online education. The Joint Commission describes the requirement for “individuals” as applying to technologists, physicians and ancillary personnel.

We must mention that on consultative surveys we find some hospitals use the online Image Gently, Image Wisely programs. Others try to provide similar content using locally developed programs. If you develop your own program, include some reference to or evaluation of the content, as compared to the “brand name” product. Also, documentation of this training usually resides in the departmental employee competency file.

What’s more, doctors typically do no have a departmental competency file. Consequently, with the addition of physicians in the EP, you will want to determine how you will document evidence of this type of training.

Radiation Safety Officer

For many years federal requirements mandated a radiation safety officer. Now there is a new EP 25 at LD.04.01.05, establishing the requirement to have a radiation safety officer.

A new EP 13 at PC.01.02.15 will establish a requirement to have a cumulative air kerma or kerma-area product documented in a retrievable format. The Joint Commission specifies an acceptable alternative if your fluoroscopy equipment cannot display this. Instead, document fluoroscopy time and the number of images acquired in a retrievable format.

We assume that most of you, like us, are now wondering, “What is air kerma?” We looked it up in Wikipedia. Generally speaking, it is some measure of ionizing radiation. Your radiology staff and physicist will understand the terminology. Plus, they will know if your equipment can display that information.

CT Imaging Protocols

PC.01.03.01, EP 25 is revised in its format but not its content. Previously this EP described the requirements for CT imaging protocols. It included five content requirements separated by commas. The new EP 25 bullets out the five requirements as:

• Clinical indication
• Contrast administration
• Age, to indicate pediatric or adult
• Patient size and body habitus
• Expected radiation dose index range

So, you may be wondering about the significance of this formatting change. Here’s our advice. If TJC bullets out five specific requirements, then you better make sure to spell out all five your CT protocol requirements. The five bullets make it more likely that someone might ask to see them, even though they were previously required.

Radiation Exposure

There is a new EP 30 for PC.02.01.01. It establishes a requirement for hospitals that provide fluoroscopy to identify the radiation exposure and skin dose threshold levels. If exceeded, it triggers further review and/ or patient evaluation to assess for adverse effects. Here your radiation safety officer and committee can help establish this threshold.

Lastly there is a new EP 20 for PI.02.01.01. This EP establishes the requirement for hospitals that perform fluoroscopy. If you exceed established skin dose threshold levels you have to review and analyze those instances. So, think of this as one more mandatory PI data element for review. Examinations might occur during document review in your PI book. Or, discussions may occur at the data use system tracer or in the visit to radiology.

Furthermore, here is the most important aspect of preparing for these fluoroscopy changes. Start discussions with your radiology staff, physicist, and radiation safety committee now. Implementing the fluoroscopy requirements must occur by January 1, 2019. We encourage readers to put together an evidence binder with these new requirements. Include a paragraph for each one describing what your hospital did to implement each new requirement. These are very detailed and very technical requirements. They compare to the last round of radiology standards implemented in 2016.

We visit many organizations where we interview the radiology staff. They know somebody worked on the requirements but, that person is not here today. And, no one knows about the completed work.

So, put together the suggested evidence book. Regardless of who is on duty, any of the radiology administrative or section heads, they can point to the book and use it to inform the surveyor about your processes.

Patton Healthcare Consulting

Patton Healthcare Consulting provides Joint Commission Compliance Assistance including support on fluoroscopy requirements. We offer a full range of pre-survey and post survey services to healthcare organizations.