The Joint Commission Releases New Fluoroscopy Requirements

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The Joint Commission Releases New Fluoroscopy Requirements

What you need to know

The Joint Commission will require ASCs to meet several new elements of performance (EP) primarily focused on fluoroscopy starting January 1, 2019. The new requirements will be applicable to accredited ASCs, office-based surgery (OBS) practices and hospital organizations that provide fluoroscopy services to their patients.

Joyce Webb, RN, project director in the Department of Standards and Survey Methods at The Joint Commission, explained the changes ASC can expect with the new and revised fluoroscopy requirements.


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Tell me about the new requirements.

WEBB: Seven new requirements will become effective in January 2019. Most of the changes focus on fluoroscopy, and one deletes the requirement to perform slice thickness accuracy testing on computed tomography (CT) units.

Joyce Webb

Joyce Webb, RN

Of the seven changes, one requires ASCs to establish a radiation safety officer. This officer will be expected to have responsibility, accountability and authority. Many ASCs already have a radiation safety officer in place, however, they must make sure that this officer has the specific authority to step in and implement safety measures if needed.

Other changes require ASCs to perform specific equipment checks and provide staff and physician training on how to effectively manage radiation exposure to pediatric and adult patients. They require ASCs to capture radiation exposure and document it in a way that it can be retrieved. In addition, the changes require ASCs to identify thresholds for radiation exposure levels and determine when further review and analysis is needed, when those thresholds are exceeded.

Why the changes and why now?

WEBB: The use of imaging continues to grow in ASCs. This is just part of The Joint Commission’s ongoing effort related to imaging. It is a big area, with many modalities, so we are using a phased approach to this work. We issued a few standards changes focused on CT, magnetic resonance imaging (MRI), positron-emission tomography (PET) and nuclear medicine (NM) in 2015; we issued two standards applicable to fluoroscopy that became effective in January 2018; and now we are issuing these seven more standards that will become effective in January 2019.

Who will be affected by the change?

WEBB: These requirements are applicable to ASCs that provide imaging services, hospitals and office-based surgery (OBS) practices.

What do ASCs need to know?

WEBB: ASCs need to know their current processes for the use and monitoring of dosimetry. Are the badges consistently used or stored properly? These points were raised through The Joint Commission’s research, which involved discussions with imaging experts and feedback from a field review when the standards were posted for public comment. ASCs need to know who is checking their fluoroscopy units to make sure that they are working properly; how often their fluoroscopy units are checked; what tests are performed on the equipment; how the test results are documented; what recommendations were made following the equipment checks; and if any needed follow-up was completed. ASCs need to learn the details of their equipment tests/checks. Tests should not be noted just with one line of verbiage but documented in detail noting the specific tests performed and whether anything needed to be repaired/fixed/recalibrated. For annual equipment performance evaluations, ASCs will have until January 2020 to demonstrate compliance. The same is true for compliance with the newly required annual staff training.

ASCs need to understand the capability of their fluoroscopy equipment and whether it can capture radiation exposure metrics. The Joint Commission understands that some older equipment, legacy units, may not have the capability to capture radiation exposure in the required metrics. If an ASC owns older equipment that cannot capture the required metrics, it will need to document the fluoroscopy time and the number of images captured.

Surgery centers also need to identify and establish guidelines for radiation exposure thresholds that warrant patient follow-up. They need to understand their processes for reviewing and analyzing when radiation exposure thresholds are exceeded, to see if there are opportunities for performance improvement.

Surveyors will be checking for compliance with these new requirements beginning January 1, 2019. And by January 2020, ASCs will need to demonstrate compliance with the new requirements that address annual equipment tests and staff training.

Any tips on how to successfully meet the new requirements?

WEBB: ASCs need to go to The Joint Commission website and download the pre-publication standards, become familiar with the requirements and share them with their team. They can use those standards to identify what processes they have in place and determine if any need to be established. ASCs should review documentation related to equipment checks and quality check (QC) logs. If they contract this work out, they need to determine who is conducting the performance evaluation and make sure the equipment tests that they perform are properly documented. This may require making some policy changes because certain ASCs might have historically received one line of verbiage instead of a detailed report communicating equipment check performance evaluation results. With the new requirements, each fluoroscopy unit will need annual performance evaluations and documentation of any recommendations, if any, for each unit.

Surgery centers also need to ensure that all physicians and staff receive required training. Often, ASCs focus on staff training but not physician training. However, if physicians will operate the equipment, they will need to be trained. Also, ensure mid-level providers, such as radiology assistants and part-time employees receive the required training. It is best not to assume anyone knows how to operate the equipment. To support patient safety, all staff physicians need to know how to operate the equipment.

Lastly, ASCs should review the job description of their radiation safety officer to make sure that it sufficiently addresses the expectations for responsibility, accountability and authority.