Compliance Checklist: Joint Commission’s Imaging Standards

1 Compliance Checklist: Joint commission 's Imaging Standards Use this tool to assess your organization's Compliance with The Joint commission 's requirements that relate to the provision of Imaging services. Modality: Magnetic Resonance Imaging (MRI). Requirement: Areas to assess: Yes No Comment Initials EP 14 Processes are in place to address the (Applies only to MRI) following MRI safety risks (staff can describe processes for): - patients with claustrophobia, anxiety, emotional distress -urgent/emergent patient care needs -patients with medical implants, devices, embedded metallic objects -preventing entry of ferromagnetic objects into MRI are a (only MRI-safe equipment fire extinguishers)*. -protecting patients from acoustic noise EP 16 Access to the MRI area is restricted.*. (Applies only to MRI) -all staff and patients are screened prior to entering the MRI area.*. -there are controls in place to prevent unauthorized access to the MRI area*.

2 -warning signage is posted at the entrance to the MRI scanner*. -signage is posted indicating that the magnet is always on (as applicable)*. EP 4 Identifies activities and frequencies in (Applies to CT, PET, writing for maintaining, inspecting and NM, MRI, x-ray and testing all medical equipment on inventory fluoroscopy). EP 10 Equipment quality control and (Applies to CT, PET, maintenance activities are identified NM, MRI and Timeframes are established for how often fluoroscopy) they are to be done EP 18 Equipment quality control and (Applies to CT, PET, maintenance activities are done NM, and MRI) QC logs are complete*. EP 22 A performance evaluation is performed (Applies only to MRI) annually by an MRI scientist, and includes all required tests. Evaluation/ testing results and recommendations are documented. 1. * = Frequent area of noncompliance Updated April 2020. Compliance Checklist: Joint commission 's Imaging Standards Use this tool to assess your organization's Compliance with The Joint commission 's requirements that relate to the provision of Imaging services.

3 Modality: Magnetic Resonance Imaging (MRI). Requirement: Areas to assess: Yes No Comment Initials EP 25 A performance evaluation that (Applies to CT, PET, includes all required tests and NM, and MRI) parameters is performed on each image acquisition monitor annually by a medical physicist or MRI scientist (for MRI only). EP 25 Documentation of staff annual training (Applies only to MRI) and ongoing education on all required topics is available EP 34 Data is collected on any MRI-related (Applies only to MRI) patient thermal injuries EP 35 Data is collected on: (Applies only to MRI) -incidents where have unintentionally entered the MRI scanner room -injuries resulting from the presence of ferromagnetic objects in the MRI. scanner room 2. * = Frequent area of noncompliance Updated April 2020. Compliance Checklist: Joint commission 's Imaging Standards Use this tool to assess your organization's Compliance with The Joint commission 's requirements that relate to the provision of Imaging services.

4 Modality: Computed Tomography (CT). Requirement: Areas to assess: Yes No Comment Initials EP 17 Dosimetry monitoring results reviewed (Applies to CT, NM, quarterly by radiation safety officer, PET, Fluoroscopy) diagnostic medical physicist, health physicist; assess ALARA. EP 18 Radiation workers checked (Applies to CT, NM, periodically for amount of radiation PET, Fluoroscopy, x-ray) exposure EP 4 Identifies activities and frequencies in (Applies to CT, PET, writing for maintaining, inspecting and NM, MRI, x-ray and testing all medical equipment on fluoroscopy) inventory EP 5 Deemed: Maintenance, inspection (Applies to CT, PET, testing in accordance with NM, MRI, x-ray and manufacturer's recommendations fluoroscopy). EP 10 Equipment quality control and (Applies to CT, PET, NM, maintenance activities are identified MRI and fluoroscopy) Timeframes are established for how often they are to be done EP 18 Equipment quality control and (Applies to CT, PET, NM, maintenance activities are done and MRI) QC logs are complete*.

5 EP 20 At least annually: (Applies only to CT) - the CTDI is measured for adult brain, adult abdomen, pediatric brain, and pediatric abdomen, or other commonly used protocols and - the radiation dose for each protocol is verified to be within 20% of dose displayed -the measurements and dose verifications are done by a medical physicist 3. * = Frequent area of noncompliance Updated April 2020. Compliance Checklist: Joint commission 's Imaging Standards Use this tool to assess your organization's Compliance with The Joint commission 's requirements that relate to the provision of Imaging services. Modality: Computed Tomography (CT). Requirement Areas to assess: Yes No Comment Initials EP 21 A performance evaluation is (Applies only to CT) performed annually by a medical physicist and includes all required tests. Evaluation/ testing results and recommendations are documented. EP 25 A performance evaluation that (Applies to CT, PET, includes all required tests and NM, and MRI) parameters is performed on each image acquisition monitor annually by a medical physicist or MRI scientist (for MRI only).

6 EP 4 A structural radiation shielding design (Applies to CT, PET, assessment is conducted prior to and NM) Imaging equipment installation or room modification The survey is conducted by a medical physicist or health physicist EP 6 A radiation protection survey is (Applies to CT, PET, conducted after installation of Imaging and NM) equipment or construction The survey is done prior to clinical use of the room and is conducted by a medical physicist or health physicist EP 32 Documentation is available for (Applies only to CT) verification of specified qualifications for each technologist who performs diagnostic CT exams EP 33 Documentation is available of (Applies only to CT) verification of specified qualifications for each medical physicist supporting CT services 4. * = Frequent area of noncompliance Updated April 2020. Compliance Checklist: Joint commission 's Imaging Standards Use this tool to assess your organization's Compliance with The Joint commission 's requirements that relate to the provision of Imaging services.

7 Modality Computed Tomography (CT). Requirement Areas to assess: Yes No Comment Initials EP 14 Documentation of staff annual training (Applies only to CT) and ongoing education is available. The training includes: -radiation dose optimization techniques -safe operation of CT equipment they will use EP 5 Radiation dose index is documented (Applies only to CT) for on every CT exam. The dose index is exam specific, summarized by series or anatomic area and retrievable EP 12 Appropriateness of exam (patient age, (Applies to CT, PET, recent Imaging exams, exam type). NM, MRI). EP 26 Imaging protocols are reviewed, kept (Applies only to CT) current. Input is provided by an interpreting MD, medical physicist, and Imaging technologist.*. Protocols are reviewed per established timeframes EP 6 Incidents where radiation dose indices (Applies only to CT) exceeded expected dose index range are reviewed and analyzed.

8 These incidents are compared to external benchmarks 5. * = Frequent area of noncompliance Updated April 2020. Compliance Checklist: Joint commission 's Imaging Standards Use this tool to assess your organization's Compliance with The Joint commission 's requirements that relate to the provision of Imaging services. Modality: Nuclear Medicine (NM) & Positron Emission Tomography (PET). Requirement: Areas to assess: Yes No Comment Initials EP 6 Minimizes risk associated with (Applies to NM, PET) selecting, handling, storing, transporting, using and disposing of radioactive materials EP 17 Dosimetry monitoring results reviewed (Applies to CT, NM, quarterly by radiation safety officer, PET, Fluoroscopy) diagnostic medical physicist, health physicist; assess ALARA. EP 18 Radiation workers checked periodically (Applies to deemed: for amount of radiation exposure CT, NM, PET, fluoroscopy, x-ray). EP 4 Identifies activities and frequencies in (Applies to CT, PET, writing for maintaining, inspecting and NM, MRI, x-ray and testing all medical equipment on fluoroscopy) inventory EP 5 Deemed: Maintenance, inspection (Applies to CT, PET, testing in accordance with NM, MRI, x-ray and manufacturer's recommendations fluoroscopy).

9 EP 10 Equipment quality control and (Applies to CT, PET, maintenance activities are identified NM, MRI and Timeframes are established for how fluoroscopy) often they are to be done EP 18 Equipment quality control and (Applies to CT, PET, maintenance activities are done NM, and MRI) QC logs are complete*. EP 1 Performs safety, operational, (Applies to MRI, CT, functional checks NM,PET, x-ray, Non-deemed: before initial use. Fluoroscopy, Deemed: Before initial use and after major repairs or upgrades 6. * = Frequent area of noncompliance Updated April 2020. Compliance Checklist: Joint commission 's Imaging Standards Use this tool to assess your organization's Compliance with The Joint commission 's requirements that relate to the provision of Imaging services. Modality: Nuclear Medicine (NM) & Positron Emission Tomography (PET). Requirement: Areas to assess: Yes No Comment Initials EP 16 Qualified staff inspect, test and (Applies to NM, PET) calibrate NM equipment annually.)

10 Results, completion dates documented. EP 23 A performance evaluation is (Applies only to NM) performed annually by a medical physicist or nuclear medicine physicist and includes all required tests. Evaluation/ testing results and recommendations are documented. EP 24 A performance evaluation that (Applies only to PET) includes all required tests is performed annually by a medical physicist Evaluation/testing results and recommendations are documented. EP 25 A performance evaluation that (Applies to CT, PET, includes all required tests and NM, and MRI) parameters is performed on each image acquisition monitor annually by a medical physicist or MRI scientist (for MRI only). EP 4 Structural shielding assessment prior (Applies to CT, PET, to installation of new/replacement of NM) existing Imaging equipment; rooms where ionizing radiation emitted or radioactive material stored, medical or health physicist EP 6 Radiation protection survey to verify (Applies to CT, PET, adequacy of shielding after installation NM) of Imaging equipment or construction by medical or health physicist EP 13 Verified dose is within 20% prescribed (Applies to Nuclear dose or range Medicine).