Joint Commission Clarifies Minimum Qualifications for CT Technologists

The Joint Commission has issued a clarification to its New Requirements for
Diagnostic Imaging Services for hospitals and critical access hospitals and for ambulatory care organizations (including those that have achieved Advanced Diagnostic Imaging certification).

The new standards include minimum qualifications for technologists performing computed tomography (CT) exams. According to The Joint Commission, accredited organizations have raised questions about Note No. 1 under standard HR.01.02.05, EP 19, which communicates an expectation that, effective January 1, 2018, all CT technologists have advanced-level CT certification.

The Joint Commission is now clarifying the intent of this note is to give organizations “heads up” about the future direction of the imaging standards, and indicates that “before introducing the 2018 requirement, Joint Commission staff will thoughtfully research how best to structure a new expectation for advanced CT certification [and] proposed standards will be posted for public comment before they are finalized.”

Joint Commission Proposes New NPSG on Pediatric CT Imaging

The Joint Commission has published a proposed new National Patient Safety Goal (NPSG) on Pediatric Computed Tomography (CT) Imaging for hospitals, critical access hospitals, and ambulatory health care. The new proposed NPSG is expected to be included as a 2017 Joint Commission NPSG.

In this standards field review, The Joint Commission is seeking input from organizations and stakeholders on the proposed new NPSG. The Joint Commission indicates that “Published data about the frequency of pediatric CT imaging varies. Despite evidence that use of CT may have stabilized or is declining after a period of increased, there is an opportunity to further prevent unnecessary radiation exposure for children.” The accrediting body contends that a new NPSG would spotlight this issue, and would motivate accredited organizations to use evidence-based practices for determining when CT examinations are necessary.

Joint Commission Revises Qualifications for CT Technologists

On February 16, 2016, The Joint Commission released New Requirements for
Diagnostic Imaging Services for hospitals and critical access hospitals and for ambulatory care organizations (including those that have achieved Advanced Diagnostic Imaging certification) that provide diagnostic imaging services.

These new requirements specify minimum qualifications for technologists who perform diagnostic computed tomography (CT) exams, and include HR.01.02.05, EP 19, an updated version of the element of performance originally published in December 2013 (and later rescinded in May 2014).

The changes will be published in the July 1, 2016 release of the Joint Commission E-dition and print accreditation manuals, but will not be effective until September 1, 2016.

In May 2015, the Centers for Medicare & Medicaid Services (CMS) also Revised Interpretive Guidelines for Hospital Radiologic and Nuclear Medicine Services.

New Requirements for Diagnostic Imaging Services – Hospitals & Critical Access Hospitals

Standard	EP	Status
HR.01.02.05	19	New
HR.01.05.03	26	New
MS.03.01.01	16	Revised
PC.01.03.01	26	Revised

New Requirements for Diagnostic Imaging Services – Ambulatory Health Care

Standard	EP	Status
HR.01.02.05	19	New
HR.01.05.03	26	New
PC.01.03.01	26	Revised

Background: Revising the Joint Commission Diagnostic Imaging Requirements

These new requirements for hospitals, critical access hospitals, and ambulatory health care support The Joint Commission’s continuing initiative to revise and update its Diagnostic Imaging Services standards, which began over two years ago.

In December 2013, The Joint Commission announced it would implement new and revised diagnostic imaging requirements as a two-phase process planned for 2014 and 2015. The original “first phase” requirements were published in December 2013, with a July 1, 2014 effective date, but later rescinded in May 2014 to undergo further review. The accrediting body also announced it would abandon the phased implementation approach planned for 2014 and 2015, and instead implement a single, comprehensive set of new and revised imaging requirements.

Following a September 2014 field review, the comprehensive set of new and revised diagnostic imaging requirements was released in January 2015, with a July 1, 2015 effective date.

Excluded from the January 2015 standards revisions was the EP related to certification and qualifications for CT technologists, which was included in its original form in the rescinded December 2013 “first phase” requirements. That requirement, and the other EPs identified above, are included in the February 2016 New Requirements for Diagnostic Imaging Services for hospitals, critical access hospitals, and ambulatory health care.

Further, EPs included in the January 2015 standards revisions do not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions. Future standards revisions are expected for these dental cone beam CT radiographic imaging studies.

CMS Revises Interpretive Guidelines for Hospital Radiologic and Nuclear Medicine Services

On May 15, 2015, CMS issued a Survey & Certification Memorandum (S&C: 15-38-Hospitals) updating its interpretive guidelines in State Operations Manual (SOM) Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals for Radiologic Services (42 CFR 482.26) and Nuclear Medicine Services (42 CFR 482.53). According to CMS, the revised interpretive guidelines “reflect current accepted standards of practice” and “provide [surveyors] more detailed instructions for compliance assessment.”

These are not new or revised Conditions of Participation (CoPs), but revision to the interpretation of existing requirements and the guidance CMS provides to surveyors. However, the organization is required to comply with the requirements of these interpretations. The revised interpretive guidelines are effective immediately.

For both Radiologic Services and Nuclear Medicine Services, new and revised interpretive guidelines includes:

Description of the types of services provided;

Discussion of safety precautions hospitals are expected to take to decrease radiation exposure risks including, but not limited to:

• Incorporation of the “As Low as Reasonably Achievable” (ALARA) principle of medical imaging, which optimizes image quality while minimizing radiation exposure in accordance with nationally recognized guidelines;
• Identification of high-risk patients for whom a diagnostic study might be contra-indicated;
• Appropriate shielding of patients and personnel that is specific to the type of medical imaging device; and
• Periodic inspection and calibration of equipment by appropriately trained personnel.

Further, the revised interpretive guidance contains a number of “blue boxes” with additional information and recommendations for optional actions which are not required under the regulations. Examples include information about the qualifications and role of medical physicists as well as dosimetry tracking for patients and devices, as applicable.

In the memorandum, CMS identifies that the U.S. populations total exposure to ionizing radiation has nearly doubled over a twenty year period, citing National Council on Radiation Protection and Measurement (NCRP) Report No. 160. CMS also references the FDA’s Center for Devices and Radiological Health’s Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging, which focuses on CT scanning, fluoroscopy, and nuclear medicine, and its two principles of radiation protection: Justification and Dose Optimization.

The revised interpretive guidance will be published in a future update to the CMS State Operations Manual (SOM) Appendix A, and may include minor changes.

Earlier this year, The Joint Commission published a comprehensive set of new diagnostic imaging requirements.

Joint Commission Publishes New Diagnostic Imaging Requirements

The Joint Commission has finalized new and revised elements of performance (EPs) for accredited hospitals that provide diagnostic imaging services. This set of standards was previously announced in December 2013 and would have gone into effect in July 2014. However, The Joint Commission determined that further research and additional revisions were needed.

The Revised Requirements for Diagnostic Imaging Services incorporate recommendations from imaging experts, professional associations, and accredited organizations about areas that must be evaluated to ensure the safe delivery of diagnostic imaging services.

Revisions include 12 new EPs and 1 revised EP under the Environment of Care (EC) chapter, 2 new EPs under the Human Resources (HR) chapter, 1 new EP under the Medication Management (MM) chapter, 5 new EPs, 1 revised EP, and 2 deleted EPs under the Provision of Care, Treatment, and Services (PC) chapter, and 3 new EPs under the Performance Improvement (PI) chapter. The proposed requirement that addressed minimum qualifications for technologists performing diagnostic computed tomography (CT) exams remains on hold pending additional research.

The new and revised Requirements for Diagnostic Imaging Services for accredited hospitals are effective July 1, 2015.

Standard	EP	Status
EC.02.01.01	14	New
EC.02.01.01	16	New
EC.02.02.01	17	New
EC.02.04.01	10	New
EC.02.04.03	15	New
EC.02.04.03	17	Revised
EC.02.04.03	19	New
EC.02.04.03	20	New
EC.02.04.03	21	New
EC.02.04.03	22	New
EC.02.04.03	23	New
EC.02.06.05	4	New
EC.02.06.05	6	New
HR.01.05.03	14	New
HR.01.05.03	25	New
MM.06.01.01	13	New
PC.01.02.15	5	Revised
PC.01.02.15	6	Deleted
PC.01.02.15	7	Deleted
PC.01.02.15	10	New
PC.01.02.15	12	New
PC.01.03.01	25	New
PC.01.03.01	26	New
PI.01.01.01	41	New
PI.01.01.01	42	New
PI.02.01.01	6	New

Top Ten Health Technology Hazards for 2015

Each year, the ECRI Institute publishes a Top 10 Health Technology Hazards list to raise awareness of the potential dangers associated with the use of medical devices, and to help healthcare providers minimize the risk of technology-related adverse events.

The 2015 Top 10 Health Technology Hazards list highlights the top 10 safety topics that ECRI deems crucial for hospitals to address in the coming year, and describes safety issues associated with those technologies.

To develop the annual list, ECRI Institute’s multidisciplinary staff of engineers, scientists, nurses, physicians, and patient safety analysts draw on the resources of the Institute’s 45-year history, as well as expertise and insight gained through testing and analyzing healthcare technologies. This includes examining health technology-related problem reports from hospitals and health systems worldwide, and reports received through the ECRI Institute Patient Safety Organization (PSO).

For the fourth year in a row, clinical alarm hazards, a Joint Commission National Patient Safety Goal, remains number one on ECRI’s list. This year, the report draws particular attention to alarm configuration practices. ECRI Institute is aware of several deaths and other cases of severe patient harm that may have been prevented with more effective alarm policies and practices.

Recall management, which appears on the list for the first time, points to overwhelmed recall and safety-alert programs as a potential for serious consequences for healthcare facilities and patients. ECRI experts are concerned that existing hospital recall tracking programs are not keeping pace with the growing number of medical device recalls issued each year. FDA reports that the annual number of medical device recalls nearly doubled between 2003 and 2012, from 604 recalls to 1,190 annually.

For each topic, ECRI Institute describes the hazard, presents recommendations for minimizing the risks, and lists helpful resources that readers can access to learn more about the topic.

Joint Commission Publishes Proposed Revisions to Diagnostic Imaging Standards, Seeks Input

On September 11, 2014, The Joint Commission published Proposed Revisions to Diagnostic Imaging Services Requirements for the Hospital Accreditation Program, and is seeking input from the field.

Earlier this year, The Joint Commission postponed the July 1, 2014 implementation of the “first phase” of new and revised diagnostic imaging requirements for accredited hospitals, critical access hospitals, and ambulatory care organizations that provide diagnostic imaging services, identifying that further research was needed to ensure the new standards sufficiently supported improvements in quality and safety.

The Joint Commission announced it would instead implement a single, comprehensive set of revised diagnostic imaging requirements. Though no new implementation date was announced, the comprehensive set of revised requirements is expected no later than July 2015.

As part of its ongoing research, The Joint Commission is seeking input on proposed standards revisions that address the following areas:

• Minimum qualifications for radiologic and nuclear medicine technologists that perform computed tomography (CT) exams.
• Orientation of technologists on safe practices related to the provision of diagnostic imaging
• Documentation of CT radiation dose

Since the proposed standards changes focus on highly technical areas, The Joint Commission “strongly encourage [organizations] to solicit feedback from clinicians and radiology staff with expertise in diagnostic imaging.”

The proposed changes revise Human Resources (HR) standards HR.01.02.05, EP 19, HR.01.05.03, EP 14, and HR.01.05.03, EP 25, and create HR.01.02.05, EP 21; revise Provision of Care, Treatment, and Services (PC) standard PC.01.02.15, EP 5, and delete PC.01.02.15 EPs 6 and 7; and create Performance Improvement (PI) standard PI.02.01.01, EP 15. (See chart below)

Comments on the proposed revisions are being accepted by The Joint Commission until October 24, 2014.

Proposed Revisions to Diagnostic Imaging Services Requirements – Hospital Accreditation Program​

Standard	EP	Status
HR.01.02.05	19	Revised
HR.01.02.05	21	New
HR.01.04.01	24	Revised and moved from HR.01.05.03, EP 14
HR.01.04.01	25	Revised and moved from HR.01.05.03, EP 25
HR.01.05.03	14	Revised and moved to HR.01.04.01, EP 24
HR.01.05.03	25	Revised and moved to HR.01.04.01, EP 25
PC.01.02.15	5	Revised
PC.01.02.15	6	Deleted
PC.01.02.15	7	Deleted
PI.02.01.01	15	New

Joint Commission Delays Implementation of New and Revised Diagnostic Imaging Requirements; Targets July 2015

On May 15, 2014, The Joint Commission published a revised timeline for implementation of new and revised diagnostic imaging standards, postponing the identified July 1, 2014 implementation of the “first phase” of the new and revised diagnostic imaging requirements, and announcing it will instead implement a single, comprehensive set of new and revised requirements in favor of the two phase approach originally planned for 2014 and 2015. The complete Joint Commission announcement is included below.

Prepublication – Diagnostic Imaging Services Requirements: Update; Delayed Implementation
Revised Timeline for Implementation of New and Revised Diagnostic Imaging Standards

In January 2014, The Joint Commission published new and revised requirements that address risks associated with diagnostic imaging for accredited hospitals and other organizations that provide diagnostic imaging services. The changes were intended to be effective July 1, 2014, with additional changes to be phased in by 2015 (see “Standards Changes for Organizations Providing Imaging Services,” Joint Commission Perspectives, January 2014).

Since that time, we have received significant feedback from key stakeholders both praising the overall effort, and raising concerns about several critical standards. This feedback sheds light on issues that may not have been either identified or sufficiently evaluated during the standards development process. Some of these issues highlighted complexities that require us to engage in further research in order to ensure that the new standards best promote the improvement of quality and safety.

Therefore, The Joint Commission is postponing the July 1, 2014 implementation of the revised diagnostic imaging requirements.

The 2014 Update 1 to the Comprehensive Accreditation Manual for hospitals, critical access hospitals, and ambulatory care will be delayed until early July for customers who purchased the print updates so that The Joint Commission can revert the imaging standards. The goal is to implement the revised standards by July 2015, which will allow for the release of a comprehensive set of requirements, rather than partial sets over 2014 and 2015. When we finalize the 2015 diagnostic imaging requirements, it is expected that the majority of the 2014 proposed requirements will be implemented as currently written. A prepublication version of the final requirements will be posted on our website six months in advance of any identified implementation date.

In order to finalize a single set of standards in 2015, we are collecting additional information about several critical areas of radiation safety. The critical areas include:

• Documentation of the radiation dose.
• Annual equipment performance evaluations by a medical physicist or Magnetic Resonance scientist.
• Minimum qualifications for radiologic technologists who perform computerized tomography (CT) exams (These requirements were to have become effective July 1, 2015. Since this subject is covered in the now postponed revised requirements, this date is also no longer effective)
• Requirements that align with the State of California’s CT law.

We value and appreciate the feedback received from imaging professionals, our accredited organizations, and other key stakeholders. The decision to postpone the implementation of these requirements is based on our goal of advancing imaging quality and safety.

Joint Commission Publishes Proposed Revisions to Radiologists’ Qualifications and Competency Requirements

On February 27, 2014 The Joint Commission published Proposed Revisions to Diagnostic Imaging Standards for Radiologists’ Qualifications and Competency for Hospital, Critical Access Hospital, and Ambulatory Health Care Accreditation Programs.

This standards field review is a follow-up to the previous standards field review of requirements that address quality- and safety-related issues associated with diagnostic imaging. The previous diagnostic imaging standards field review resulted in the December 20, 2013 publication of Revised Requirements for Diagnostic Imaging Services.

In this standards field review, The Joint Commission is seeking input on the proposed requirements that address the qualifications and competency for radiologists who provide diagnostic computed technology (CT) services.

For hospitals and critical access hospitals, the proposed revisions introduce a new element of performance (EP) under Medical Staff (MS) standard MS.06.01.03 and two new EPs under Medical Staff (MS) standard MS.06.01.05. For ambulatory health care, the proposed revisions add three EPs under Human Resources (HR) standard HR.02.01.03.

Comments on the proposed revisions are being accepted by The Joint Commission until April 10, 2014.

Top Ten Health Technology Hazards for 2014

Each year, the ECRI Institute publishes a Top 10 Health Technology Hazards list to raise awareness of the potential dangers associated with the use of medical devices and to help healthcare providers minimize the risk of technology-related adverse events.

The 2014 Top 10 Health Technology Hazards list highlights the top 10 safety topics that warrant particular attention during the coming year, and describes safety issues associated with those technologies. Some are hazards that are occurring with regularity. Some are problems that are becoming more prevalent, given the way technology is evolving. And some are well-known risks that periodically warrant renewed attention.

To develop the annual list, ECRI Institute’s multidisciplinary staff of engineers, scientists, nurses, physicians, and patient safety analysts draw on the resources of the Institute’s 45-year history, as well as expertise and insight gained through testing and analyzing healthcare technologies. This includes examining health technology-related problem reports from hospitals and health systems worldwide, and reports received through the ECRI Institute Patient Safety Organization (PSO).

For the third year in a row, clinical alarm hazards, remains number one on ECRI’s list. For each topic, ECRI Institute describes the hazard, presents recommendations for minimizing the risks, and lists helpful resources that readers can access to learn more about the topic. The 2014 Top 10 Health Technology Hazards list includes:

1. Alarm hazards
2. Infusion pump medication errors
3. CT radiation exposures in pediatric patients
4. Data integrity failures in EHRs and other health IT systems
5. Occupational radiation hazards in hybrid ORs
6. Inadequate reprocessing of endoscopes and surgical instruments
7. Neglecting change management for networked devices and systems
8. Risks to pediatric patients from “adult” technologies
9. Robotic surgery complications due to insufficient training
10. Retained devices and unretrieved fragments