TJC Adds New Fluoroscopy Imaging Requirement for Office-Based Surgery

PUBLISHED: May 20, 2019
Relevant to: Office-Based Surgery

The Joint Commission (TJC) has announced a new requirement for its office-based surgery accreditation program. The new requirement is for office-based surgery practices that provide fluoroscopy imaging services and is effective January 1, 2020.

EC.02.02.01, EP 17, is not a new requirement – it is already applicable to TJC-accredited critical access hospitals, hospitals, and ambulatory care organizations. EP 17 is now also applicable to office-based surgery and requires, for practices providing computed tomography (CT), positron emission tomography (PET), nuclear medicine (NM), or fluoroscopy services:

  • At least quarterly review of dosimetry monitoring results.
  • Review should be conducted by the radiation safety officer, diagnostic medical physicist, or health physicist to determine that staff radiation exposure levels are “as low as reasonably achievable” (ALARA) and below regulatory limits.
    • Per TJC, office-based surgery practices should use the following US Nuclear Regulatory Commission federal regulation (10 CFR 20.1003) for the definition of ALARA:
      • ALARA means making every reasonable effort to maintain exposures to radiation as far below the dose limits in this part as is practical consistent with the purpose for which the licensed activity is undertaken, taking into account the state of technology, the economics of improvements in relation to state of technology, the economics of improvements in relation to benefits to the public health and safety, and other societal and socioeconomic considerations, and in relation to utilization of nuclear energy and licensed materials in the public interest.
    • Per TJC, this EP does 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.

TJC has added EP 17 to its OBS requirements because it aligns with current radiological practice standards. Included with today’s notice is an example policy related to this requirement.

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