New TJC HR Requirements for Fluoroscopy

PUBLISHED: Jul 27, 2018
Relevant to: Ambulatory Care, Clinical Lab, Critical Access Hospitals, Hospitals

Today’s StayAlert! Notice reviews the new Human Resource requirements that TJC has published for Fluoroscopy and CT services. As StayAlert! has previously reviewed, these new Fluoroscopy and CT requirements are effective January 1, 2019 and are applicable to ambulatory care, critical access hospitals, hospitals, and office-based surgery practices.

Within the HR Chapter, TJC requires under HR.01.05.03 that the organization:

  • Verifies and documents that individuals (including physicians, nonphysicians, and ancillary personnel) who perform diagnostic computed tomography (CT) examinations and/or use fluoroscopic equipment participate in annual and ongoing education including but not limited to the following:
  • Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® ( and Image Wisely® ( campaigns.
  • Safety procedures related to the operation of CT and or fluoroscopy equipment being used.

Included with today’s notice is an example policy reflecting the above described requirements, as well as a link to the prepublication standards. StayAlert! will review additional changes in upcoming notices.

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