Joint Commission Announces Deleted Requirement Related to Annual Training for Physicians, Staff using Fluoroscopy Equipment

PUBLISHED: Jun 28, 2019
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals, Office-Based Surgery

The Joint Commission (TJC) has announced that, effective immediately, element of performance (EP) 15 for Human Resources (HR) standard HR.01.05.03 is deleted. This EP went into effect earlier this year and was applicable to the Hospital, Critical Access Hospital, Ambulatory Care and Office-Based Surgery accreditation programs.

The EP had required organizations to verify and document that individuals (physicians, non-physicians, ancillary personnel) using fluoroscopic equipment participate in annual training on radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® and Image Wisely® campaigns and safe procedures for operation of the types of fluoroscopy equipment they would use.

TJC received stakeholder feedback that the EP was both redundant and burdensome to comply with on an annual basis. According to TJC, “Assessment of staff and physician competency to provide fluoroscopy services will continue to be assessed during the on-site survey using accreditation standards that currently exist in the HR and Medical Staff chapters.”

Included with today’s notice is an updated example policy reflecting this deleted EP.

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