The New Joint Commission Imaging Requirements – How to En - PowerPoint Presentation

Slide1

The New Joint Commission Imaging Requirements – How to Ensure That Your Facility is Ready

Gregg C. DaversaDirector, Business DevelopmentWest PhysicsSlide2

Objectives

Identify which JC-accredited facilities will be impacted by the 2014 standard changes, and the dates for full complianceIdentify which imaging modalities will be affected Discuss why the JC made the changes in imaging standardsReview each standard and identify how it will impact image quality, patient care, and patient/personnel safetyReview each standard and identify how the JC-accredited organization will be expected to meet the revised standardsUnderstand how your facility can prepare for the changes and be completely ready for your next JC surveySlide3

JC Accreditation Facts

JC released the new imaging standards in “pre-publication” form on December 20, 2013Effective date for the new standards will be July 1, 2014New JC imaging standards will impact hospitals, critical access hospitals, and ambulatory care centersModalities impacted will be MRI, CT, NM & PET (including hybrid modalities)Dental Cone Beam CT (CBCT) used for maxillofacial region for diagnosis or treatment planning is excluded from the standard changesStandards sections impacted are Environment of Care, Human Resources, Medication Management, Provision of Care,

T

reatment, Services, and Performance ImprovementSlide4

What Prompted These Changes to the Standards

Specific to Imaging?Progression of JC Sentinel Event Alert, Issue 47 to more formal standardsProgression of historical JC National Patient & Safety Goals to more formal standardsPatient and payer (e.g., CMS) expectations for higher patient safety and quality standards

Need for greater parity with other imaging industry standards such as those of the ACR and IAC accreditation programs

Various highly publicized imaging-related medical eventsSlide5

Environment of Care (EC)Slide6

EC.02.01.01 – Organization Manages S

afety And Security Risks(14) For facilities that provide MRI services: The facility manages safety risks in the MRI environment associated with the following:

Patients who may experience claustrophobia, anxiety, or emotional distress

Patients who may require urgent or emergent medical care

Patients with medical implants, devices, or imbedded foreign objects (e.g. shrapnel, etc.)

Ferromagnetic objects entering the MRI environment

Acoustic noiseSlide7

EC.02.01.01 – Organization Manages S

afety And Security Risks(16) For facilities that provide MRI Services: The facility manages safety risks by doing the following:

Restricting

access of everyone not

trained in MRI safety or screened by

MRI-trained

staff from the scanner room and the area that immediately precedes the entrance to the MRI

scanner

room

Making sure that these

restricted

areas

are controlled by and under the direct supervision of

MRI-trained

staffPosting signage at the entrance of

the MRI scanner that conveys the risk of the dangers of the magnetic field. Signage to also

indicate that the magnet is always on with the exception of those that can be routinely turned off by the operatorSlide8

EC.02.02.01 – Organization Manages Risks Related To Hazardous Materials And Waste

(17) Facilities that provide CT, PET or NM services will have staff dosimetry results reviewed by the RSO or a diagnostic medical physicist at least quarterly to assess whether staff radiation exposures are ALARA and below regulatory limitsSlide9

EC.02.04.01 – Organization

Manages Medical Equipment Risks(7) The facility identifies quality control and maintenance activities to maintain the quality of diagnostic images produced. The organization identifies how often these activities should be conducted.Slide10

EC.02.04.03 – Organization I

nspects, Tests, And Maintains Medical Equipment(15) The facility maintains the quality of the diagnostic images produced.

(17) CT scanners are tested at least annually by a diagnostic medical physicist:

Measure radiation dose in the form of CTDIvol

Adult brain

Adult abdomen

Pediatric brain

Pediatric abdomen

Substitute procedures can be used if the above are not commonly performed at the facilitySlide11

EC.02.04.03 – Organization I

nspects, Tests, And Maintains Medical Equipment(17) Cont.Verify that the radiation dose in form of CTDIvol displayed by the CT system for each tested protocol is within 20% of the CTDIvol

measured by the physicist

. The dates, results, and verifications of these measurement results are documented

This EP is only applicable to CT systems capable of displaying radiation dose in the form of CTDIvolSlide12

EC.02.04.03 – Organization I

nspects, Tests, And Maintains Medical Equipment(19) At least annually, a diagnostic medical physicist conducts a performance evaluation of all CT imaging equipment. Evaluation includes use of phantoms to assess:

Image

(CT Number)

uniformity

Slice thickness accuracy

Slice position accuracy (when prescribed from a scout image)

Alignment light accuracy

Table travel accuracy

Radiation beam width

High-contrast resolution

Low-contrast resolution

Geometric or distance accuracy

CT number accuracy

Artifact evaluationSlide13

EC.02.04.03 – Organization I

nspects, Tests, And Maintains Medical Equipment(20) At least annually, a diagnostic medical physicist or MRI scientist conducts a performance evaluation of all MRI imaging equipment. Evaluation includes the use of phantoms to assess:

Image uniformity for all RF coils used clinically

SNR for all coils used clinically

Slice thickness accuracy

Slice position accuracy

Alignment light accuracy

High-contrast resolution

Low-contrast resolution (or CNR)

Geometric or distance accuracy

Magnetic field homogeneity

Artifact evaluationSlide14

EC.02.04.03 – Organization I

nspects, Tests, And Maintains Medical Equipment(21) At least annually, a diagnostic medical physicist conducts a performance evaluation of all NM imaging equipment. Evaluation includes the use of phantoms to assess:

Image uniformity/system uniformity

High-contrast resolution/system spatial resolution

Low-contrast resolution or detectability (N/A for planar acquisitions)

Sensitivity

Energy resolution

Count-rate performance

Artifact evaluationSlide15

EC.02.04.03 – Organization I

nspects, Tests, And Maintains Medical Equipment(22) At least annually, a diagnostic medical physicist conducts a performance evaluation of all PET imaging equipment. Evaluation includes the use of phantoms to assess:

Image uniformity/system uniformity

High-contrast resolution/system spatial resolution

Low-contrast resolution or detectability (N/A for planar acquisitions)

Artifact evaluation

Tests recommended but not required:

Sensitivity

Energy resolution

Count-rate performanceSlide16

EC.02.04.03 – Organization I

nspects, Tests, And Maintains Medical Equipment(23) Annual performance evaluation by a diagnostic medical physicist of image acquisition display monitors connected to MRI, CT, PET & NM systems to assess:

Maximum and minimum luminance

Luminance uniformity

Resolution

Spatial accuracySlide17

EC.02.06.05 – Organization M

anages Its Environment During Demolition, Renovation, Or New Construction To Reduce

R

isk

T

o

T

hose

I

n

T

he

O

rganization

(4) Facilities that provide CT, PET or NM services will have a structural shielding design conducted by a medical physicist:

Prior to installation of new imaging equipmentPrior to replacement of existing imaging equipment

Prior to modification to rooms where ionizing radiation will be emitted or radioactive materials will be stored (e.g., scan rooms or hot labs)Slide18

EC.02.06.05 – Organization M

anages Its Environment During Demolition, Renovation, Or New Construction To Reduce Risk To

T

hose

I

n

T

he

O

rganization

(6) Facilities that provide CT, PET or NM services will have a radiation protection survey conducted by a medical physicist after installation of imaging equipment or construction in rooms where ionizing radiation will be emitted or radioactive materials will be stored. This survey will v

erify the adequacy of installed shielding. This survey is conducted prior to clinical use of the room.Slide19

Human Resources (HR)Slide20

HR.01.02.05 – Organization Verifies

Staff Qualifications(19) The facility verifies and documents that radiologic technologists who perform CT exams meet the following requirements by July 1, 2015:American Registry of Radiologic Technologists (ARRT) (R)

or

Nuclear Medicine Technology Certification Board (NMTCB) and

Trained and experienced in the operation of CT equipment

WPC Note: Best practice is to conduct primary source verificationSlide21

HR.01.02.05 – Organization Verifies

Staff Qualifications(20) The facility verifies and documents that medical physicists that support CT services have board certification in: Diagnostic Radiologic Physics by the American Board of Radiology (ABR) orDiagnostic Imaging Physics by the American Board of Medical Physics

or

Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine

or

A graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university,

and

Formal graduate-level coursework in the biological sciences with at least 1 course in biology or radiation biology and 1 course in anatomy, physiology, or a similar topic related to the practice of medical physics,

and

Documented experience in a clinical CT environment conducting at least 10 CT performance evaluations under the direct supervision of a board-certified medical physicist.Slide22

HR.01.05.03 – Staff Participate

In Ongoing Education And Training

(14) The facility verifies and documents that radiologic technologists who perform CT exams participate in ongoing education that includes annual training on radiation dose reduction techniques (e.g., Image Gently and Image Wisely).Slide23

HR.01.05.03 – Staff Participate

In Ongoing Education And Training(25) The facility verifies and documents that

MRI

technologists participate in ongoing education

that includes MRI safety training:

Patient screening for ferromagnetic items, medical implants, NSF

Patient positioning to avoid RF burns

Equipment and supplies acceptable to be safely used in MRI environment

Safety response procedures for patients who need emergent medical care

MRI equipment emergency shutdown procedures (e.g., magnet quench)

Patient hearing protection

Patient claustrophobia, anxiety, emotional distressSlide24

Medication Management (MM)Slide25

MM.06.01.01 – Organization Safely

Administers Medications(13) For NM & PET, before administration of a radioactive pharmaceutical for diagnostic purposes, staff verify that the dose to be administered is within 20% of the prescribed dose, or, if the dose is prescribed as a range, staff verify that the dose to be administered is within the prescribed range.Slide26

Provision of Care, Treatment, and Services (PC)Slide27

PC.01.02.15 – Organization Provides

For Diagnostic Testing(5) For CT, the facility documents in the patient’s medical record the radiation dose measured in CTDIvol or DLP for every study produced during a CT examination:

Only applicable to CT systems capable of providing a CTDIvol or DLP measurement

Does not apply to radiation therapy treatment planning (SIM CT) or attenuation correction-only CTSlide28

PC.01.02.15 – Organization Provides

For Diagnostic Testing(6) For facilities that provide diagnostic CT, the interpretive report of the CT study includes the patient’s CTDIvol or DLP radiation dose. The dose is either recorded in the patient’s interpretive report or included on the protocol page.

Best practice will be patient’s radiation dose value to be included in the physician interpretative diagnostic report

Applicable to only CT scanners capable of calculating and displaying radiation dose valuesSlide29

PC.01.02.15 – Organization Provides

For Diagnostic Testing(10) Prior to conducting a diagnostic imaging study, the facility verifies the following:

Correct patient

Correct imaging site

Correct patient positioning

CT only: Correct imaging protocol

CT only: Correct scanner parametersSlide30

PC.01.02.15 – Organization Provides

For Diagnostic Testing(12) The facility considers the patient’s age and recent imaging exams when deciding on the most appropriate type of imaging exam:To prevent unnecessary duplication of exams (reduce radiation exposure)

WPC Notes: Utilize EMR or RIS to support decision process. Reference ACR appropriateness criteriaSlide31

PC.01.03.01 – Organization Provides

For Diagnostic Testing(25) For CT, the facility establishes imaging protocols based on current standards of practice, which address key criteria including:

Clinical indication

Contrast administration

Age (pediatric or adult)

Patient size and body habitus

Expected radiation dose rangeSlide32

PC.01.03.01 – Organization Provides

For Diagnostic Testing(26) For CT, imaging protocols are reviewed and kept current with input from an: Interpreting radiologistMedical physicist

Lead imaging technologist

To make certain that they adhere to current standards of practice and account for changes in CT imaging equipment. These reviews are conducted at time frames identified by the organization.

WPC Note: Reference

standard of

practice:

AAPM

http

://www.aapm.org/pubs/CTProtocols/

Adult Brain, Brain perfusion, Chest, ABD,

PelvisSlide33

Performance Improvement (PI)Slide34

PI.01.01.01 – Organization

Collects Data To Monitor Its Performance

(46) For MRI, the facility collects data on patient burns that occur during MRI exams.

(47) For MRI, the facility collects data on:

Incidents where ferromagnetic items entered the MRI scanner room

Injuries resulting from the presence of ferromagnetic items in the MRI scanner roomSlide35

PI.02.01.01 – Organization Compiles

And Analyzes Data(6) For CT, the facility compiles and analyzes data on patient CT radiation doses and compares it with external benchmarks, when such benchmarks are available.

Best practice will involve dose tracking and analysis software technology

ACR Dose Index Registry, NEXT and other external benchmarks.Slide36

PI.02.01.01 – Organization Compiles

And Analyzes DataACRNational Radiology Data Registry (2008)

Dose Index Registry “DIR” (2011)

5 million CT studies from 600 participating facilities. Most studies from a single index in the world

Cost to participate: $500.00 - one time entry fee

Annual fee ranges from $500.00 to $10,000 depending of number of radiologists working at facility and number of distinct locations within the organizationSlide37

PI.02.01.01 – Organization Compiles

And Analyzes DataCT dose tracking software solutions:RaySafe

S1

(Fluke)

Dose

Watch (GE

)

Dose Monitor(

PACSHealth

)

Radimetrics

(Bayer)

imalogiX (Medlnt)

DoseTrack (Sectra)AccuRad (Aware)Scannerside (RightDose)Radiance (UPenn)Slide38

Benefits Of CT Dose T

racking SoftwareAccurate dose reporting and myriad analysis capabilitiesIdentify studies that fall above or below median threshold dose values and allow corrective actionsProves success of dose reduction effortsVehicle to transfer dose value to

medical record

Archive for patient dose values

Compare dose values to other

databases

Reads DICOM format and/or utilizes OCR

Reduce patient radiation dose!Slide39

Factors To A

ddress Before Purchase of CT Dose Tracking SoftwareFull license purchase (outright purchase) orSubscription model (pay for each study)Age, make, and model of CT scanner (structured report)

Single or multi-site installation

Network bandwidth

Manage dose values through PACS, RIS, EHR

Compatibility with dictation vendor and version

Manage patients with different unique identifier numbers in same network

IT dept. must be part of the dose tracking implementation

Finally – who will actually

manage

it?Slide40

8 Key Important Take

Home PointsJuly 1, 2014 effective date for standards to be implemented (except CT tech credentialing, which is July 1, 2015)Annual equipment testing required by medical physicist for MRI, CT, NM, PETRadiation structural shielding design for CT, NM & PET by medical physicistRadiation protection survey for CT, NM & PET by medical physicist

Minimum credentialing requirements for technologists and medical physicists

Record, track and analyze patient CT radiation dose

Analyze and benchmark CT and MRI safety data

Annual dose reduction and MRI safety training requiredSlide41

Gregg c. daversa

gregg.daversa@westphysics.comPhone: 866-275-WEST (9378)www.westphysics.com

QUESTIONS