Inpatient Facility Coding & Compliance Alert

Get a quick scoop on 4 key areas for hospitals.

Your long wait for diagnostic imaging standards is finally over! On Jan. 9, 2015, the Joint Commission published the Prepublication Standards in the diagnostic imaging services to be effective July 1, 2015.

The new and revised elements of performance (EPs) apply to accredited hospitals, critical access hospitals, and ambulatory health care organizations that provide diagnostic imaging services. 

Background: These are the same standards that were supposed to go into effect July 1, 2014. However, the Joint Commission postponed the implementation of new and revised diagnostic imaging requirements as it finally concluded that further research was needed to “ensure that our imaging standards remain up-to-date and sufficiently address quality and safety,” according to Margaret VanAmringe, MHS, executive vice president of public policy and government relations for the Joint Commission.

The Prepublication Standards changes focus on highly technical areas of radiation safety. Read on for the update on revisions in critical areas in the elements of performance in diagnostic imaging.

Tune Your Radar to Radiation Safety

The Standards EC.02.01.01 and EC.02.04.01 lay stress on the following areas of radiation safety:

1. The hospital needs to have ways to manage situations where the patient might be at a potential safety risk such as when he experiences claustrophobia, anxiety or distress or when he has medical implants or embedded ferromagnetic material within. The patient may otherwise need urgent medical care on priority.

2. The hospitals also need to assign adequately trained staff to screen people, restrict and monitor their access to the scanner room. 

3. Additionally, the radiation safety officer reviews results of staff dosimetry monitoring to assess whether staff radiation exposure levels are “As Low As Reasonably Achievable” (ALARA).

4. The hospital identifies quality control and maintenance activities to maintain the quality of the diagnostic imaging equipment.

Brush Up on the Responsibilities of the Medical Physicist

The elements of performance for EC.02.04.03 and EC.02.06.05 describe the important accountability and responsibility areas for the medical physicists.

1. The revisions clearly define that a diagnostic medical physicist does an annual inspection, testing, and maintenance of the imaging equipments such as: Computed tomography (CT) services where he measures the radiation dose for CT protocols of the adult brain, adult abdomen, pediatric brain, and pediatric abdomen, or other commonly used CT protocols.

2. He also conducts an annual performance evaluation of all CT imaging equipment, MRI or magnetic resonance imaging and all nuclear medicine imaging equipment, including positron emission tomography (PET) and documents the results. He is required to assess the imaging metrics such as image uniformity, accuracy of slice thickness, slice position, alignment light and geometric distance; signal to noise ratio, high and low contrast resolution, magnetic field homogeneity, and artifact evaluation as applicable.

3. As per the standard EC.02.06.05, the medical physicist or health physicist also conducts a structural shielding design assessment to specify required radiation shielding prior to installation of new imaging equipment, replacement of existing imaging equipment, or modification to rooms where ionizing radiation will be emitted or radioactive materials will be stored (such as scan rooms or hot labs).

Work on Your Staff Qualifications and Training

Get ready for the stringent standards of qualifications for staff. Hospitals will have to assume the onus and ensure staff training and education as follows:

1. Revision to the Element of Performance (EP) 20 for HR.01.02.05 requires the medical physicists performing CT services to have board certification in Diagnostic Radiologic Physics or radiologic physics by the American Board of Radiology, or in Diagnostic Imaging Physics by the American Board of Medical Physics, or in Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine, or meet all of the following requirements:

• 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.
• College coursework in the biological sciences with at least one course in biology or radiation biology and one course in anatomy, physiology, or a similar topic related to the medical physics.
• Documented experience in a clinical CT environment.

2. In another revision to the existing EP 14, HR.01.05.03, rather than the hospital documenting and verifying the fact that the radiologic technologists who perform CT participate in ongoing education and annual training, the revision now puts the onus on the hospital to orient the radiation dose reduction techniques that incorporate the principles and concepts included in Image Gently® and Image Wisely® initiatives. 

Take Charge to Ensure Safe Imaging Practices

To uphold quality and safety, the EPs enforce safe MRI practices protocols such as:

1. The revised EP 25, HR.01.05.03 requires the hospital to orient the technologists who perform magnetic resonance imaging (MRI) on safe MRI practices. It specifically adds that hospitals should orient the staff about “MRI system quench and cryogen safety procedures” as a part of “MRI system emergency shutdown procedures.” 

2. In EP PC.01.02.15, the revision adds that “The CT radiation dose must be exam-specific, summarized by series or anatomic area, and documented in a retrievable format.” It also cautions that “While the CTDIvol and DLP are useful indicators for monitoring radiation doses emitted by the CT machine, they do not represent the patient’s radiation dose.”

3. The erstwhile requirement for hospitals in California to keep electronic archives of the CT study and protocols page stands deleted now.

4. The hospitals are to verify the patient identity, imaging site, positioning, correct applicable imaging protocol, and parameters prior to conducting the study.

5. EP PC.01.03.01 requires the hospital to adopt “imaging protocols based on current standards of practice, which address key criteria including clinical indication, contrast administration, age (to indicate whether the patient is pediatric or an adult), patient size and body habitus, and the expected radiation dose index range.”

6. Further, EP PI.01.01.01 requires the hospital to collect data on patient thermal injuries and injuries related to erroneous presence of ferromagnetic material in the scanner room.

7. EP PI.02.01.01 (data analysis and compilation) has a new clause that requires the hospital to keep a record of, review and analyze incidents when the radiation dose during diagnostic CT exceeded the expected dose ranges as per the protocol.

The proposed requirement that addressed minimum qualifications for technologists performing diagnostic computed tomography (CT) exams remains on hold pending additional research. You can see the article “Don’t wait; update yourself on the revised diagnostic imaging standards for hospitals” in Inpatient Facility Coding and Compliance Alert, Volume 3, Number 10 for the revisions the Joint Commission posted for feedback last September.

Final takeaway: It’s now time to familiarize yourself with the standards and imbibe these into your imaging protocols for the year 2015. Make sure that your imaging staff is well versed with the changes that they will be expected to follow this July onwards.

Want to know more: The revisions are presented in strikethrough and underlined text for easy identification. There are separate documents related to: 

- Hospital and Critical Access Hospitals proposed revisions for diagnostic imaging http://www.jointcommission.org/assets/1/6/HAP-CAH_DiagImag_Prepub_July2015release_20150105.pdf

- Ambulatory Care proposed revisions for Diagnostic imaging http://www.jointcommission.org/assets/1/6/AHC_DiagImag_Prepub_July2015release_20150105.pdf.