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About The Joint Commission Accreditation Requirements for CT Diagnostic Imaging

Marcella Lobo

Are you concerned that your diagnostic imaging—CT—services are less than fully prepared to meet The Joint Commission (TJC) accreditation standards? The 12 revised diagnostic standards for CT went into effect in 2015 and include CT dose optimization among other standards.

See our video providing a detailed examination of TJC performance requirements for CT dose optimization.

What the standards govern

Equipment: Equipment needs to meet original equipment manufacturer guidelines for quality control and preventive maintenance. You will be asked to show your plan for meeting the manufacturer’s preventive maintenance guidelines. When you acquire new equipment, ensure that a qualified medical physicist performs equipment testing and that documentation exists.

People: Is staff appropriately trained and can they demonstrate competency? Is their training current with TJC requirements? Are staff credentials documented? The surveyor may interview your CT staff, radiologists, and medical physicist, and will review HR records.

Process: Effective dose index range has been added to CT protocols and it is critically important that protocols are followed. Incorporate updates as equipment changes, as knowledge increases, and as algorithms are modified. Protocols must be followed exactly by your staff. Documentation is important to have ready for TJC surveyors.

Organizing your TJC survey preparation activities around these three areas—equipment, people, and process—supports the goal of delivering the care your patients deserve.

“Hospital radiology departments are involved with many accrediting and regulatory agencies including federal, state and local entities. We’ve helped hundreds of hospitals meet requirements with our the assistance of our qualified medical physicists.”

- Shawn Pickett
Practice Director, Radiation Safety Support

See how a LANDAUER medical physics consultant can help you facility meet and maintain compliance.