Skip to main content

How a Joint Commission Hospital System Optimized Radiation Dose in 3 Months

Marcella Lobo

LifePoint Health, a 72-hospital system, in support of its mission to “make communities healthier,” committed to the goal of reducing radiation dose. To reach that goal, the system chose to optimize and standardize CT radiation dose system-wide, but major challenges stood in the way of reaching that goal:

Geography. The effort required enterprise-wide engagement across 72 hospitals in 22 states and 4 time zones, stretching from the Mid-Atlantic to Nevada. Large system coordination. The system’s CT scanners were used by 60 professional radiology groups comprising hundreds of individuals. All needed to be coordinated for a consistent approach to radiation dose optimization.

Diverse CT scanners. The system included 99 CT scanners of 15 different makes and models. Expertise with all was required to achieve effective radiation dose optimization.

Deadline pressure. To support its initiative, LifePoint used a grant from the Centers for Medicare & Medicaid Services Partnership for Patients Hospital Engagement Network program. The program had a short timeline: LifePoint Health had to show progress toward system-wide CT dose optimization within just one year. Given the scope and complexity of the challenge, LifePoint leadership formed a strategic partnership with LANDAUER® medical physicist consultants to advance the initiative.

Working together, LifePoint and the LANDAUER team developed a 5-step plan:

Define opportunities for improvement and establish goals through a 400-member educational collaborative. Collect baseline data from the three highest-volume CT examinations Analyze and standardize. The LANDAUER team analyzed the data, and then worked with the LifePoint team to develop standardized, Joint Commission-compliant protocols.

Educate and implement. Through the educational collaborative, the protocols were shared enterprise-wide for review by local medical physicists and staff. After review, the protocols were implemented.

Review. To measure the initiative’s impact, data were collected from 7,500 CT examinations at 99 different scanners over a period of two weeks. As a result, LifePoint Health found real opportunities for CT radiation dose optimization and a path for continuous improvement.