Presentation on theme: "Gregg C. Daversa Director, Business Development West Physics"— Presentation transcript:
1 Gregg C. Daversa Director, Business Development West Physics The New Joint Commission Imaging Requirements – How to Ensure That Your Facility is ReadyGregg C. DaversaDirector, Business DevelopmentWest Physics
2 ObjectivesIdentify which JC-accredited facilities will be impacted by the 2014 standard changes, and the dates for full complianceIdentify which imaging modalities will be affectedDiscuss 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 survey
3 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, Treatment, Services, and Performance Improvement
4 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 standardsNeed for greater parity with other imaging industry standards such as those of the ACR and IAC accreditation programsVarious highly publicized imaging-related medical events
6 EC.02.01.01 – Organization Manages Safety 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 distressPatients who may require urgent or emergent medical carePatients with medical implants, devices, or imbedded foreign objects (e.g. shrapnel, etc.)Ferromagnetic objects entering the MRI environmentAcoustic noise
7 EC.02.01.01 – Organization Manages Safety 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 roomMaking 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 operator
8 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 limits
9 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.
10 EC.02.04.03 – Organization Inspects, 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 CTDIvolAdult brainAdult abdomenPediatric brainPediatric abdomenSubstitute procedures can be used if the above are not commonly performed at the facility
11 EC.02.04.03 – Organization Inspects, 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 documentedThis EP is only applicable to CT systems capable of displaying radiation dose in the form of CTDIvol
12 EC.02.04.03 – Organization Inspects, 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) uniformitySlice thickness accuracySlice position accuracy (when prescribed from a scout image)Alignment light accuracyTable travel accuracyRadiation beam widthHigh-contrast resolutionLow-contrast resolutionGeometric or distance accuracyCT number accuracyArtifact evaluation
13 EC.02.04.03 – Organization Inspects, 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 clinicallySNR for all coils used clinicallySlice thickness accuracySlice position accuracyAlignment light accuracyHigh-contrast resolutionLow-contrast resolution (or CNR)Geometric or distance accuracyMagnetic field homogeneityArtifact evaluation
14 EC.02.04.03 – Organization Inspects, 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 uniformityHigh-contrast resolution/system spatial resolutionLow-contrast resolution or detectability (N/A for planar acquisitions)SensitivityEnergy resolutionCount-rate performanceArtifact evaluation
15 EC.02.04.03 – Organization Inspects, 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 uniformityHigh-contrast resolution/system spatial resolutionLow-contrast resolution or detectability (N/A for planar acquisitions)Artifact evaluationTests recommended but not required:SensitivityEnergy resolutionCount-rate performance
16 EC.02.04.03 – Organization Inspects, 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 luminanceLuminance uniformityResolutionSpatial accuracy
17 EC – Organization Manages Its Environment During Demolition, Renovation, Or New Construction To Reduce Risk To Those In The Organization(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 equipmentPrior to modification to rooms where ionizing radiation will be emitted or radioactive materials will be stored (e.g., scan rooms or hot labs)
18 EC – Organization Manages Its Environment During Demolition, Renovation, Or New Construction To Reduce Risk To Those In The Organization(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 verify the adequacy of installed shielding. This survey is conducted prior to clinical use of the room.
20 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) orNuclear Medicine Technology Certification Board (NMTCB) andTrained and experienced in the operation of CT equipmentWPC Note: Best practice is to conduct primary source verification
21 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 orDiagnostic Radiological Physics by the Canadian College of Physicists in Medicine orA 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, andFormal 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, andDocumented experience in a clinical CT environment conducting at least 10 CT performance evaluations under the direct supervision of a board-certified medical physicist.
22 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).
23 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, NSFPatient positioning to avoid RF burnsEquipment and supplies acceptable to be safely used in MRI environmentSafety response procedures for patients who need emergent medical careMRI equipment emergency shutdown procedures (e.g., magnet quench)Patient hearing protectionPatient claustrophobia, anxiety, emotional distress
25 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.
26 Provision of Care, Treatment, and Services (PC)
27 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 measurementDoes not apply to radiation therapy treatment planning (SIM CT) or attenuation correction-only CT
28 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 reportApplicable to only CT scanners capable of calculating and displaying radiation dose values
29 PC.01.02.15 – Organization Provides For Diagnostic Testing (10) Prior to conducting a diagnostic imaging study, the facility verifies the following:Correct patientCorrect imaging siteCorrect patient positioningCT only: Correct imaging protocolCT only: Correct scanner parameters
30 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 criteria
31 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 indicationContrast administrationAge (pediatric or adult)Patient size and body habitusExpected radiation dose range
32 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 physicistLead imaging technologistTo 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:AAPMAdult Brain, Brain perfusion, Chest, ABD, PelvisPhysicistTechnologistRadiologist
34 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 roomInjuries resulting from the presence of ferromagnetic items in the MRI scanner room
35 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 technologyACR Dose Index Registry, NEXT and other external benchmarks.
36 PI.02.01.01 – Organization Compiles And Analyzes Data ACRNational 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 worldCost to participate: $ one time entry feeAnnual fee ranges from $ to $10,000 depending of number of radiologists working at facility and number of distinct locations within the organization
38 Benefits Of CT Dose Tracking Software Accurate 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 recordArchive for patient dose valuesCompare dose values to other databasesReads DICOM format and/or utilizes OCRReduce patient radiation dose!
39 Factors To Address Before Purchase of CT Dose Tracking Software Full license purchase (outright purchase) orSubscription model (pay for each study)Age, make, and model of CT scanner (structured report)Single or multi-site installationNetwork bandwidthManage dose values through PACS, RIS, EHRCompatibility with dictation vendor and versionManage patients with different unique identifier numbers in same networkIT dept. must be part of the dose tracking implementationFinally – who will actually manage it?
40 8 Key Important Take Home Points July 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 physicistMinimum credentialing requirements for technologists and medical physicistsRecord, track and analyze patient CT radiation doseAnalyze and benchmark CT and MRI safety dataAnnual dose reduction and MRI safety training required