Gregg C. Daversa Director, Business Development West Physics The New Joint Commission Imaging Requirements – How to Ensure That Your Facility is Ready Gregg C. Daversa Director, Business Development West Physics

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

JC Accreditation Facts JC released the new imaging standards in “pre-publication” form on December 20, 2013 Effective date for the new standards will be July 1, 2014 New JC imaging standards will impact hospitals, critical access hospitals, and ambulatory care centers Modalities 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 changes Standards sections impacted are Environment of Care, Human Resources, Medication Management, Provision of Care, Treatment, Services, and Performance Improvement

What Prompted These Changes to the Standards Specific to Imaging? Progression of JC Sentinel Event Alert, Issue 47 to more formal standards Progression of historical JC National Patient & Safety Goals to more formal standards Patient 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 events

Environment of Care (EC)

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 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 noise

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 room Making sure that these restricted areas are controlled by and under the direct supervision of MRI-trained staff Posting 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

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

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.

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 CTDIvol Adult brain Adult abdomen Pediatric brain Pediatric abdomen Substitute procedures can be used if the above are not commonly performed at the facility

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

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) 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 evaluation

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 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 evaluation

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 uniformity High-contrast resolution/system spatial resolution Low-contrast resolution or detectability (N/A for planar acquisitions) Sensitivity Energy resolution Count-rate performance Artifact evaluation

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 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 performance

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 luminance Luminance uniformity Resolution Spatial accuracy

EC.02.06.05 – 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 equipment Prior 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)

EC.02.06.05 – 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.

Human Resources (HR)

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 verification

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) or Diagnostic 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.

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).

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 distress

Medication Management (MM)

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.

Provision of Care, Treatment, and Services (PC)

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 CT

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 values

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 parameters

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

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 range

PC.01.03.01 – Organization Provides For Diagnostic Testing (26) For CT, imaging protocols are reviewed and kept current with input from an: Interpreting radiologist Medical 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, Pelvis Physicist Technologist Radiologist

Performance Improvement (PI)

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 room

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.

PI.02.01.01 – Organization Compiles And Analyzes Data ACR National 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 organization

PI.02.01.01 – Organization Compiles And Analyzes Data CT 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)

Benefits Of CT Dose Tracking Software Accurate dose reporting and myriad analysis capabilities Identify studies that fall above or below median threshold dose values and allow corrective actions Proves success of dose reduction efforts Vehicle 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!

Factors To Address Before Purchase of CT Dose Tracking Software Full license purchase (outright purchase) or Subscription 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?

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, PET Radiation structural shielding design for CT, NM & PET by medical physicist Radiation 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 required

QUESTIONS Gregg c. daversa gregg.daversa@westphysics.com Phone: 866-275-WEST (9378) www.westphysics.com