At the 2018 AAPM Spring Clinical Meeting in Las Vegas, Dr. Andrea Browne of The Joint Commission (TJC) presented on proposed updates to TJC's Elements of Performance relevant to diagnostic imaging.

Dr. Browne began with a review of all the Environment of Care standards that apply to diagnostic imaging, including several that have recently been moved or re-categorized. She also touched on sections in Human Resources, Leadership, Medication Management, Medical Staff, Provision of Care, and Performance Improvement and reviewed the new requirement as of January 1, 2018 that facilities keep a "library" of service and maintenance manuals for all their medical equipment. Dr. Browne took time to show the top citations for ambulatory care centers (IC.02.02.01, "The organization reduces the risk of infections associated with medical equipment, devices, and supplies," 60%) and hospitals (L5.02.01.35, "The hospital provides and maintains systems for extinguishing fires, 86%). Of MRI and CT standards scored in 2017, the top citation was for MRI Safety (25%) and for CT Protocol Review (25%), respectively. Dr. Browne also shared some typical surveyor observations, such as employees not wearing dosimeter badges and no process for reviewing thermal injuries.

In the final part of Dr. Browne's presentation, which drew the most attention from the audience, she discussed proposed changes to the standards relating to fluoroscopy. The proposed changes, which are available here, relate to all fluoroscopic procedures performed at accredited hospitals, critical access hospitals, ambulatory care, and office-based medical facilities. TJC would require specific tests performed annually on fluoroscopic equipment, such as "high-contrast resolution," "low-contrast resolution," "exposure rate for typical exams" (to a phantom, Dr. Browne clarified), and "automatic dose rate and automatic exposure control function performance." TJC would also add fluoroscopy procedures to its requirement for maintaining and reviewing protocols, which previously only applied to computed tomography. Also like CT, fluoroscopy procedures that exceed specified dose threshold set by the facility would require investigation (the current language says "ranges" but Dr. Browne informed the audience that it would be updated to a threshold). Under the proposed revisions, the "radiation safety officer" (RSO) would be defined to "mak[e] certain that radiologic services are provided in accordance with law, regulation, and organizational policy." Dr. Browne admitted that RSO was the best name they could think of for the role, acknowledging that the position was already well defined.

The revisions also tighten credentialing and education requirements for individuals operating fluoroscopic equipment, who Dr. Browne defined as whoever sets up and activates the machine. According to Dr. Browne, the proposed changes were motivated by the concern of TJC members that many technologists and physicians who employ and operate fluoroscopic equipment don't have a complete understanding of the equipment capabilities and dose reduction methods. She noted that the Joint Commission goes through an extensive literature review as well as technical advisory and standards review panels when implementing or changing standards.

After the presentation, several physicists present had the opportunity to ask Dr. Browne specific questions about the proposed changes to the standards. Many physicists spoke up about the annual testing requirement, which allows health physicists as well as medical physicists to perform the required tests. One physicist noted that the potential for damaging radiation effects were highest in fluoroscopic systems among all diagnostic modalities and expressed concern that health physicists may not have the required training to test this equipment effectively. Dr. Browne responded that TJC has received considerable input from the Health Physics community to consider the competency of health physicists in regards to supporting patient safety through the use of fluoroscopic equipment. Several physicists also were concerned that the language for fluoroscopic testing didn't allow for assistance, as for computed tomography, magnetic resonance, and nuclear medicine. Dr. Browne assured the attendees that the language would be updated to match the other modalities. Other physicists expressed concern that it was impossible to police physicians on the use of radiation during fluoroscopic procedures and that the modality of fluoroscopy didn't lend itself to the use of CT-like "protocols." Dr. Browne noted that "protocol" is probably a poor choice of words for the requirement. Another physicist concern brought up during the meeting was the expanded role of the RSO. Dr. Browne responded that she believed that someone needed to fill this proposed role in healthcare facilities. She noted that TJC has already received a lot of feedback from the medical physics community on the proposed requirements and that changes were certain to be made. Comments on the new requirements were being accepted until April 20, 2018. The Joint Commission will then review the input and revise the standards, and may re-issue for comment before they are finalized July 1, 2018, and take effect in January, 2019.