March 17, 2010 | | Comments 1
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Look beyond The Joint Commission for rules on who inspects imaging items

The Joint Commission does not specify in the environment of care standards who inspects imaging equipment, but where this all kind of spins out from is in the CMS Conditions of Participation (COPs).

The Joint Commission has been working very diligently– though often, seemingly, at the business end of a sharp stick — to come into closer compliance with the COPs.

The COPs section on nuclear medicine (and yes I recognize that imaging and nuclear medicine are not necessarily synonymous, but sometimes compliance becomes a function of how far you can stretch a concept) requires the following:

  • Nuclear medicine equipment must be maintained in safe operating condition and inspected, tested and calibrated at least annually by qualified personnel
  • The hospital must develop and implement a preventive maintenance schedule to ensure that nuclear medicine equipment is maintained in safe operating condition
  • Nuclear medicine equipment must be inspected, tested and calibrated at least annually by qualified personnel in accordance with federal and state laws, regulations, and guidelines

Things get a little squirrelly there at the end with the invocation of “qualified personnel,” which then becomes, to some extent, a self-determination exercise by the organization.

However, there is the further caveat relative to federal and state laws, etc., which, may define further what is expected. I would check with your states about the management of radiation safety programs (oversight of which used to be the territory of the Nuclear Regulatory Commission, but defaulted to the states some several years ago).

Generally, whenever you have a radiation safety program, you have a radiation physicist involved somewhere, maybe on a contract basis, and usually overseeing the quality control and assurance processes for the program.

But the actual maintenance of the equipment usually falls to the clinical engineers, again either as an in-house pursuit or on a contract basis, with the decision being based on the equipment involved and the expertise of those charged with maintaining the equipment.

Not everyone has the resources — human or otherwise — to manage imaging equipment in-house, given that imaging equipment is some of the most expensive in the inventory.

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Filed Under: Environment of care


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

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  1. And to throw a little gasoline on this fire… if you’re accredited under the Joint Commission’s ambulatory program and seek their Advanced Imaging Accreditation (which you MUST have from one of the accrediting bodies if you want to bill Medicare / Medicaid for the technical component of PET, CT or MRI, starting January 1, 2012), then you have to conform with new EC requirements for each modality. Right now, MRI is the only one that has black-and-white safety criteria (which might be appropriate since the others are addressed in the COPs).

    Specifically for MRI, there must be working practices to (minimally) address claustrophobia, code situations, contraindicated implants, and ferromagnetic projectiles. This will mean more than ‘oh, we have a paragraph about that in our P&P manual.’ This will mean real, demonstrable practices to help mitigate these risks.

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