Joint Commission Releases Fluoroscopy Standards

Medical Physics Consultants, Inc

Recently the Joint Commission approved revisions to their standards for organizations providing fluoroscopy services which will become effective January 1, 2019.   We knew this was coming and now you might be wondering how the new requirements will affect your operations. Read on to find out!


At least annually, hospitals providing fluoroscopic services will be required (through a diagnostic medical physicist) to evaluate the following elements:

  • Beam alignment and collimation
  • Tube potential/kilovolt peak (kV/kVp) accuracy
  • Half-value layer
  • High-contrast resolution
  • Low-contrast detectability
  • Maximum exposure rate in all imaging modes (this includes CINE and DSA)
  • Displayed air-kerma rate and cumulative-air kerma accuracy (when applicable)

Hospitals will also be responsible for verifying and documenting annually that individuals who use the equipment participate in ongoing education that includes the following:

  • Radiation dose optimization techniques for pediatric and adult patients addressed in Image Gently®
  • Safe operating procedures on all fluoroscopy equipment used

It should be noted the Joint Commission defines “individuals” to include physicians, non-physicians and ancillary personnel which means anyone who pushes the button on the fluoroscopy machine must have training.  We recognize this is going to be a challenge for many of you; be assured we are developing a suitable training module you will be able to obtain from your friendly MPC physicist before the requirement goes into effect.  

We, at MPC, view the three biggest challenges hospitals will face are the following:

  1. You will now be required to designate an individual as the Radiation Safety Officer
  2. You will now be required to identify skin dose thresholds and corresponding trigger levels for further review.   
  3. You will be required to document cumulative-air kerma or kerma-area product in a retrievable format.  

These three requirements will be somewhat easy for larger hospitals who are familiar with the concept of a Radiation Safety Officer through the nuclear medicine department, are well versed in peak skin dose measurements and perhaps are utilizing newer equipment with dose metric information.  Smaller hospital systems without a radiation safety officer, who don’t have a policy on monitoring radiation exposure and skin dose, or facilities using older equipment without cumulative-air kerma or kerma-area product displays are up for a challenge.

Let’s discuss the first hurdle:  the need to identify an individual to accept the responsibilities of the Radiation Safety Officer.  This individual will be responsible for making certain radiation services are provided in accordance with law, regulation, and organizational policy.  This person will also be held accountable for implementing the following:

  • Monitoring and verifying compliance with established radiation safety practices (including oversight of dosimetry monitoring)
  • Providing recommendations for improved radiation safety
  • Intervening as needed to stop unsafe radiation use practices
  • Implementing corrective action for those unsafe practices

The second challenge may be for hospitals to establish trigger and review levels for radiation exposure and skin dose.  This could be easy or very overwhelming, depending on the size of your institution and the support from your physics staff.

The final hurdle will be for facilities using fluoroscopy equipment that is not capable of displaying cumulative-air kerma or kerma-area product.  You will be responsible for recording the fluoroscopy time and number of images acquired in a retrievable format.

While this newest publication from the Joint Commission is focused on fluoroscopy you should also be aware there are several changes to the existing CT standard.  The requirement to evaluate slice thickness accuracy has been eliminated, slice position accuracy has been better defined and the requirement for ongoing education clarified to include all individuals, not only technologists as the standard implied previously.  

As is always true to the Joint Commission style, there are exceptions.  These requirements do not impact fluoroscopy equipment used for therapeutic radiation treatment or cone beam dental machines.  

Of course you can always call your MPC physicist to learn more on how we are moving forward with you to meet these requirements.