Here are 10 Joint Commission citations imaging staff should watch out for in 2016

Here are 10 Joint Commission citations imaging staff should watch out for in 2016

by John W. Mitchell, Senior Correspondent | January 12, 2016
CT MRI Risk Management X-Ray
In an online webinar conducted yesterday by the Association for Medical Imaging Management (AHRA), hospital-based imaging managers got a rundown on recent Joint Commission imaging citations, as well as a word of caution.

“The main takeaway is to be ready to support recent and new standards, such as medical management and provisions of care for performance improvement,” Judith Atkins, MSN and President/CEO of McKenna Consulting told HCB News. “A lot has changed in recent years, based on CMS influence. CMS considers imaging to be a very important modality and they want surveyors to look at the service aggressively.”

She noted that scoring in 2016 would be the same as in 2015. However, she gave many examples in her presentation of recent non-compliances that are either becoming more common or are likely to increase in hospital imaging department Joint Commission surveys. These included:

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  • C-arm and other portable devices being held to operating room standards.

  • Disinfectant protocols that do not allow that table to dry in time to be fully effective before placing another patient on the table.

  • Imaging equipment protocols not offering the same standard of care throughout the hospital, such as hospital-owned physician practices or between the cardiology and imaging departments.

  • Patient tubes being placed on the patient’s stomach (contamination) during transport to the imaging department

  • Imaging techs conducting airway reviews that do not have this function identified in their job description or have documented training.

  • Evidence of proper history and physicals conducted by radiologists, and generation of immediate post procedure reports.

  • Building engineering safety violations lacking proper long-term corrective plans and funding.

  • Properly documented protocols to prove that patients are not being over-radiated.

  • Properly using the two-identifier system (and matching with the order).

  • Matching imaging physician protocols with protocols in the medical staff bylaws.


“While we have not seen a lot of citations for immediate threat to life, safety, and environment, of care standards yet, this could change at any time,” Atkins stressed. She also added that there are 23 conditions of participation required for a hospital to be reimbursed by Medicare. Recently, radiology departments have often been involved in some failure of physical services, which must be corrected within 45 days.

While the survey demands year-round commitment to process improvement, the intent is better patient care. She said it is important in a successful survey for the imaging staff to be able to articulate how they are living the standards, as well as proving their actions through proper documentation.

“CMS, through the accreditation process, wants you (imaging departments) to reduce risk and improve safety,” stressed Atkins. “So be proactive in understanding what others in imaging have learned though the (recent) survey process.”

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