Standards 2011–2012: What The Joint Commission Wants From Hospital Imaging Departments

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Judith M. Atkins, RN, MSNThe Joint Commission’s 2011–2012 standards will bring changes for hospital radiology departments, according to Judith M. Atkins, RN, MSN, president and CEO of McKenna Consulting in Charleston, West Virginia, and Robert A. Wise, MD, medical advisor to the Joint Commission’s Division of Healthcare Quality Evaluation. Atkins outlined some of these changes in “Joint Commission 2011–2012: Update for Hospital Imaging Department,” presented in Dallas, Texas, on August 15, 2011, during the annual meeting of AHRA: The Association For Medical Imaging Management; Wise provided comments later. Changes in accreditation requirements and processes implemented in line with Joint Commission standards are not specific to radiology, Wise observes. They will affect hospital imaging departments in a variety of areas, however. Key Changes One such area is personnel. Hospitals must now have in place a chief nurse, with oversight responsibility for nursing wherever it occurs, including the imaging department. Consequently, Atkins points out, “It’s important that you be able to show that your radiology nurses have some connection to your chief nurse, whether it is via quarterly report or by attending some meetings.” Similarly, the 2011–2012 requirements place a renewed emphasis on scope of practice. Under this umbrella, radiology-department staff members are permitted to perform only those tasks for which they are qualified by their licensure, registration, or certification. No exceptions are permitted. In a slightly different vein, a modification to the accreditation-participation requirement mandates that the CEO of all participating organizations must sign a contract agreeing to meet all these accreditation requirements in order to participate in the accreditation process. The executive must certify that information pertaining to incidents and initiatives, whether occurring before, during, or after an accreditation survey, is truthful and accurate. Atkins says that this might cause headaches for hospital radiology departments, noting, “When physicians predocument a postprocedural note—and there are many physicians who do so before the procedure—it is fraud, as far as the Joint Commission is concerned. “
 In keeping with new accreditation processes implemented for 2011–2012, the Joint Commission will use tracer methodology, wherein surveyors will evaluate radiology and other specific diagnostic areas based on patient care. Systems and processes will be scrutinized in accordance with the experiences of individual patients, as opposed to those of patients as a whole. “The Joint Commission standard is the goal you need to reach, and the element of performance (EP) is the action step you need to take to reach the goal,” Atkins explains. All EPs listed in the 2011–2012 Joint Commission manual bear a designation of A or C; compliance with EPs designated A is assessed according to whether an adverse event or deviation from a requirement did not occur at all or, if it did, how many times it occurred, while compliance with EPs designated C is assessed on the basis of frequency or percentage. Numeric scores assigned for EP compliance range from 0 to 2, with 0 indicating noncompliance (less than 80%, or three occurrences); 1 indicating partial compliance (80% to 89%, or two occurrences); and 2 indicating full compliance (90% to 100%, or one occurrence). When representatives of the Joint Commission are actually at hospitals’ doors, Atkins observes, they consider occurrences instead of percentages in applying the tracer methodology. “If they’re looking for the medical-history and physician-examination update and find one not done, that’s one occurrence, and you can still be compliant,” she says, “but by the third one, you’re out—it’s a zero.” She adds that the Joint Commission has produced additional EPs to align with the conditions of participation, and will continue to do so. Hospitals will also be issued requirements for improvement when they are found to be in partial compliance with an EP. Over the next year, Atkins and Wise say, hospital radiology departments can also expect the Joint Commission to focus more keenly on imaging quality and safety. Wise says, “We are thinking about how to assess whether radiology departments are addressing areas of concern—for instance, whether they are identifying problems with their procedures and introducing measures to rectify them, how they determine whether their staff understand the technology and whether it is working properly, and what information needs to be shared with patients that currently is not being shared, and that is just scratching the surface.” Getting Ready Hospital radiology departments can take a number of steps to grapple with these changes in processes and these new areas of focus, Wise and Atkins say. Wise adds, “As far as the closer look at safety is concerned, we would hope that the recommendations contained in issue 47 of our Sentinel Event Alert1 would be adopted as basic guidelines” that set forth what to do and what not to do in terms of using diagnostic radiology. In the alert, the Joint Commission advocates that diagnostic radiation be used sparingly and cautiously, and that information about patients’ recent exposure to radiation in the course of their care be obtained from other providers prior to subjecting them to additional procedures. 
 “Experts disagree about the extent of the risks of cancer from diagnostic imaging, but they do concur that care should be taken to weigh the medical necessity of a given level of radiation exposure against the risks, and that steps should be taken to eliminate avoidable exposure to radiation,” Wise explains, pointing out that the alert focuses on diagnostic radiation alone and covers neither therapeutic radiation nor fluoroscopy.
 As for specific practices that health-care providers might employ to reduce patients’ exposure to radiation, the alert recommends the use of imaging techniques other than CT, such as ultrasound or MRI, coupled with collaboration between radiologists and referring physicians about the appropriate use of diagnostic imaging. Radiologists are also asked to ensure that the proper protocol is in place for each patient and to review all protocols against the latest evidence annually (or at least every two years). Also recommended is the implementation of centralized quality and safety monitoring for all imaging equipment that can emit high amounts of radiation on a cumulative basis.
 Just as significantly, Wise says, hospital radiology departments can—and should—assess whether current processes truly support patient safety and quality of care or are an impediment to them. “To my knowledge, over-radiation has rarely, if ever, been caused by equipment itself, but rather, by a lack of technologist education,” he notes. To illustrate his point, he cites a case in which a patient was found to have been given an excessive dose of radiation “not because there was something wrong with the machine, but because the technologists did not know the meaning of the numbers,” he says. Atkins concurs, adding that taking into account and planning for factors that might not otherwise come into play is key, given new safety goals and the increased use of unannounced surveys by the Joint Commission (both at the behest of CMS and for its own purposes). She deems cardiac catheterization a case in point. “One of the new national safety goals is aimed at the prevention of urinary-tract infections, and radiology has a role here, with Foley catheters and how they are handled,” Atkins says. “If I were you, I would look into this now. It’s a big national emphasis.” Transplants are another example. Transplant safety, Atkins reports, can affect radiology if a department does anything with tissue management and catheterization-laboratory implants. This is the case even in environments where tissue is not actually transplanted into patients, but merely removed, she says. In general, Atkins advises, preparation should be executed for the next patient, not in anticipation of a visit from the next set of surveyors. She asks, “Why wouldn’t you do these things all the time, if they proactively reduce risk?” Julie Ritzer-Ross is a contributing writer for