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Very important to be able to locate while TJC is on site is the definition of annual. We’ll need to find out whether the location of the quote below has changed – it’s currently in the Environment of Care Chapter just BEFORE the Chapter Outline. </div>
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<p class="MsoNormal"><span style="font-size:11.0pt">Very important to be able to locate while TJC is on site is the definition of annual. We’ll need to find out whether the location of the quote below has changed – it’s currently in the Environment of Care
Chapter just BEFORE the Chapter Outline.<o:p></o:p></span></p>
<p class="p1"><o:p> </o:p></p>
<p class="p1"><o:p> </o:p></p>
<p class="MsoNormal"><span style="font-size:14.0pt">Annually/every 12 months/once a year/every year = 1 year from the last event, plus or minus 30 days</span><span style="font-size:11.0pt"><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt">If you can’t tell them <u>where this is in the TJC standard</u> while TJC is on site and you’re even one day past 365, then you’ll be cited for it.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt"><o:p> </o:p></span></p>
<div>
<p class="MsoNormal" style="text-autospace:none"><span style="font-family:"Calibri",sans-serif;color:black;mso-ligatures:none">Peace,<o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-family:"Calibri",sans-serif;color:black;mso-ligatures:none">Loretta<o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace:none"><b><span style="font-family:"Calibri",sans-serif;color:#1E6B52;mso-ligatures:none"><o:p> </o:p></span></b></p>
<p class="MsoNormal" style="text-autospace:none"><b><span style="font-family:"Calibri",sans-serif;color:#1A5632;mso-ligatures:none">Loretta Johnson, Ph.D., DABR, FAAPM | Assistant Professor</span></b><b><span style="font-family:"Calibri",sans-serif;color:#1E6B52;mso-ligatures:none"><o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:10.5pt;font-family:"Calibri",sans-serif;mso-ligatures:none">Director | Division of Physics and Engineering<o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:10.5pt;font-family:"Calibri",sans-serif;mso-ligatures:none">Department of Radiology | Heersink School of Medicine<o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:10.5pt;font-family:"Calibri",sans-serif;mso-ligatures:none">UAB | The University of Alabama at Birmingham<o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:10.5pt;font-family:"Calibri",sans-serif;mso-ligatures:none">GSB Suite #301 | 619 19<sup>th</sup> Street South | Birmingham, AL 35249<o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-size:10.5pt;font-family:"Calibri",sans-serif;mso-ligatures:none">P: 205.934.7592 |<span style="color:#1A5632">
<a href="mailto:lorettajohnson@uabmc.edu"><span style="color:#1A5632">lorettajohnson@uabmc.edu</span></a></span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-family:"Calibri",sans-serif;mso-ligatures:none"><o:p> </o:p></span></p>
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<p class="MsoNormal"><span style="font-family:"Calibri",sans-serif;color:#1A5632;mso-ligatures:none"><a href="https://urldefense.com/v3/__https://www.uab.edu/medicine/radiology/__;!!KGKeukY!wKaINCwEeNju5locnXeqaBMdKrQWs0463O-CbHR96XJEVZSSlZHj4b8n0Ifx86LD-L2SOTHRCpoIR_fg0ikajn91Jl8h58RD7sbVR11b7Qvw-vYPhw$"><span style="color:#1A5632">https://www.uab.edu/medicine/radiology/</span></a></span><span style="font-size:11.0pt"><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt"><o:p> </o:p></span></p>
<div style="border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt 0in 0in 0in">
<p class="MsoNormal"><b><span style="font-family:"Calibri",sans-serif;color:black">From:
</span></b><span style="font-family:"Calibri",sans-serif;color:black">Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces@lists.osu.edu> on behalf of Dxmedphys new list <intl_dxmedphys_wd_osu_list@lists.osu.edu><br>
<b>Reply-To: </b>Mary Ellen Jafari <MaryEllen.Jafari@kp.org><br>
<b>Date: </b>Tuesday, July 15, 2025 at 11:20 AM<br>
<b>To: </b>Dxmedphys new list <intl_dxmedphys_wd_osu_list@lists.osu.edu><br>
<b>Subject: </b>EXT MSG [Intl_DxMedPhys] Revised TCJ standards 1/1/2026</span><span style="font-family:"Calibri",sans-serif;color:black;mso-ligatures:none"><o:p></o:p></span></p>
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<div>
<p class="MsoNormal"><o:p> </o:p></p>
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<div>
<p class="MsoNormal" style="mso-line-height-alt:.75pt"><span style="font-size:1.0pt;color:white">In case you haven’t heard, TJC is consolidating and revising its requirements effective 1/1/2026 to more closely align with CMS requirements. The EPs specific to
imaging and radioactive materials will be in different sections and have<o:p></o:p></span></p>
</div>
<p class="MsoNormal">In case you haven’t heard, TJC is consolidating and revising its requirements effective 1/1/2026 to more closely align with CMS requirements. The EPs specific to imaging and radioactive materials will be in different sections and have
different reference numbers.<o:p></o:p></p>
<p class="MsoNormal">I don’t think there are any major changes in the content though.<o:p></o:p></p>
<p class="MsoNormal"> <o:p></o:p></p>
<p class="MsoNormal">As an example, the Environment of Care and Life Safety chapters have been replaced with a new Physical Environment (PE) chapter.
<o:p></o:p></p>
<p class="MsoNormal"> <o:p></o:p></p>
<p class="MsoNormal">I have attached a very helpful document that lists each EP and its new location and number. I have also attached the new Hospital Accreditation Survey Process Guide which is the guide the surveyors use. The Hospital Radiologic Services
Evaluation Module starts on page 188. <o:p></o:p></p>
<p class="MsoNormal"> <o:p></o:p></p>
<p class="Default">One item that concerns me in the Hospital Radiologic Services Evaluation module is on page 192. It sounds like TJC is not on same page as AAPM, however I would think that as long as we are following our facility policy, we should be fine.<o:p></o:p></p>
<p class="Default" style="margin-left:0in;text-indent:0in;mso-list:l0 level1 lfo2">
<![if !supportLists]><span style="mso-list:Ignore">•<span style="font:7.0pt "Times New Roman"">
</span></span><![endif]><i>Proper shielding is applied to a patient who is undergoing a procedure using ionizing radiation.
</i><o:p></o:p></p>
<p class="MsoNormal"> <o:p></o:p></p>
<p class="MsoNormal">Mary Ellen<o:p></o:p></p>
<p class="MsoNormal"> <o:p></o:p></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">Mary Ellen Jafari, MS, DABR (D,N), MRSE, MRSO, FACR, FAAPM, CIIP</span><o:p></o:p></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">Chief Physicist and Regional Radiation Safety Officer</span><o:p></o:p></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif"> </span><o:p></o:p></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">Kaiser Permanente</span><o:p></o:p></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">Southern California Permanente Medical Group Medical Imaging Technology and Informatics</span><o:p></o:p></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">199 S. Los Robles Ave., Pasadena CA 91101</span><o:p></o:p></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">626-430-1231 (office mobile)</span><o:p></o:p></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif"><a href="mailto:Maryellen.Jafari@kp.org"><span style="color:#467886">Maryellen.Jafari@kp.org</span></a></span><o:p></o:p></p>
<p class="MsoNormal"> <o:p></o:p></p>
<p class="MsoNormal"><b><span style="font-size:8.0pt;font-family:"Arial",sans-serif;color:blue">NOTICE TO RECIPIENT:</span></b><span style="font-size:8.0pt;font-family:"Arial",sans-serif;color:black"> If you are not the intended recipient of this e-mail, you
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