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<div dir="ltr"><div>We have had inspectors ask about the availability of lead aprons in the x-ray room -- for those who may need to hold a patient; but, no inspector to my knowledge has asked about patient shielding.</div><div><br></div><div>Jerry</div><div><div dir="ltr" class="gmail_signature" data-smartmail="gmail_signature"><div dir="ltr"><div><div dir="ltr"><div><div dir="ltr"><div><div><font size="2" face="Tahoma"><br></font></div><div><font size="2" face="Tahoma"><br></font></div><div><font size="2" face="Tahoma">Jerry Thomas, MS, FAAPM, DABR, CHP, DABSNM</font></div>
<div><font size="2" face="tahoma">Diagnostic Medical Physicist / Radiation Safety Officer</font></div>
<div><font size="2" face="tahoma">Ascension Via Christi Hospitals Wichita</font></div>
<div><font size="2" face="tahoma">Wichita, KS 67214</font></div>
<div><font size="2" face="tahoma"></font> </div>
<div><font size="2" face="tahoma">Phone: 316-268-5958 (office)</font></div>
<div><font size="2" face="tahoma"> 240-447-1014 (cell)</font></div></div></div></div></div></div></div></div></div><br></div><br><div class="gmail_quote gmail_quote_container"><div dir="ltr" class="gmail_attr">On Tue, Jul 15, 2025 at 12:51 PM Rebecca Milman via Intl_dxmedphys_wd_osu_list <<a href="mailto:intl_dxmedphys_wd_osu_list@lists.osu.edu">intl_dxmedphys_wd_osu_list@lists.osu.edu</a>> wrote:<br></div><blockquote class="gmail_quote" style="margin:0px 0px 0px 0.8ex;border-left:1px solid rgb(204,204,204);padding-left:1ex"><div class="msg-8402208508464580232">
<div style="font-size:1px;color:rgb(255,255,255);line-height:1px;height:0px;max-height:0px;opacity:0;overflow:hidden;display:none">
Thanks, Mary Ellen. I had not seen this. I would hope TJC would consider local regulations and recommendations from national and international organizations about patient shielding. Out of curiosity, has anyone had a TJC (or any other) inspector</div>
<div style="font-size:1px;color:rgb(255,255,255);line-height:1px;max-height:0px;opacity:0;overflow:hidden;display:none"></div>
<div dir="ltr">Thanks, Mary Ellen. I had not seen this.<div><br></div><div>I would hope TJC would consider local regulations and recommendations from national and international organizations about patient shielding. </div><div><br></div><div>Out of curiosity, has anyone had a TJC (or any other) inspector ask about patient shielding in the past 10 years?</div><div><br></div><div>Rebecca.</div></div><br><div class="gmail_quote"><div dir="ltr" class="gmail_attr">On Tue, Jul 15, 2025 at 10:19 AM Mary Ellen Jafari via Intl_dxmedphys_wd_osu_list <<a href="mailto:intl_dxmedphys_wd_osu_list@lists.osu.edu" target="_blank">intl_dxmedphys_wd_osu_list@lists.osu.edu</a>> wrote:<br></div><blockquote class="gmail_quote" style="margin:0px 0px 0px 0.8ex;border-left:1px solid rgb(204,204,204);padding-left:1ex"><div>
<div style="font-size:1px;color:rgb(255,255,255);line-height:1px;height:0px;max-height:0px;opacity:0;overflow:hidden;display:none">
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</div>
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<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.<u></u><u></u></p>
<p class="MsoNormal">I don’t think there are any major changes in the content though.<u></u><u></u></p>
<p class="MsoNormal"><u></u> <u></u></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.
<u></u><u></u></p>
<p class="MsoNormal"><u></u> <u></u></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. <u></u><u></u></p>
<p class="MsoNormal"><u></u> <u></u></p>
<p>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.<span style="color:windowtext"><u></u><u></u></span></p>
<p style="margin-left:0in;text-indent:0in">
<u></u><span>•<span style="font:7pt "Times New Roman"">
</span></span><u></u><i>Proper shielding is applied to a patient who is undergoing a procedure using ionizing radiation.
<u></u><u></u></i></p>
<p class="MsoNormal"><u></u> <u></u></p>
<p class="MsoNormal">Mary Ellen<u></u><u></u></p>
<p class="MsoNormal"><u></u> <u></u></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">Mary Ellen Jafari, MS, DABR (D,N), MRSE, MRSO, FACR, FAAPM, CIIP<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">Chief Physicist and Regional Radiation Safety Officer<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">Kaiser Permanente<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">Southern California Permanente Medical Group Medical Imaging Technology and Informatics<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">199 S. Los Robles Ave., Pasadena CA 91101<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">626-430-1231 (office mobile)<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif"><a href="mailto:Maryellen.Jafari@kp.org" target="_blank"><span style="color:rgb(70,120,134)">Maryellen.Jafari@kp.org</span></a><u></u><u></u></span></p>
<p class="MsoNormal"><u></u> <u></u></p>
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