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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.<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.<span style="color:windowtext"><o:p></o:p></span></p>
<p class="Default" style="margin-left:0in;text-indent:0in;mso-list:l0 level1 lfo1">
<![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.
<o:p></o:p></i></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<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">Chief Physicist and Regional Radiation Safety Officer<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">Kaiser Permanente<o:p></o:p></span></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<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">199 S. Los Robles Ave., Pasadena CA 91101<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">626-430-1231 (office mobile)<o:p></o:p></span></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><o:p></o:p></span></p>
<p class="MsoNormal"><o:p> </o:p></p>
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