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My interpretation is that TJC is allowing some latitude for the facility or practice to define "proper. " Our workaround for Ohio's language requiring gonadal shielding "unless it would interfere with the radiologic procedure"</div>
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<div dir="ltr">My interpretation is that TJC is allowing some latitude for the facility or practice to define "proper."<div><br></div><div>Our workaround for Ohio's language requiring gonadal shielding "unless it would interfere with the radiologic procedure" was to define any shielding present within the field of view to "interfere with the radiologic procedure" whenever using digital image receptors. Ohio is pretty good about deferring to judgment calls by a medical physicist when they are made and documented prospectively.</div></div><br><div class="gmail_quote gmail_quote_container"><div dir="ltr" class="gmail_attr">On Tue, Jul 15, 2025 at 4:28 PM Mary Ellen Jafari 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="msg3569983730090926736">
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California Department of Public Health Radiological Health Bureau inspectors ask us about gonadal shielding but if we show them our policy stating that it is not used unless requested by the patient, caregiver, or guardian, they are fine with</div>
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<p class="MsoNormal">California Department of Public Health Radiological Health Bureau inspectors ask us about gonadal shielding but if we show them our policy stating that it is not used unless requested by the patient, caregiver, or guardian, they are fine
with that. The issue for them seems to be if we are following our policy or not.<u></u><u></u></p>
<p class="MsoNormal">MEJ<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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<p class="MsoNormal"><b><span style="font-size:11pt;font-family:Calibri,sans-serif">From:</span></b><span style="font-size:11pt;font-family:Calibri,sans-serif"> Jerry Thomas <<a href="mailto:jerry.thomas@ascension.org" target="_blank">jerry.thomas@ascension.org</a>>
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<b>Sent:</b> Tuesday, July 15, 2025 12:15 PM<br>
<b>To:</b> Rebecca Milman <<a href="mailto:milman@gmail.com" target="_blank">milman@gmail.com</a>><br>
<b>Cc:</b> Mary Ellen Jafari <<a href="mailto:MaryEllen.Jafari@kp.org" target="_blank">MaryEllen.Jafari@kp.org</a>>; DxMedPhys List <<a href="mailto:intl_dxmedphys_wd_osu_list@lists.osu.edu" target="_blank">intl_dxmedphys_wd_osu_list@lists.osu.edu</a>><br>
<b>Subject:</b> Re: [EXTERNAL] Re: [Intl_DxMedPhys] Revised TCJ standards 1/1/2026<u></u><u></u></span></p>
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<p class="MsoNormal">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.<u></u><u></u></p>
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<p class="MsoNormal">Jerry<u></u><u></u></p>
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<p class="MsoNormal"><span style="font-size:10pt;font-family:Tahoma,sans-serif">Jerry Thomas, MS, FAAPM, DABR, CHP, DABSNM</span><u></u><u></u></p>
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<p class="MsoNormal"><span style="font-size:10pt;font-family:Tahoma,sans-serif">Diagnostic Medical Physicist / Radiation Safety Officer</span><u></u><u></u></p>
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<p class="MsoNormal"><span style="font-size:10pt;font-family:Tahoma,sans-serif">Ascension Via Christi Hospitals Wichita</span><u></u><u></u></p>
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<p class="MsoNormal"><span style="font-size:10pt;font-family:Tahoma,sans-serif">Wichita, KS 67214</span><u></u><u></u></p>
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<p class="MsoNormal"><span style="font-size:10pt;font-family:Tahoma,sans-serif">Phone: 316-268-5958 (office)</span><u></u><u></u></p>
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<p class="MsoNormal"><span style="font-size:10pt;font-family:Tahoma,sans-serif"> 240-447-1014 (cell)</span><u></u><u></u></p>
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<p class="MsoNormal">On Tue, Jul 15, 2025 at 12:51<span style="font-family:Arial,sans-serif"> </span>PM Rebecca Milman 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:<u></u><u></u></p>
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<p class="MsoNormal"><span style="font-size:1pt;color:white">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<u></u><u></u></span></p>
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<p class="MsoNormal">Thanks, Mary Ellen. I had not seen this.<u></u><u></u></p>
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<p class="MsoNormal">I would hope TJC would consider local regulations and recommendations from national and international organizations about patient shielding. <u></u><u></u></p>
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<p class="MsoNormal">Out of curiosity, has anyone had a TJC (or any other) inspector ask about patient shielding in the past 10 years?<u></u><u></u></p>
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<p class="MsoNormal">Rebecca.<u></u><u></u></p>
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<p class="MsoNormal">On Tue, Jul 15, 2025 at 10:19<span style="font-family:Arial,sans-serif"> </span>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:<u></u><u></u></p>
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<p class="MsoNormal"><span style="font-size:1pt;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<u></u><u></u></span></p>
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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.
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<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.<u></u><u></u></p>
<p>•<span style="font-size:7pt;font-family:"Times New Roman",serif">
</span><i>Proper shielding is applied to a patient who is undergoing a procedure using ionizing radiation.
</i><u></u><u></u></p>
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<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</span><u></u><u></u></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">Chief Physicist and Regional Radiation Safety Officer</span><u></u><u></u></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif"> </span><u></u><u></u></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">Kaiser Permanente</span><u></u><u></u></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">Southern California Permanente Medical Group Medical Imaging Technology and Informatics</span><u></u><u></u></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">199 S. Los Robles Ave., Pasadena CA 91101</span><u></u><u></u></p>
<p class="MsoNormal"><span style="font-size:11pt;font-family:Calibri,sans-serif">626-430-1231 (office mobile)</span><u></u><u></u></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></span><u></u><u></u></p>
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