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I tried sending the pdf but it bounces back as exceeding the OHSU file size limit. Mary Ellen Jafari, MS, DABR (D,N), MRSE, MRSO, FACR, FAAPM, CIIP Chief Physicist and Regional Radiation Safety Officer Kaiser Permanente Southern California Permanente</div>
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<p class="MsoNormal">I tried sending the pdf but it bounces back as exceeding the OHSU file size limit.
<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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<p class="MsoNormal"><b><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">From:</span></b><span style="font-size:11.0pt;font-family:"Calibri",sans-serif"> Di Zhang <skintchenzhang@gmail.com>
<br>
<b>Sent:</b> Wednesday, July 16, 2025 11:10 AM<br>
<b>To:</b> Mary Ellen Jafari <MaryEllen.Jafari@kp.org><br>
<b>Cc:</b> DxMedPhys List <intl_dxmedphys_wd_osu_list@lists.osu.edu><br>
<b>Subject:</b> Re: [Intl_DxMedPhys] Revised TCJ standards 1/1/2026<o:p></o:p></span></p>
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<p class="MsoNormal"><o:p> </o:p></p>
<p><strong><span style="font-size:13.5pt;font-family:"Aptos",sans-serif;color:red">Caution:
</span></strong><span style="font-size:13.5pt;color:red">This email came from outside Kaiser Permanente. Do not open attachments or click on links if you do not recognize the sender.</span><o:p></o:p></p>
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<p class="MsoNormal">Thank you Mary Ellen for this important information. Could you please attach the new Hospital Accreditation Survey Process Guide? I don't think it was included in your email.<o:p></o:p></p>
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<p class="MsoNormal"><o:p> </o:p></p>
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<p class="MsoNormal">Regards,<o:p></o:p></p>
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<p class="MsoNormal">Di Zhang, PhD, MBA, DABR, DABSNM<o:p></o:p></p>
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<p class="MsoNormal">Radiological Science<o:p></o:p></p>
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<p class="MsoNormal">UCLA School of Medicine<o:p></o:p></p>
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<p class="MsoNormal"><o:p> </o:p></p>
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<p class="MsoNormal">On Tue, Jul 15, 2025 at 9:19<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">intl_dxmedphys_wd_osu_list@lists.osu.edu</a>>
wrote:<o:p></o:p></p>
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<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>
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<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto">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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto">I don’t think there are any major changes in the content though.<o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"> <o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto">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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"> <o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto">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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"> <o:p></o:p></p>
<p class="m219133144875539811default">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="m219133144875539811default">•<span style="font-size:7.0pt;font-family:"Times New Roman",serif">
</span><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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"> <o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto">Mary Ellen<o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"> <o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif"> </span><o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif">Kaiser Permanente</span><o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><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" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><span style="font-size:11.0pt;font-family:"Calibri",sans-serif"><a href="mailto:Maryellen.Jafari@kp.org" target="_blank"><span style="color:#467886">Maryellen.Jafari@kp.org</span></a></span><o:p></o:p></p>
<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"> <o:p></o:p></p>
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<p class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto"><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 are prohibited from sharing, copying, or otherwise using or disclosing its contents. If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently
delete this e-mail and any attachments without reading, forwarding or saving them. v.173.295 Thank you.</span><o:p></o:p></p>
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<p class="MsoNormal"><o:p> </o:p></p>
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<p class="MsoNormal"><span class="gmailsignatureprefix">-- </span><o:p></o:p></p>
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<p class="MsoNormal">Regards,<o:p></o:p></p>
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<p class="MsoNormal">Di<o:p></o:p></p>
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