[Intl_DxMedPhys] Revised TCJ standards 1/1/2026

[Rebecca Milman]

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 ask about
patient shielding in the past 10 years?

Rebecca.

On Tue, Jul 15, 2025 at 10:19 AM Mary Ellen Jafari via
Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:

> 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
>
> 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.
>
> I don’t think there are any major changes in the content though.
>
>
>
> As an example, the Environment of Care and Life Safety chapters have been
> replaced with a new Physical Environment (PE) chapter.
>
>
>
> 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.
>
>
>
> 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.
>
> •                   *Proper shielding is applied to a patient who is
> undergoing a procedure using ionizing radiation. *
>
>
>
> Mary Ellen
>
>
>
> Mary Ellen Jafari, MS, DABR (D,N), MRSE, MRSO, FACR, FAAPM, CIIP
>
> Chief Physicist and Regional Radiation Safety Officer
>
>
>
> Kaiser Permanente
>
> Southern California Permanente Medical Group Medical Imaging Technology
> and Informatics
>
> 199 S. Los Robles Ave., Pasadena CA 91101
>
> 626-430-1231 (office mobile)
>
> Maryellen.Jafari at kp.org
>
>
>
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> v.173.295  Thank you.
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