[Intl_DxMedPhys] [EXTERNAL] Re: Revised TCJ standards 1/1/2026

[Jerry Thomas]

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.

Jerry


Jerry Thomas, MS, FAAPM, DABR, CHP, DABSNM
Diagnostic Medical Physicist / Radiation Safety Officer
Ascension Via Christi Hospitals Wichita
Wichita, KS  67214

Phone:  316-268-5958  (office)
            240-447-1014  (cell)


On Tue, Jul 15, 2025 at 12:51 PM Rebecca Milman via
Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:

> 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
> 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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>


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