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

[Mary Ellen Jafari]

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.
MEJ

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<mailto:Maryellen.Jafari at kp.org>

From: Jerry Thomas <jerry.thomas at ascension.org>
Sent: Tuesday, July 15, 2025 12:15 PM
To: Rebecca Milman <milman at gmail.com>
Cc: Mary Ellen Jafari <MaryEllen.Jafari at kp.org>; DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu>
Subject: Re: [EXTERNAL] Re: [Intl_DxMedPhys] Revised TCJ standards 1/1/2026


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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<mailto: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<mailto: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<mailto:Maryellen.Jafari at kp.org>

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