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

[Dave Jordan]

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" 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.

On Tue, Jul 15, 2025 at 4:28 PM Mary Ellen Jafari via
Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:

> 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
>
> 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
>
>
>
> *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
>
>
>
> *Caution: *This email came from outside Kaiser Permanente. Do not open
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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>
> 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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