[Intl_DxMedPhys] EXT MSG Revised TCJ standards 1/1/2026

[Mary Ellen Jafari]

So does that mean that testing say, an MRI scanner, 2 months early is not acceptable? That seems illogical.

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: Mary Ellen Jafari
Sent: Tuesday, July 15, 2025 2:06 PM
To: Johnson, Loretta M <lorettajohnson at uabmc.edu>
Subject: RE: EXT MSG [Intl_DxMedPhys] Revised TCJ standards 1/1/2026

Excellent point, thank you for mentioning this!  I will have to check.

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: Johnson, Loretta M <lorettajohnson at uabmc.edu<mailto:lorettajohnson at uabmc.edu>>
Sent: Tuesday, July 15, 2025 11:03 AM
To: Mary Ellen Jafari <MaryEllen.Jafari at kp.org<mailto:MaryEllen.Jafari at kp.org>>; DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Subject: Re: EXT MSG [Intl_DxMedPhys] Revised TCJ standards 1/1/2026


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Very important to be able to locate while TJC is on site is the definition of annual.  We’ll need to find out whether the location of the quote below has changed – it’s currently in the Environment of Care Chapter just BEFORE the Chapter Outline.




Annually/every 12 months/once a year/every year = 1 year from the last event, plus or minus 30 days

If you can’t tell them where this is in the TJC standard while TJC is on site and you’re even one day past 365, then you’ll be cited for it.

Peace,
Loretta

Loretta Johnson, Ph.D., DABR, FAAPM | Assistant Professor
Director | Division of Physics and Engineering
Department of Radiology | Heersink School of Medicine
UAB | The University of Alabama at Birmingham
GSB Suite #301 | 619 19th Street South | Birmingham, AL 35249
P: 205.934.7592 | lorettajohnson at uabmc.edu<mailto:lorettajohnson at uabmc.edu>

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From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu>> on behalf of Dxmedphys new list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Reply-To: Mary Ellen Jafari <MaryEllen.Jafari at kp.org<mailto:MaryEllen.Jafari at kp.org>>
Date: Tuesday, July 15, 2025 at 11:20 AM
To: Dxmedphys new list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Subject: EXT MSG [Intl_DxMedPhys] Revised TCJ standards 1/1/2026

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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