[Intl_DxMedPhys] Revised TCJ standards 1/1/2026

[Mary Ellen Jafari]

I tried sending the pdf but it bounces back as exceeding the OHSU file size limit.

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: Di Zhang <skintchenzhang at gmail.com>
Sent: Wednesday, July 16, 2025 11:10 AM
To: Mary Ellen Jafari <MaryEllen.Jafari at kp.org>
Cc: DxMedPhys List <intl_dxmedphys_wd_osu_list at lists.osu.edu>
Subject: Re: [Intl_DxMedPhys] Revised TCJ standards 1/1/2026


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________________________________
Thank you Mary Ellen for this important information. Could you please attach the new Hospital Accreditation Survey Process Guide? I don't think it was included in your email.

Regards,
Di Zhang, PhD, MBA, DABR, DABSNM
Radiological Science
UCLA School of Medicine

On Tue, Jul 15, 2025 at 9:19 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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--
Regards,
Di
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