[Intl_DxMedPhys] [External] Re: EXT MSG Re: Requirement for dose monitoring

Mon Aug 24 13:45:22 EDT 2026

Hi all,

This TJC site<https://urldefense.com/v3/__https://www.jointcommission.org/en-us/accreditation/accreditation-360/prepublication-cah-and-hap-requirements-streamlined-to-reduce-burden__;!!KGKeukY!yVbGPIzWr_rsX8sQNhwAHdteaKwen0hz37Bjh8dlQNxYgYZ_jc5_1gZwcdoDFANhZ0wBdciTM208f1KXc4Kve1c7SkRfJX9G5pdS5E9AfNiVUx1mSzw$ > <https://urldefense.com/v3/__https://www.jointcommission.org/en-us/accreditation/accreditation-360/prepublication-cah-and-hap-requirements-streamlined-to-reduce-burden__;!!KGKeukY!yVbGPIzWr_rsX8sQNhwAHdteaKwen0hz37Bjh8dlQNxYgYZ_jc5_1gZwcdoDFANhZ0wBdciTM208f1KXc4Kve1c7SkRfJX9G5pdS5E9AfNiVUx1mSzw$ > is helpful and includes standard /EP requirements, cross walks, disposition reports, and Survey Process Guides (SPGs).

The TJC Disposition Report tracks where prior EPs have been moved, consolidated, or split.

We found other relevant EPs that were affected, including lightened requirements for shielding, fluoroscopy CAK documentation, and CT dose documentation. It is helpful to review these against your state requirements and hospital policies. Also importantly, some EPs have been removed from formal accreditation standards and are now addressed within the SPG. As a result, some compliance expectations persist even when a specific standard is no longer available as a direct reference point.

The Disposition Report lists the former fluoroscopy skin dose review EP was replaced with a general radiation safety oversight for radiologic services and compliance/recommendation/interventions related to radiation safety practices:
      [image.png]

Also, here is a relevant update regarding CAK documentation:
      [image.png]

The SPG states the organization should be able to present the surveyor medical records with documented fluoro radiation dose for 5 recent inpatients:
      [image.png]      
               [image.png]
The TJC Sentinel Event Policy also continues to identify the following as a SE, referencing NCRP Statement 11:

      [image.png]

                  [image.png]

As requirements evolve and standards are streamlined, our expertise and influence become increasingly valuable. Our understanding of the evidence, regulations, and best practices that support safe, high-quality care will remain essential in ensuring important principles continue to guide patient care.

Best regards,

Izabella

Izabella Barreto, PhD, MBA, DABR, DABSNM
Division Chief of Medical Physics
Associate Professor of Radiology and Imaging Sciences
Department of Radiology and Imaging Sciences
Emory University School of Medicine
Cell: (407) 529-7960
Email: Izabella.Barreto at emory.edu<mailto:Izabella.Barreto at emory.edu>

Admin Assistant: Alex Dill, MBA<mailto:alexandria.dill at emoryhealthcare.org>
Visit our Medical Physics Website<https://urldefense.com/v3/__https://med.emory.edu/departments/radiology/clinical_divisions/medical-physics.html__;!!KGKeukY!yVbGPIzWr_rsX8sQNhwAHdteaKwen0hz37Bjh8dlQNxYgYZ_jc5_1gZwcdoDFANhZ0wBdciTM208f1KXc4Kve1c7SkRfJX9G5pdS5E9AfNiVCufVvFw$ >
Submit Medical Physics Requests Here<mailto:radmedphys at emory.edu>

Sent at a time convenient for me, no after-hours response is expected.

[Emory University primary logo with shield]

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu> on behalf of Lemieux, Bryan P. via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu>
Date: Monday, August 24, 2026 at 10:31 AM
To: Johnson, Loretta M <lorettajohnson at uabmc.edu>; Stephanie M. Leon <Stephanie.M.Leon at hitchcock.org>; intl_dxmedphys_wd_osu_list at lists.osu.edu <intl_dxmedphys_wd_osu_list at lists.osu.edu>
Subject: [External] Re: [Intl_DxMedPhys] EXT MSG Re: Requirement for dose monitoring

Your state may still have a requirement for dose documentation, possibly in terms of at least fluoro time.

Also, while JC removed some things, they still have a Sentinel Event for patient burns (which includes radiation burns).  I would be very interested if anyone has a way to effectively and proactively identify, investigate and intervene in possible patient radiation burns that is not tied to dose monitoring………

Its also tied to some quality measures.

Bryan Lemieux MS CHP DABMP
Associate Chief for Radiation Safety
Radiation Safety Officer
UK HealthCare
From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+bryan.lemieux=uky.edu at lists.osu.edu> On Behalf Of Johnson, Loretta M via Intl_dxmedphys_wd_osu_list
Sent: Monday, August 24, 2026 9:52 AM
To: Stephanie M. Leon <Stephanie.M.Leon at hitchcock.org>; intl_dxmedphys_wd_osu_list at lists.osu.edu
Subject: Re: [Intl_DxMedPhys] EXT MSG Re: Requirement for dose monitoring

CAUTION: External Sender

Is your radiation safety officer going to allow them to opt out of dose monitoring? Peace, Loretta Loretta Johnson, Ph. D. , DABR, FAAPM | Associate Professor Division of Imaging Physics Department of Radiology | Heersink School of Medicine UAB
Is your radiation safety officer going to allow them to opt out of dose monitoring?

Peace,
Loretta

Loretta Johnson, Ph.D., DABR, FAAPM | Associate Professor
Division of Imaging Physics
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>

https://urldefense.com/v3/__https://www.uab.edu/medicine/radiology/__;!!KGKeukY!yVbGPIzWr_rsX8sQNhwAHdteaKwen0hz37Bjh8dlQNxYgYZ_jc5_1gZwcdoDFANhZ0wBdciTM208f1KXc4Kve1c7SkRfJX9G5pdS5E9AfNiVZmiZZwQ$ <https://urldefense.com/v3/__https://www.uab.edu/medicine/radiology/__;!!KGKeukY!3PpNQTSRa_7oyKwYbJ4SBQyUn3EybE5XnTsIdRV49Iqbm_WqxuWioHJ6jRdJeAOI4wTBfHQTTMlZbsDXD_cXyVOiMeugkrF_s5vS8hYQlGKFQlVrvQ$>

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+lorettajohnson=uabmc.edu at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list-bounces+lorettajohnson=uabmc.edu 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: "Stephanie M. Leon" <Stephanie.M.Leon at hitchcock.org<mailto:Stephanie.M.Leon at hitchcock.org>>
Date: Tuesday, August 11, 2026 at 2:21 PM
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 Re: [Intl_DxMedPhys] Requirement for dose monitoring

Thanks to all who responded already! I was not imagining that there used to be a relevant TJC requirement. However, it is gone now. Stephanie M. Leon, PhD, DABR, DABSNM Chief of Diagnostic Medical Physics Associate Professor of Radiology Tel
Thanks to all who responded already! I was not imagining that there used to be a relevant TJC requirement. However, it is gone now.

Stephanie M. Leon, PhD, DABR, DABSNM
Chief of Diagnostic Medical Physics
Associate Professor of Radiology

Tel (603) 650-3796
Dartmouth-Health.org<https://urldefense.com/v3/__http:/Dartmouth-Health.org__;!!NoSwA-eRAg!ADcCl68OJkbTYrpBcJWbdN0QvZLTKoxmyLXo7HFBGr6jJOOC8jno2gtBrDZVcr590IbKEZJ--nwqMSQ1Tk4F4Qsbsk-RFLnqnNlX6Q$>
[cid:image001.png at 01DD33B3.1E610420]<https://urldefense.com/v3/__https:/www.dartmouth-health.org/__;!!KGKeukY!yTuIAOaPrlYFdbY1HfZEUyQF7tjiw18b0c0FqOji4JUOSdBLQjHyjlD2hUIMYv2EUIPj-IJa92UrMuzjG9Vw_aiyig36-fHnY0mT9h4wCOyCJtaZP7oJrQ$>

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 Stephanie M. Leon via Intl_dxmedphys_wd_osu_list
Sent: Tuesday, August 11, 2026 2:42 PM
To: intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>
Subject: [Intl_DxMedPhys] Requirement for dose monitoring **EXTERNAL**

Hi all, I am trying to find in the current TJC standards any requirement for patient radiation dose monitoring for fluoroscopy. Am I missing it? Or is there a relevant non-TJC requirement? Our cath lab wants to opt out of our dose monitoring
Hi all, I am trying to find in the current TJC standards any requirement for patient radiation dose monitoring for fluoroscopy. Am I missing it? Or is there a relevant non-TJC requirement? Our cath lab wants to opt out of our dose monitoring
Hi all,

I am trying to find in the current TJC standards any requirement for patient radiation dose monitoring for fluoroscopy. Am I missing it? Or is there a relevant non-TJC requirement? Our cath lab wants to opt out of our dose monitoring program, and I am looking for any accreditation-related reason why they can’t (our state regs do not require it).

Stephanie M. Leon, PhD, DABR, DABSNM
Chief of Diagnostic Medical Physics
Associate Professor of Radiology
Tel (603) 650-3796
Dartmouth-Health.org<https://urldefense.com/v3/__http:/Dartmouth-Health.org__;!!NoSwA-eRAg!ADcCl68OJkbTYrpBcJWbdN0QvZLTKoxmyLXo7HFBGr6jJOOC8jno2gtBrDZVcr590IbKEZJ--nwqMSQ1Tk4F4Qsbsk-RFLnqnNlX6Q$>
[cid:image001.png at 01DD33B3.1E610420]<https://urldefense.com/v3/__https:/www.dartmouth-health.org/__;!!KGKeukY!2GlIfYKlZJ2X0OKjopqQiJqso8FX6T7mUX06M3bQPzq787W5aN9Ga1fC-jfEx9RNDnKAnv-1RHGuihSE0S2Bjd4Yso30I9_YxRvXZG_GV2zaQuOIxZxZuw$>

IMPORTANT NOTICE REGARDING THIS ELECTRONIC MESSAGE:

This message is intended for the use of the person to whom it is addressed and may contain information that is privileged, confidential, and protected from disclosure under applicable law. If you are not the intended recipient, your use of this message for any purpose is strictly prohibited. If you have received this communication in error, please delete the message and notify the sender so that we may correct our records.

IMPORTANT NOTICE REGARDING THIS ELECTRONIC MESSAGE:

This message is intended for the use of the person to whom it is addressed and may contain information that is privileged, confidential, and protected from disclosure under applicable law. If you are not the intended recipient, your use of this message for any purpose is strictly prohibited. If you have received this communication in error, please delete the message and notify the sender so that we may correct our records.

-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://lists.osu.edu/pipermail/intl_dxmedphys_wd_osu_list/attachments/20260824/3bb2f74c/attachment.html>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image001.png
Type: image/png
Size: 39709 bytes
Desc: image001.png
URL: <http://lists.osu.edu/pipermail/intl_dxmedphys_wd_osu_list/attachments/20260824/3bb2f74c/attachment.png>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image.png
Type: image/png
Size: 53659 bytes
Desc: image.png
URL: <http://lists.osu.edu/pipermail/intl_dxmedphys_wd_osu_list/attachments/20260824/3bb2f74c/attachment-0001.png>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image.png
Type: image/png
Size: 22433 bytes
Desc: image.png
URL: <http://lists.osu.edu/pipermail/intl_dxmedphys_wd_osu_list/attachments/20260824/3bb2f74c/attachment-0002.png>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image.png
Type: image/png
Size: 118638 bytes
Desc: image.png
URL: <http://lists.osu.edu/pipermail/intl_dxmedphys_wd_osu_list/attachments/20260824/3bb2f74c/attachment-0003.png>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image.png
Type: image/png
Size: 57425 bytes
Desc: image.png
URL: <http://lists.osu.edu/pipermail/intl_dxmedphys_wd_osu_list/attachments/20260824/3bb2f74c/attachment-0004.png>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image.png
Type: image/png
Size: 10973 bytes
Desc: image.png
URL: <http://lists.osu.edu/pipermail/intl_dxmedphys_wd_osu_list/attachments/20260824/3bb2f74c/attachment-0005.png>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: image.png
Type: image/png
Size: 20246 bytes
Desc: image.png
URL: <http://lists.osu.edu/pipermail/intl_dxmedphys_wd_osu_list/attachments/20260824/3bb2f74c/attachment-0006.png>