The topic of radiation safety and radiation dose monitoring has moved from state-specific regulations to a national trend with the Joint Commission's recent announcement of new and revised diagnostic imaging standards. The call for radiation dose management and tracking has graduated from being advised to being mandated -- from both a legal perspective and from within the world of healthcare's patient safety foundation.
The questions that many organizations find themselves asking are "Where does this leave me?" and "Are we prepared for compliance?"
Neomi Mullens of Ascendian Healthcare Consulting.The race to implement effective solutions for radiation dose safety was brought to the forefront when several states took a progressive initial stance regarding patient safety and quality by creating control measures to govern certain radiology procedures that utilize radiation dose as part of an exam. By implementing legislation that mandated the monitoring of radiation dose and reporting of any radiation dose incidents, states such as California and Texas left healthcare providers with no option but to comply with new laws and, at the very least, enhance their radiation safety initiatives to include a means by which to adhere to these new standards.
But does being compliant equate to a clinically proficient, "patient first" radiation safety program? Not always.
Following the legal reforms, numerous individual hospitals and healthcare organizations outside of these states quickly embraced the call for radiation dose safety changes by beginning to build more robust radiation safety programs and re-evaluating internal radiation safety practices. Many of these organizations are top-tier healthcare providers that are often looked to for setting standards and trends within the healthcare industry.
The restructuring of their radiation safety initiatives enhanced current practices around several points:
- Review of CT protocols
- Development of incident management policies and procedures
- Procurement of new technologies and software to track and monitor radiation dose
- Revision of general workflows and daily practices for performing radiology exams
Several entities have adopted radiation safety initiatives such as these in an effort to become compliant according to their own organizational standards and goals. With these self-initiated efforts underway, many organizations are ahead of the game, but where will the standardization among efforts come into play, and what about those organizations that haven't engaged in any of these proactive measures?
The answer came this past December when the Joint Commission announced new and revised diagnostic imaging standards.
Putting radiation dose safety on the back burner is no longer an option for those healthcare organizations that aren't located within a state regulated by legislative mandates, and exclusivity is taken away from many of the organizations that opted to engage in radiation safety initiatives on their own accord. The Joint Commission's announcement of revised imaging standards blankets all Joint Commission-accredited hospitals, critical access hospitals, and ambulatory healthcare organizations that provide diagnostic imaging services, effective July 1, 2014, with additional requirements to be phased in by 2015.
The only question that remains is whether you are prepared for integration of and compliance with these new standards.
In assessing your organization's preparedness, it may be helpful to understand where you stand in forming internal radiation safety policies, and whether you are on the path to success or need to drive initiatives harder to deliver responsible healthcare.
Signs you may not be prepared:
- Lack of organizational radiation safety committee and regular radiation safety meetings
- Radiology exams being performed by unregistered and uncertified technologists
- Inability to track patient radiation dose history or exam history within patient records
- Outdated and substandard CT protocol use
- No policies or procedures regarding radiation dose tracking or incident management
Signs you're on the path to compliance:
- Organized radiation safety committee that conducts regular standards reviews
- Open communication with clinical staff regarding radiation safety best practices
- Development of a dynamic radiation safety program
- Defined radiation safety incidents and incident management policies and procedures
- Exploration of technical solutions to monitor and capture patient radiation dose
Signs you are prepared to comply:
- Implementation of a robust and dynamic radiation safety program
- Engaged radiation safety committee and physicist who regulate radiation safety practices and initiatives on a regular basis
- Annual performance evaluations of imaging equipment by a medical physicist
- Registration and certification of all radiology technologists
- Updated protocols for all imaging procedures including the pediatric population
- Method for collecting and storing patient dose data within the patient's clinical record
- Collection of data on incidents where preidentified radiation dose limits have been exceeded
Mandated compliance can no longer be ignored when it comes to radiation dose management. Preparation for new regulations and standards is no longer an option and, in fact, is only a first step in the development of a truly effective radiation safety program. With new radiation management spreading throughout the industry, the expectation and demand for optimized radiation safety practices will drive healthcare organizations to implement new methodologies and programs to keep up with highly competitive industry-wide initiatives.
Neomi Mullens is a project manager at Ascendian Healthcare Consulting and a frequent contributor on the subject of enterprise dose management and tracking. You may contact her directly at [email protected] or visit the Ascendian website for more information.
