The Joint Commission Deletes Fluoroscopy User Training Requirement

Seriously, are we confused here?

The Joint Commission has announced its decision to delete the fluoroscopy user training requirement from the requirements that went into effect January 1, 2019. They released this statement June 17,2019:

“Effective immediately, The Joint Commission is deleting Standard HR.01.05.03, element of performance (EP) 15 from the Ambulatory Care, Critical Access Hospital, Hospital, and Office-Based Surgery Program.”

“The Joint Commission has determined through stakeholder and customer feedback that this requirement is redundant to other accreditation requirements and would be burdensome to conform with annually. Therefore, an annual training requirement will not be required, and an assessment of staff and physician competency to provide fluoroscopy services will continue to be assessed during the on-site survey using accreditation standards that currently exist in the Human Resources and Medical Staff chapters.”

Seriously, are we confused here?

This was, in my opinion, one of the best standards that The Joint Commission ever wrote. It reached over the lines from radiology and asked the physicians using fluoro to be safe by demonstrating that they knew how to safely protect their patients.  This is still an area that is dangerous to the patient if used by untrained operators and it can easily deliver radiation amounts that can be hazardous to the patient. UNLESS, we change the definition of hazardous. If we intend to amend our Informed Consent forms to include normal reactions to be expected such as reddening of the skin and hair loss, then we will not have to worry about any unexpected reactions.  Normally that would not be an expected side effect, but in the hands of untrained operators, it can happen.

Medical treatment and service in all facilities and communities are not the same. I challenge you to go the most recent healthgrades listing to confirm this fact. Policy standards for the many cannot be based on standard operating procedures by the few. I recently had a close-up with hospital services in the hinterland and I was sorely disappointed.

In addition to the troops marching to stop shielding the patients, it seems the faction that believes that “a little bit of radiation can be good for you” is winning the war.

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4 thoughts on “The Joint Commission Deletes Fluoroscopy User Training Requirement

  1. Good Lord. What’s next?? Will the JRCERT decide to remove all fluoro competencies from it’s list? This is crazy irresponsible!!

  2. Implementation of an institution wide policy defining radiation dose AND time limits will begin placing rails on this problem. Any case exceeding the established limits must be reported to the radiation safety committee. Each case will be reviewed by a physicist and determinations for improvements will be reported on the radiation safety committee minutes quarterly. This initiative must be driven by physicians on the radiation safety committee and they must hold their peers accountable for their use of radiation on patients. ALARA must be reestablished throughout the institution, especially in light of all of the sub specialties now given permission from the hospitals to use fluoroscopy.

    1. Elizabeth Young you are so right about those physicians on the radiation safety committee holding peers accountable for their use of radiation on patients. I’ve heard accounts of the 5 minute timer on a mobile C-arm used in surgery being reset 12 times during one case. That adds up to 1 solid hour of one region of a patient being exposed to radiation. That, coupled with a mid-range kVp and a considerably short source-to-skin distance, results in a patient’s radiation dose being of great concern.

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