June 28, 2016 -- Radiology departments may think complying with the Joint Commission's 2015 accreditation standards for CT is an overwhelming undertaking, but it's not as hard as it seems, according to a presentation given at the recent International Society for Computed Tomography (ISCT) 2016 Symposium in San Francisco.
Sure, the accreditation requirements are made up of a long list of tasks organized under four main areas of practice. But many of these requirements are things your department may already be doing, as the Joint Commission looked to the American College of Radiology (ACR) for guidance when it crafted the new standards, said presenter Dr. Myron Pozniak of the University of Wisconsin-Madison.
So to succeed, keep one simple rule of thumb in mind, he told session attendees.
"Whatever you're doing to comply with these new standards, document it," he said.
More scrutiny for CT
It's been almost a year since the Joint Commission (formerly known as JCAHO) published new accreditation standards that outlined a higher level of scrutiny for CT practices. The new standards are in addition to Medicare requirements mandated by the Protecting Access to Medicare Act of 2014, and cover all CT, PET/CT, and SPECT/CT exams (except for interventional studies or those acquired in an inpatient setting).
The standards address four areas of practice: environment of care, human resources, provision of care, and performance improvement, Pozniak said. He outlined each area and suggested ways radiology practices or departments can make sure they're ready for a Joint Commission visit:
How to prepare?
The Joint Commission's CT examination process is still evolving, Pozniak said. There are currently only three radiologists in the organization's pool of examiners -- and one of these is an interventionalist. In fact, the majority of examiners are nurses.
"Examiners are currently receiving training in imaging standards, but at the moment, they're not looking at fine detail," he said.
Pozniak conducted his own informal survey with colleagues about Joint Commission visits to determine what kind of questions the organization is asking, he told session attendees. Typical questions included the following:
"They want to see that a radiologist, a physicist, and a technologist have been reviewing protocols," Pozniak said.
Document, document, document
To be ready for a visit from the Joint Commission, a radiology department should make sure staff credentialing and training are documented and that this paperwork is accessible, Pozniak said. In addition, subscribe to the Joint Commission's Perspectives newsletter, where you can find any revisions to accreditation standards.
But no matter what, create a paper trail of everything the department is doing to comply, Pozniak concluded.
"These new standards can be daunting," he said. "Just make sure you have your policies in place, and document, document, document."