Revamping Your Dose Safety Policies and Procedures: Part 1

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NeomiNeil SinghBy Neomi Mullens and Neil Singh 

The recent radiation dose safety regulatory requirements have many imaging managers rushing to update their outdated imaging policies and procedures. But where do you begin? How do you identify all healthcare provider roles impacted, and how do you implement the changes at an enterprise level to ensure proper adoption and accuracy?

This may be an initiative that needs to be addressed throughout your organization and not only within your radiology department, as regulatory requirements and new standards are being developed and adopted routinely for the healthcare industry as a whole. Regarding radiation safety initiatives specifically, the policies and procedures manual is only one of the eight components of a robust radiation safety program: workflows, standardization of imaging protocols, an automated dose management solution, risk management guidelines, education, a radiation safety committee, and marketing are the other equally important radiation safety program components. The imaging policies and procedures should be developed simultaneously with the other seven components of the radiation safety program.


Why Your Imaging Policies and Procedures Manual Needs a Makeover 

When was the last time your organization’s imaging policies and procedures manual was updated? Do you know where it’s located? Is it sitting in a shelf next to the other imaging binders or hidden in the department’s intranet? This should be the first indication that your organization needs to review and identify the gaps in the existing imaging policies and procedures. The imaging policy and procedure requirements have tremendously changed over the last three years. If your healthcare organization is regulated by The Joint Commission (TJC) or operates in California or Texas, then your policies and procedures must be updated to meet regulatory requirements.

Unless your imaging policies and procedure were updated in the last 12 months, your organization’s imaging policies and procedures may already be outdated. Most old imaging policies and procedures were based on the ALARA principle (As Low As Reasonably Achievable), which was the industry standard, but served only as an “approach” that didn’t provide any realistic imaging guidelines or dose thresholds. Since then, the American College of Radiology (ACR) and The American Association of Physicists in Medicine (AAPM) have developed more defined imaging guidelines for imaging device dose output (not the patient’s effective dose delivered).

Upon review of the TJC 2014 Standards and the SGR patch, there are many components which must be included in an organization’s imaging policies and procedures.

An overview of The Joint Commission’s 2014 Standards:

  • By July 1, 2015 all individuals performing CT procedures must be American Registry of Radiological Technologist (ARRT) or Nuclear Medicine Technology Certification Board (NMTCB) registered.
  • Healthcare providers must have a robust internal radiation safety program, which includes a strong ongoing education/training component powered by Image Gently® and Image Wisely®.
  • Healthcare providers who provide CT imaging services must report the patient’s radiation dose (CTDI and DLP) information in the diagnostic imaging report as well as make it part of the patient’s medical record (PACS, EHR, etc.).
  • For the elements of performance, healthcare providers must have adult and pediatric CT imaging protocols benchmarked and reviewed annually by a physicist.
    • ACR and AAPM benchmarks are recommended, but not enforced.

The Protecting Access to Medicare Act (SGR patch):

  • Ordering physician decision support for advanced imaging procedure.
  • Improved and stricter patient radiation dose safety controls and levels.
  • CT equipment must meet the National Electrical Manufacturer Association (NEMA) standards.


Developing Your New Imaging Policies and Procedures

Alright, you have received your marching orders from the powers that be… so now what? First, check if your organization meets the requirements stated above. If not, how will you get your organization there, and what will it take? As mentioned above, your imaging policies and procedures have to be developed simultaneously with your internal radiation safety program. By developing an inclusive program that accounts for each of the multiple critical components of a radiation safety program, you will build the foundation by which your policies and procedures will guide and regulate your organizational practices to ensure the best patient safety possible.

Begin by outlining the existing workflow for all roles impacted and involved in the radiation safety program: technologists, ordering physicians, radiologists, medical physicists, risk management, etc. This must include the technical and clinical components of the caregiver’s workflow. After the current state workflow has been identified, begin developing the future state workflow with the proper imaging decision and risk management support checks and balances embedded in everyone’s workflows.

The imaging device protocols should be reviewed, and dose output by device manufacturer, exam type, patient type, and phantom size must be captured and implemented in the policies and procedures. The organization should collaborate with the risk management representatives and the Chief of Physicians in developing a decision support workflow and model to implement throughout the enterprise. Developing new imaging policies and procedures is a large task and must encompass everything from automated dose management solution workflow to educating and consulting staff and patients.


In part two of this article series, we will cover the implementation and management of your updated policies and procedures.


The American College of Radiology. House of Representatives Passes 12-Month SGR Patch; Numerous ACR Supported Imaging Provisions Included in Legislation. 2014. Available at: Accessed May 13, 2014.

The Joint Commission. Prepublication – Diagnostic Imaging Services Requirements. 2013. Available at: Accessed May 13, 2014.

Neomi Mullens is a Project Manager at Ascendian Healthcare Consulting and a frequent and published contributor to the subject of Enterprise Dose Management and Tracking. You may contact her directly at or visit the Ascendian website for more information at

Neil Singh is a Senior Consultant at Ascendian Healthcare Consulting and a frequent speaker and published contributor to the subject of Enterprise Dose Management and Tracking.

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