Valuable Tips for Joint Commission Surveys

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By Lori Chabot

Wow, what a great AHRA Spring Conference last week in Savannah! There were so many excellent sessions to learn from that it was hard for me to choose what I was going to write about. I attended the Basic Track, and one of the most interesting sessions for me was “Introduction to Regulatory & Compliance.” Cindy Winter was a wonderful speaker. I am going to touch on a few of the key items she covered during this session.

I am sure most of you are thinking, “How can learning about The Joint Commission (JC) be the most interesting topic she learned from?” Here is why. The first tool I found invaluable were the compliance checklists that were shared with us. These will be so helpful for any upcoming JC visits. The organization that Cindy works just had their JC visit and among the many tips she shared with us, she noted that JC now wants imaging protocols to have been reviewed and approved by the senior leaders, such as the CMO, and the med exec team in your organizations. In the future, more than just procedural timeouts will need proper documentation. What this means is that for a CT exam the technologist should pause to verify with the patient the position they are being scanned in and the exam that is being performed. It is then important that the CT technologist document the CT protocol used. If your organization has a number for this protocol, this can be what is documented.

As many of us have already seen, JC is paying much more attention to how imaging staff is caring for and storing their lead aprons. Make sure you are aware of what your apron manufacturer’s recommendations are for what is acceptable in damage to the lead, such as hole size. JC is also beginning to cite facilities if their lead aprons are not hung correctly. Make sure to roll your aprons in to avoid creases if using pegs. They may begin to cite facilities for using pegs instead of larger hangars.

When replacing or putting in new imaging equipment you must have the physicist perform shielding design testing of the space before and after the installation. You must remember that this is required even if this is not a new build and only a replacement in existing imaging space. It is very beneficial to have all physicist credential information readily available if requested from JC.

These were just a few of the key topics that I know will be helpful for each of us. This was my second AHRA conference, and I found the learning to be invaluable. Not only did the sessions provide excellent tools to take back to our organizations; the dialogue between leaders and the friendships made will benefit each of us tremendously.

Lori Chabot is the radiology section manager at Saint Mary Hospital in Grand Junction, CO. She can be reached at


  1. Can you or anyone provide the references in the JC documents of the above?? I spoke with my radiologist and he has never heard of the issues with protocols for the JC. There are state requirements, but this is the first he has ‘heard’/seen for the JC. Thank you!!!

  2. MM.04.01.01 EP 15 “For hospitals that use Joint Commission accreditation for deemed status purposes: Processes for the use of preprinted and electronic standing orders, order sets, and protocols for medication orders include the following:- Review and approval of standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership- Evaluation of established standing orders and protocols for consistency with nationally recognized and evidence-based guidelines- Regular review of such standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the standing orders and protocols- Dating, timing, and authenticating of standing orders and protocols by the ordering practitioner or another practitioner responsible for the patient’s care in accordance with professional standards of practice; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations.”
    My facility was cited for this because we did not have our Fluoro, CT, and MRI policies approved by the Medical Executive Committee, Nursing Administration and Pharmacy if they contained any biological including, but not limited to IV contrast, oral contrast, barium, radionuclide, or any other medication. We only had approvals by the Radiology Medical Director, physicist and Director of Imaging Services.

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