Joint Commission Advanced Imaging Accreditation Includes MRI Safety!

A few weeks ago the announcements came down, CMS had ‘deemed’ three organizations to accredit the new classification of Advanced Imaging in order to be eligible for Medicare & Medicaid reimbursement: the American College of Radiology (ACR), the Intersocietal Commission, and the Joint Commission (TJC).

The other two have had modality-specific accreditation programs for years, so what was the TJC going to do? Well, they’ve released their accreditation criteria, and one of the most wonderful surprises is that MRI safety is more prominent than it is in either of the other two ‘imaging’ accrediting bodies!

That’s right, the ACR, despite having been the name behind three publications of the ‘White Paper on MR Safety’  (now the ‘Guidance Document for Safe MRI Practices’), has no physical safety standards for their MRI accreditation program. And at last check, ICAMRL didn’t even have the contemporary terminology for MRI safety-tested medical devices in their standards. So, in an amazing ‘come from behind’ showing, TJC has now bested the veteran agencies in patient safety protections.

From the perspective of MRI patient safety, one of the most wonderful things is the addition to the Joint Commission’s Environment of Care (EC) standard. In this updated version (effective immediately), TJC explicitly mandates MRI safety protections:

Excerpted from EC 02.01.01, EP 14

At a minimum, the organization manages safety risks in the magnetic resonance imaging (MRI) environment associated with the following:
– Patients who may experience claustrophobia, anxiety, or emotional distress
– Patients who may require urgent or emergent medical care
– Metallic implants and devices
– Ferrous objects entering the MRI environment

OK, I might have chosen a slightly different list, but these four items nail some of the greatest environmental threats to the safety of patients and staff in the MRI suite. And given that it’s the first requirement from an accrediting body (the recent MRI safety changes to the healthcare building code, Guidelines, are regulatory / licensure requirements), I’m more than happy to give JCAHO a little slack.

If you would like to download your own PDF copy of the changes to the ambulatory accreditation program’s Environment of Care standards, which includes the explicit MRI safety requirements, identified above, please click here.

In a nutshell, these new standards echo many, many prior recommendations, including JCAHO’s own, for MRI safety. Namely, these are to plan for emergent situations, screen patients more effectively for contraindications, and screen for ferromagnetic materials.

With the new EC standards it is no longer acceptable to simply say, ‘yeah, we have a policy and procedure manual that outlines how to handle each of these.’ Now, as a part of regular accreditation, providers will have to provide risk assessments and explain how their actions are proportionate responses to those risks.

Earlier in that same EC standard, it makes specific mention to seeking external sources of information to establish risks and responses. For MRI, that list would likely include the ACR Guidance Document, the VA’s MRI Design Guide, the ASHE monograph ‘Designing and Engineering MRI Safety’, the ECRI Institute’s Top-10 Medical Technology Hazards, and perhaps even the MHRA MRI risk assessment.

What recommendation is common to all of these industry-standard-setting publications (that explicitly addresses one of the 4 new EC requirements)? The use of ferromagnetic detection systems.

As you conduct your risk assessments, and determine a path to MRI safety and regulatory conformance, I hope that you’ll contact the people at Mednovus regarding their ferromagnetic MRI screening systems. When your next state or accreditation surveyor comes around, you’ll be so very glad you did.

Tobias Gilk, President & MRI Safety Director
Mednovus, Inc.

Click for Tobias Gilk's Twitter Profile Click here for Tobias’ Twitter Profile

2 thoughts on “Joint Commission Advanced Imaging Accreditation Includes MRI Safety!

  1. Tobias Gilk Post author

    I very well may have short-changed ICAMRL in the description of their MR safety standards. Lest there be any confusion, here ( is the page where you can go and download the PDF of the IAC’s MR site accreditation requirements for yourself.

    My beef with most MRI safety accreditation ‘requirements’ is that they aren’t really ‘requirements’ at all. Most are worded in the form of ‘develop standards to prevent this bad thing or the other.’

    Well, my standard for responding to a cardiac arrest is to type all the particulars of the patient’s condition into the computer, then print it out, along with the unabridged medical history of that patient, go to the photocopier, reduce the collection of documents until it all fits on a piece of paper 1-inch wide by 3-inches long. Then I band that paper around the leg of a carrier pigeon, and tie a tiny magnifying glass to the other leg. Then I release the carrier pigeon, who flies to my 2nd cousin Flaco’s house. Flaco then hops on his bicycle rickshaw and takes the paper and magnifying glass to Kinkos, where he blows it up enough that it can be read. Then he rides the enlarged paper to his girlfriend, Sarah, who works as a 9-1-1 dispatcher, and she’ll send an ambulance.

    That, my friends, is a standard, or policy. It’s godawful, unworkable, and subject to all manner of breakdowns, but it’s a policy. In contrast, I’d like to see…

    “1. All MRI technologists must have current Basic Life Support (BLS) certification at the health care provider level.
    2. Prospectively designate an area outside the MRI scanner room for emergent patient treatment / resuscitation.
    3. Demonstrate and document emergency preparedness on at least an annual basis with a mock-code drill.
    4. Upon the determination that a code event is occurring, immediately remove the patient from the MRI scanner room to the prospectively-designated treatment area, securing the MRI scanner room upon exit.
    5. Immediately call for code-team, or paramedic response.”

    That, my friends, is a measurable standard based on performance, and not on the existence of a sheaf of paper with “Manual” on the front cover.

  2. Pingback: Latest Health Risk Assessments Auctions | World online health review

Leave a Reply

Your email address will not be published. Required fields are marked *

Change the CAPTCHA codeSpeak the CAPTCHA code