The hospital’s imaging services have a designated leader and follow current safe imaging prac...

(1)

The hospital designates an individual to serve as the radiation safety officer who is responsible for making certain that radiologic services are provided in accordance with law, regulation, and hospital policy. This individual has the necessary authority and leadership support to do the following: - Monitor and verify compliance with established radiation safety practices (including oversight of dosimetry monitoring). - Provide recommendations for improved radiation safety. - Intervene as needed to stop unsafe practices. - Implement corrective action.

(2)

The hospital provides radiology services that meet safety standards approved by nationally recognized professional organizations. At a minimum, diagnostic radiology services are maintained and available at all times the hospital provides services, including emergency services. Note: If the hospital also provides other radiology services, such as therapeutic radiology, the requirements of this element of performance also apply to those services.

(3)

The hospital establishes or adopts diagnostic computed tomography (CT) imaging protocols based on current standards of practice that address key criteria, including the following: - Clinical indication - Contrast administration - Age (to indicate whether the patient is pediatric or adult) - Patient size and body habitus - Expected radiation dose index range Note: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

(4)

Diagnostic computed tomography (CT) imaging protocols are reviewed and kept current with input from an interpreting physician, medical physicist, and lead imaging technologist to make certain that they adhere to current standards of practice and account for changes in CT imaging equipment. These reviews are conducted at time frames identified by the hospital. (For rehabilitation and psychiatric distinct part units in hospitals, refer to MS.17.01.03, EP 5, for supervision of radiologic services) Note: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.