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The Joint Commission

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Joint Commission accreditation medical physicist support. The Joint Commission (TJC) accreditation readiness for imaging and radiation safety. Physics testing, documentation, and compliance for healthcare facilities.

Requirements

  • At least annually, a diagnostic medical physicist performs a performance evaluation of all CT imaging equipment
  • At least annually, a diagnostic medical physicist measures CTDIvol for adult and pediatric brain and abdomen protocols and confirms it is within 20% of the value the console displays
  • At least annually, a diagnostic medical physicist or MRI scientist performs a performance evaluation of all MRI imaging equipment
  • At least annually, a diagnostic medical physicist or nuclear medicine physicist inspects, tests and calibrates nuclear medicine imaging equipment, and in hospital and critical access hospital programs a diagnostic medical physicist conducts a performance evaluation of PET imaging equipment (ambulatory care programs allow a medical physicist or nuclear medicine physicist for PET)
  • Dosimetry monitoring for CT, PET, nuclear medicine and fluoroscopy is reviewed at least quarterly by the radiation safety officer, a diagnostic medical physicist or a health physicist

Benefits

  • The Joint Commission is one of the accrediting organizations CMS recognizes for CT, MRI, nuclear medicine and PET under MIPPA
  • Imaging requirements cover CT dose, equipment performance and MRI safety
  • A physics-backed dose-optimization and MRI safety program that also supports ACR and state requirements

Accreditation Process

  • Readiness review of the imaging requirements with a medical physicist
  • On-site survey by Joint Commission surveyors (hospital surveys are unannounced)
  • Accreditation decision

Maintenance Requirements

  • Resurveys occur within three years (CMS requires unannounced resurveys no later than 36 months after the prior accreditation effective date)
  • Annual equipment performance evaluations by the role each program specifies (in hospital programs: a diagnostic medical physicist for CT and PET, a diagnostic medical physicist or MRI scientist for MRI, and a diagnostic medical physicist or nuclear medicine physicist for nuclear medicine)
  • Quarterly review of dosimetry monitoring
  • Annual CTDIvol verification against the console display

What the Joint Commission requires for diagnostic imaging

The Joint Commission's imaging requirements set expectations for CT dose, CT and MRI equipment performance, nuclear medicine and PET equipment, and MRI safety. Since the Accreditation 360 changes took effect in January 2026, the hospital and critical access hospital requirements sit in the National Performance Goals (Goal 13, Protecting Patients and Providers in Imaging) and the Physical Environment chapter; the ambulatory programs, including advanced diagnostic imaging, keep the Environment of Care standard EC.02.04.03, where, for example, PET equipment may be evaluated by a medical physicist or nuclear medicine physicist. The evaluator roles listed on this page follow the hospital and critical access hospital wording; ambulatory programs say "medical physicist" and allow a nuclear medicine physicist for PET. Confirm the current edition of the manual for your program before you rely on a specific standard number.

How DRPS supports Joint Commission readiness

A qualified DRPS medical physicist performs the annual equipment performance evaluations, measures CTDIvol against the console display, reviews CT protocols against dose notification and alert values, and helps document dosimetry monitoring and the MRI safety program. The physics records are organized so they are ready when surveyors ask for them.

Go deeper

Preparing for a survey? See our accreditation support service or request a quote.