Image Wisely is a joint initiative of the American College of Radiology, Radiological Society of North America, American Society of Radiological Technologists and American Association of Physicists in Medicine.

June 17, 2019

The Joint Commission Deletes Fluoroscopy User Training Requirement

The Joint Commission has decided to delete the fluoroscopy user training requirement from the requirements that went into effect Jan. 1, 2019. Please see below for The Joint Commission’s full statement:

Effective immediately, The Joint Commission is deleting Standard HR.01.05.03, element of performance (EP) 15 from the Ambulatory Care, Critical Access Hospital, Hospital, and Office-Based Surgery programs.

For reference, the text of the deleted EP is as follows:

Standard HR.01.05.03, EP 15: The <organization> verifies and documents that individuals (including physicians, non-physicians, and ancillary personnel) who use fluoroscopic equipment participate in ongoing education that includes annual training on the following:
- Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® and Image Wisely® campaigns
- Safe procedures for operation of the types of fluoroscopy equipment they will use
Note 1: Information on the Image Gently and Image Wisely initiatives can be found online at and
Note 2: This element of performance does not apply to fluoroscopy equipment used for therapeutic radiation treatment planning or delivery.

Since the launch of HR.01.05.03, EP 15 on January 1, 2019, The Joint Commission has determined through stakeholder and customer feedback that this requirement is redundant to other accreditation requirements and would be burdensome to conform with annually. Therefore, an annual training requirement will not be required, and an assessment of staff and physician competency to provide fluoroscopy services will continue to be assessed during the on-site survey using accreditation standards that currently exist in the "Human Resources" and "Medical Staff" chapters.

This deletion will be posted on The Joint Commission website. It will no longer be part of the Comprehensive Accreditation Manuals for the above programs as of the January 2020 Edition® update and January 2020 hard copy publications.

Questions may be directed to Joyce Webb, MBA, RN, project director, Department of Standards and Survey Methods, The Joint Commission, at