Radiology Quality
& Compliance Guide

Texas Freestanding Emergency Medical Care Facilities are regulated under:

The primary radiology provision is:

26 TAC §509.51 — Radiology

Texas requires the facility to:

• Adopt, implement, and enforce policies for emergency radiological procedures.
• Provide radiological services immediately available on the premises.
• Maintain plain-film X-ray capability.
• Provide CT services immediately available on the premises.
• Provide ultrasound services immediately available on the premises.
• Ensure examination reports are read, dated, signed, and authenticated by an appropriately licensed practitioner.
• Comply with applicable federal, state, and local laws and standards.

Texas DSHS Radiation Control regulates medical X-ray equipment.

A facility using medical X-ray equipment must maintain an appropriate:

DSHS identifies separate categories including:

• Computed Tomography
• Fluoroscopy
• Radiographic machines
• Other radiation-producing equipment

The facility's certificate should accurately reflect:

• Legal entity
• Facility location
• Equipment
• Authorized categories of use
• Radiation Safety Officer
• Additional authorized locations where applicable

A survey-ready FSER should maintain the current registration and supporting documentation in its radiology compliance file.

A registered medical X-ray facility should maintain a designated:

Radiation Safety Officer — RSO

DSHS requires submission of the RSO designation as part of medical X-ray registration.

Texas guidance states that a facility may have only one RSO per registration and requires appropriate notification when the RSO changes.

The RSO should have clear responsibility for oversight of:

• Radiation safety policies
• Staff compliance
• Personnel monitoring
• Radiation incidents
• Equipment-related safety
• Regulatory communication
• Exposure records
• Corrective actions

Texas requires registrants to develop and implement written operating and safety procedures.

DSHS specifically identifies 25 TAC §§289.227 and 289.229 as requiring appropriate written procedures for medical radiation operations.

Policies should reflect the equipment and procedures actually used within the FSER.

Recommended areas include:

• General radiographic procedures
• CT procedures
• Radiation safety
• Patient identification
• Pregnancy screening
• Personnel monitoring
• Equipment operation
• Repeat/reject analysis
• Contrast administration
• Contrast reactions
• Extravasation
• Infection prevention
• Equipment cleaning
• Emergency procedures
• Downtime
• Critical-result communication

Texas HHSC specifically requires procedure manuals to include procedures for examinations performed and other related operational topics.

The manual should address:

• Each imaging examination routinely performed
• Infection-control procedures
• Treatment/examination room processes
• Personnel dress requirements
• Equipment cleaning

A procedure manual should be available to staff and periodically reviewed.

Texas requires radiology services to be performed on an appropriate written order.

Orders should come from a physician, dentist, podiatrist, or other practitioner acting within the scope of their license and education.

The order should also contain a concise reason for the examination.

A quality imaging order therefore should answer:

and

Correct patient identification should occur before every imaging procedure.

Recommended controls include:

• At least two patient identifiers
• Matching order to patient
• Confirming examination
• Confirming body part
• Confirming laterality when applicable
• Confirming pregnancy status when relevant
• Matching images to the correct medical record

Wrong-patient or wrong-exam near misses should be reported through the facility's patient-safety program.

Before imaging begins, staff should verify:

For higher-risk procedures, consider a formal preprocedure verification process.

Incorrect imaging can expose patients to unnecessary radiation and delay diagnosis.

Facilities should maintain a clearly defined pregnancy-screening process for examinations involving ionizing radiation when clinically appropriate.

The policy should address:

• Patient age/population
• Pregnancy questions
• Pregnancy testing when appropriate
• Documentation
• Emergency exceptions
• Physician involvement
• Risk-benefit decision-making

Urgent emergency imaging should not be unnecessarily delayed when the clinical benefit outweighs potential radiation risk.

Texas HHSC requires radiology policies to address precautions against:

• Radiation hazards
• Electrical hazards
• Mechanical hazards

and appropriate shielding where radiation sources are used.

Radiation protection should follow the principle of:

ALARA

This means radiation exposure should be minimized while still obtaining diagnostically adequate imaging.

Texas requires acceptable monitoring devices for personnel who may be exposed to radiation hazards and requires exposure records to be maintained.

A radiation-monitoring program should address:

• Who requires a dosimeter
• Proper badge location
• Badge exchange frequency
• Lost badges
• Exposure reports
• Investigation thresholds
• Occupational exposure follow-up

Staff should never intentionally share dosimeters.

Exposure reports should be:

• Reviewed
• Retained
• Available for inspection
• Investigated when unusual exposures occur

The Radiation Safety Officer should periodically review occupational exposure trends.

Only appropriately trained, qualified, and authorized personnel should perform imaging examinations.

Personnel files should include applicable:

• Texas licensure/certification
• Education
• Orientation
• Equipment-specific training
• Competency assessments
• Continuing education
• Radiation-safety training

The scope of work assigned to staff should match their legal authorization and demonstrated competency.

New radiology personnel should receive documented orientation before independent operation.

Orientation should cover:

• Facility equipment
• Emergency procedures
• Radiation safety
• Patient identification
• Contrast
• Infection prevention
• Critical findings
• EMR/PACS
• Downtime
• Equipment failure

Training and competency are not the same.

Competency should demonstrate that the employee can safely perform assigned responsibilities.

Potential competency topics include:

• General radiography
• CT operation
• Contrast injection
• Radiation safety
• Pediatric imaging
• Trauma imaging
• Equipment cleaning
• PACS operation
• Emergency response

Competency should be reassessed according to facility policy and applicable requirements.

Imaging equipment should have a structured quality-control and maintenance program.

Maintain records for:

• Preventive maintenance
• Equipment calibration
• Repairs
• Service calls
• Quality-control tests
• Performance evaluations
• Software updates
• Equipment failures

DSHS regulates the registration and operation of medical radiation machines and provides inspection and regulatory guidance for facilities operating X-ray equipment.

DSHS identifies the post-installation survey among records associated with medical X-ray equipment registration and operation.

Facilities should maintain applicable:

• Installation records
• Acceptance testing
• Post-installation radiation survey
• Shielding documentation
• Service documentation

CT represents an important area of radiation-safety oversight because patient radiation doses can be substantially higher than conventional radiography.

CT quality management should address:

• Protocol optimization
• Dose management
• Pediatric protocols
• Repeat scans
• Contrast use
• Equipment QC
• Technologist competency
• Diagnostic image quality

Protocols should be reviewed periodically with appropriate clinical and radiology leadership.

Pediatric imaging should use pediatric-specific protocols whenever applicable.

Quality review should consider:

• Patient size
• Clinical indication
• Scan range
• Repeat examinations
• Radiation dose
• Alternative modalities

Facilities should avoid simply applying adult CT techniques to smaller pediatric patients.

Repeat imaging exposes the patient to additional radiation and may indicate technical or workflow problems.

Facilities should monitor:

• Repeated examinations
• Rejected images
• Causes
• Technologist trends
• Equipment trends

Possible causes include:

• Positioning
• Motion
• Exposure selection
• Wrong protocol
• Equipment malfunction

Trending repeat/reject information provides an important performance-improvement opportunity.

Imaging should provide sufficient diagnostic information for the clinical question.

Poor-quality studies should be reviewed for:

• Positioning
• Exposure
• Artifacts
• Motion
• Field of view
• Contrast timing
• Reconstruction
• Equipment issues

Texas HHSC requires all examination reports to be:

• Read
• Dated
• Signed
• Authenticated

by an appropriately licensed physician or practitioner acting within their scope.

The facility should ensure that all imaging performed has a final interpretation.

Many FSERs use remote radiologists.

A teleradiology program should address:

• Credentialing
• Privileging
• Availability
• Turnaround time
• Critical results
• Preliminary reports
• Final reports
• Communication
• Downtime

The interpreting physician should meet organizational credentialing and privileging requirements.

Emergency imaging requires timely interpretation.

Useful quality metrics include:

• X-ray completion-to-report
• CT completion-to-report
• Ultrasound completion-to-report
• STAT report turnaround
• Critical-result notification time

Performance should be reviewed against internally established targets.

Critical or unexpected imaging findings require reliable communication.

The facility should maintain a defined process for findings such as:

• Intracranial hemorrhage
• Aortic catastrophe
• Pulmonary embolism
• Pneumothorax
• Bowel perforation
• Acute stroke finding
• Ectopic pregnancy
• Other immediately dangerous conditions

Documentation should support:

A patient may leave before a final interpretation identifies an important abnormality.

Policies should address:

• Final report reconciliation
• Newly identified critical findings
• Provider notification
• Patient contact
• Return-to-ER instructions
• Documentation of attempts

This is a particularly important risk-management issue for FSERs using remote interpretation.

If preliminary interpretations are used, the facility should have a process for identifying clinically meaningful discrepancies between preliminary and final interpretations.

Review should determine:

• Clinical significance
• Whether the patient was discharged
• Whether treatment changed
• Whether the physician was notified
• Whether the patient was contacted

These discrepancies can be valuable QAPI data.

CT contrast administration should follow an approved protocol.

Processes should address:

• Patient screening
• Allergies
• Renal-risk assessment where appropriate
• Contrast selection
• Dose
• Route
• IV access
• Administration
• Observation
• Reaction management

The facility should be prepared to recognize and treat contrast reactions.

Emergency medications and equipment should be available.

Events should be documented and reviewed.

Potential monitoring categories include:

• Mild reaction
• Moderate reaction
• Severe reaction
• Anaphylaxis

Significant events should enter the facility's quality system.

Policies should address:

• Recognition
• Immediate treatment
• Clinical assessment
• Documentation
• Discharge instructions
• Escalation

Extravasation events should be tracked for trends involving IV placement, equipment, or workflow.

Texas requires ultrasound capability to be immediately available on the premises at an FSER.

Policies should address:

• Personnel qualifications
• Examination scope
• Equipment maintenance
• Image storage
• Interpretation
• Documentation
• Infection prevention

If emergency physicians perform bedside ultrasound, the facility should define:

• Authorized examinations
• Physician privileging
• Training requirements
• Competency
• Image retention
• Documentation
• Quality review

POCUS should be incorporated into professional practice evaluation when clinically appropriate.

Texas requires radiology procedure manuals to address infection control and equipment cleaning.

Radiology infection-prevention practices should address:

• CT table cleaning
• X-ray equipment
• Ultrasound probes
• Positioning equipment
• High-touch surfaces
• Isolation patients

Probe cleaning and disinfection should be appropriate to how the probe is used and consistent with manufacturer instructions.

Facilities should distinguish between:

• External probes
• Probes contacting nonintact skin
• Endocavitary probes, if applicable

Most FSERs do not operate MRI systems.

If MRI is offered, the facility must implement an MRI-specific safety program appropriate to its equipment and scope.

If MRI is not offered:

Most standard FSER imaging uses radiation-producing machines rather than radioactive materials.

If radioactive materials are used, additional DSHS Radiation Control licensing requirements may apply.

Texas HHSC requires policies regulating the use, removal, handling, and storage of licensed radioactive material.

The patient's medical record should contain authenticated reports of examinations performed.

Texas specifically requires authenticated, dated examination reports to be added to the medical record.

Records should support:

• Patient
• Examination
• Date/time
• Ordering practitioner
• Performing technologist
• Interpreting practitioner
• Final report

PACS and imaging systems should protect:

• Patient confidentiality
• Data integrity
• Authorized access
• Record availability

Policies should address account access, security, and terminated-user access.

Radiology downtime planning should address:

• PACS outage
• EMR outage
• CT failure
• X-ray failure
• Ultrasound failure
• Internet outage
• Teleradiology outage
• Power loss

Because Texas requires certain imaging capability to be immediately available on premises, significant equipment downtime should trigger timely operational and leadership escalation.

When an imaging system becomes unavailable:

Do not return unsafe equipment to clinical service until appropriately evaluated.

Preventive maintenance should be current for:

• CT
• X-ray
• Ultrasound
• Contrast injector
• PACS-related systems where applicable

Missed preventive maintenance should receive documented corrective action.

A policy should address unexpected radiation events.

Potential examples include:

• Wrong patient
• Wrong body part
• Excessive exposure
• Repeat CT due to error
• Equipment malfunction
• Pregnancy-related exposure
• Staff overexposure

Events should be escalated according to applicable reporting requirements.

Radiology quality should evaluate the complete process:

Pre-Exam

• Order appropriateness
• Patient identification
• Pregnancy screening
• Preparation

Examination

• Protocol
• Technique
• Radiation safety
• Image quality

Post-Exam

• Interpretation
• Critical communication
• Final report
• Clinical follow-up

Recommended monthly indicators include:

Patient Safety

• Wrong-patient imaging
• Wrong-exam events
• Wrong-side events
• Near misses

Radiation

• Repeat/reject rate
• Occupational exposure alerts
• Radiation incidents

CT

• Repeat CT examinations
• Protocol deviations
• Dose concerns

Contrast

• Contrast reactions
• Extravasations

Reporting

• CT turnaround time
• X-ray turnaround time
• Ultrasound turnaround time
• Critical-result notification compliance

Interpretation

• Preliminary/final discrepancies
• Missed findings
• Addended reports

Equipment

• CT downtime
• X-ray downtime
• PM completion

Personnel

• License/certification compliance
• Competency compliance

The FSER Quality Committee should routinely review:

Licensure / Registration

Is the DSHS X-ray registration current?

RSO

Is the Radiation Safety Officer designation current?

Equipment

Are required maintenance and QC activities current?

Staff

Are personnel appropriately qualified and competent?

Radiation Safety

Are personnel monitoring and exposure records current?

Image Quality

Are repeat/reject rates acceptable?

CT

Are CT protocols and radiation-safety practices appropriate?

Contrast

Were reactions or extravasations identified?

Reporting

Did radiology turnaround meet targets?

Critical Results

Were critical findings communicated reliably?

QAPI

Were identified deficiencies corrected and effectiveness verified?

Use:

Example:

Finding: CT report turnaround averaging 42 minutes.

Goal: ≤30 minutes.

Root Cause: Teleradiology queue delay during evening hours.

Corrective Action: Revised escalation protocol and backup radiologist coverage.

Follow-Up: Average turnaround 24 minutes.

Sustainability: Maintained for three consecutive months.

Status: Effectiveness Verified / Closed.

For an accredited FSER operating under the Joint Commission Ambulatory Health Care framework, radiology should be incorporated into the organization's broader systems for:

• Patient identification
• Provision of care
• Staff competency
• Equipment management
• Infection prevention
• Medication/contrast safety
• Communication of critical results
• Medical-record integrity
• Performance improvement
• Emergency management

Joint Commission publishes a specific 2026 Standards for Ambulatory Care manual, which should be used to confirm the exact standards and Elements of Performance applicable to the organization's accreditation scope.

A useful survey binder can include:

Section 1 — Regulatory

• DSHS Certificate of Registration
• Equipment inventory
• RSO documentation
• Post-installation surveys
• Applicable licenses

Section 2 — Policies

• Operating and safety procedures
• Radiation safety
• Pregnancy screening
• Contrast
• Critical results
• Equipment downtime
• Infection prevention

Section 3 — Personnel

• Licensure
• Credentials
• Orientation
• Competency
• Radiation-safety education

Section 4 — Equipment

• Preventive maintenance
• QC
• Service reports
• Equipment inspections

Section 5 — Radiation Safety

• Dosimeter records
• Exposure reports
• Radiation surveys
• RSO reviews

Section 6 — CT Quality

• CT protocols
• Pediatric protocols
• Dose review
• Repeat analysis

Section 7 — Quality

• Repeat/reject data
• Critical-result compliance
• Turnaround times
• Contrast events
• QAPI projects

Section 8 — Corrective Action

• Prior survey findings
• Action plans
• Evidence of correction
• Effectiveness monitoring