Radiation Oncology


Radiation Oncology Practice Accreditation FAQ

Apply for Accreditation

Topics

  1. What are the program goals?
  2. Is an on-site survey performed?
  3. What happens during the on-site survey?
  4. What type of computer access will we need?
  5. What happens after the site survey is over
  6. What happens if my facility does not "pass"?
  7. What are the benefits to my practice?
  8. Do patients really care or know about accreditation?
  9. How soon can my survey be scheduled?
  10. How soon will we receive the accreditation report?
  11. Who makes the recommendations and accreditation decision?
  12. What can my practice begin doing to prepare for an ACR accreditation survey?
  13. What are the costs of an accreditation survey?
  14. How do I start the survey process?
  15. Who signs the survey agreement? Does every radiation oncologist in the practice have to sign a release (consent) form?
  16. What is an FML number?
  17. If my facility is already accredited, when should I start the renewal process?

1. What are the program goals?

A: The goals of the program are to provide impartial, third party, peer review; to recognize quality radiation oncology practices through accreditation; to make recommendations for improvement in practice and patient outcomes according to the recognized standards of the scientific community; and to provide a referral list for patients.

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2. Is an on-site survey performed?

A: Yes. On site surveys are performed by board-certified radiation oncologists and medical physicists. In addition, in order to verify that accredited facilities maintain consistent quality during the 3-year accreditation period, on site surveys may also be performed at any time during the accreditation period. Any facility chosen for a random on site survey will be notified in advance. There is no additional cost to the facility for the random survey.

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3. What happens during the on-site survey?

A: During the on site review, the surveyors tour the facility, conduct an interview the medical director, the chief of physics, the chief therapist and/or department manager and other key personnel; review 10 (number may vary with multi-site surveys) pre-selected patient records using the web based data collection process, verify information submitted in the application, review the facility's quality assurance and improvement program, peer review activities and policies and procedures.

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4. What type of computer access will we need?

A: We need a minimum of two computers (four monitors) with internet access for the surveyors.

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5. What happens after the site survey is over?

A: At the end of the day, the survey team will conduct a short meeting with the personnel who participated in the morning interview session. This is basically an opportunity for questions and clarification; the surveyors will not provide information on the facility's accreditation status at that time.

Following the survey, the medical director will receive a detailed narrative report that includes tables comparing the facility’s staffing and equipment ratios to similar size and type of accredited facilities, comments and recommendations regarding the reviewed patient cases and, recommendations for improvement. For accredited facilities, a certificate and marketing kit will be included with the final report.

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6. What happens if my facility does not "pass"?

A: There are two options:

Deferred with 90 days to submit a Corrective Action Plan.
After the Corrective Action Plan is approved by the Committee, the facility will be required to perform a self-audit (measures for self-audit will be selected by the Committee) and submit the results no later than 6 months after receipt of response to corrective action. Following Committee approval of the self-audit, the facility may be granted a 3 year accreditation.

Denied with 90 days to submit a Corrective Action Plan.  
After the Corrective Action Plan is approved by the Committee, the facility will be required to participate in a follow up survey (6-9 months after receipt of response to corrective action). A re-application fee of $5,000 must be submitted with the survey agreement. The surveyors will complete a report of their findings which will be reviewed by the Committee. Following Committee approval of this report, the facility may be granted a 3 year accreditation.

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7. What are the benefits to my practice?

A: Benefits to the practice include: an objective peer review assessment of the practice; evidence through an external audit that demonstrates to referring physicians, patients, peers, regulatory agencies (some states require routine external audits) and payers, the facility’s commitment to quality care; and specific recommendations for improvement from experienced, practicing radiation oncologists and physicists. Some facilities use the survey report to support their requests for increased staffing and equipment improvements/replacements.

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8. Do patients really care or know about accreditation?

A: In today's world, patients have access to a wealth of information and are very knowledgeable about health care issues. They are continually seeking high-quality, appropriate care. ACR accreditation is widely recognized as a measure of quality care and all accredited facilities are listed on the ACR website.

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9. How soon can my survey be scheduled?

A: A survey can usually be scheduled 30 to 90 days after the completed application is submitted. The scheduled dates are based on the available dates submitted by the facility.

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10. How soon will we receive the accreditation report?

A: On average, most facilities receive the final report within eight to twelve weeks after completion of the on site survey.

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11. Who makes the recommendations and accreditation decision?

A: The surveyors act as data collectors only; all data from the application and the survey are compiled and submitted to the ACR Committee on Radiation Oncology Practice Accreditation who make the final recommendations regarding accreditation. This committee is composed of board certified radiation oncologists and medical physicists who undergo special training in order to participate. Any questions or concerns about your survey should be referred to ACR staff. Surveyors should not be contacted directly by any members of the facility staff.

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12. What can my practice begin doing to prepare for an ACR accreditation survey?

A: Review the following:

ACR Practice Parameters and Technical Standards for Radiation Oncology
http://www.acr.org/Quality-Safety/Standards-Guidelines/Practice-Guidelines-by-Modality/Radiation-Oncology

AAPM Task Group Reports (in particular TG-51, TG-40/TG-142, and TG-53)
Reviewing these documents and incorporating them into your facility’s operational policies and procedures is an important step in the accreditation process.

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13. What are the costs of an accreditation survey?

A: The cost is $9,500.00 for a single site; additional sites are $3,000.00 each. Surveyors' expenses are included in the survey fee.

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14. How do I start the survey process?

A: The medical director of the radiation oncology facility must request the survey by submitting a completed on-line application, survey fee, signed survey agreement and release forms (consent) from each physician in the practice.

Your facility will receive an e mail from the Radiation Oncology Practice Accreditation (ROPA) website when your application has been approved. You will also receive an e mail when your site visit has been scheduled confirming the date and introducing the team members.  At this time, you will be asked to submit your list of cases for review.

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15. Who signs the survey agreement? Does every radiation oncologist in the practice have to sign a release (consent) form?

A: The Director (Chair, Chief) of Radiation Oncology must sign the survey agreement. This is the person who will receive the final report. Each radiation oncologist must sign a release (consent) form. The survey agreement and consent forms are submitted with the application.

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16. What is an FML number?

A: This is a number assigned to your facility by ACR staff. If you are a new facility, you will not have a number assigned until your application is submitted. If you are already accredited, the FML will be on your (previous) final report.

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17. If my facility is already accredited, when should I start the renewal process?

A: We suggest that you submit your application for renewal approximately nine months prior to the expiration date of your accredited status.

For more information, contact ACR staff at 1-800-770-0145 or e-mail rad-onc-accred@acr.org. The application is available at https://ropa.acr.org/pages/Login.aspx.

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