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Diagnostic Modality Accreditation

Program Overview

Overview

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The application process for the Diagnostic Modality Accreditation Program includes six programs:

Due to federally mandated requirements for mammography accreditation and the treatment-based survey (i.e., not based on review of images) for radiation oncology practices, practice sites seeking accreditation in these modalities need to apply separately.

Application for Accreditation

 The application for accreditation in the Diagnostic Modality Accreditation Program is a two-step process:

  1. Provide the ACR with information regarding your practice site characteristics (i.e. personnel) and modality-specific information (including equipment). A practice site is defined as each different geographical location where imaging is performed.
  2. Submit clinical images and depending on the specific modality, scanning protocols, patient reports, phantom images, and dose measurements. Information may also be collected on modality-specific quality control and quality assurance programs.

When a facility has applied for accreditation in a modality but no module or unit has yet passed the evaluation process, the facility will be considered under review. Full accreditation in the modality is only granted when all modules or units have passed the complete evaluation process or the facility has notified the ACR in writing that any module or unit that did not pass has been withdrawn from service. The 3-year period of accreditation extends from the date the first module or unit passes the full evaluation.

At the completion of the accreditation review process, the ACR will send a separate, confidential final report for each modality to the modality-specific supervising physician at the practice site. This peer review document discusses the results of the evaluation, defines areas that can be improved and provides recommendations for consideration by the facility.

Program Materials Distribution

The Diagnostic Modality Accreditation Program application, renewal materials, testing materials and final reports will be sent to the attention of the modality-specific supervising physician at the practice site. This supervising physician or his/her designee will be responsible for distributing the materials to the appropriate staff and should provide adequate support for staff to complete the accreditation program materials within the designated time frame. Compliance with the designated time frames is mandatory.

Time Frame for Submission of Accreditation Materials

Submission of all accreditation materials is subject to set timelines in order to provide adequate time for review, feedback and resubmission of testing materials (see Table 1). Modality renewal information is sent to the modality-specific supervising physician at the practice site eight months prior to the modality expiration date. Completed renewal information should be returned to the ACR within 60 calendar days from the date sent in order to avoid delays in the accreditation process and possible expiration prior to accreditation approval. All testing materials must be submitted to the ACR within 45 calendar days from the date sent or the application will be made inactive. Application fees for inactivated applications will not be refunded.

No images will be accepted for review that predate the application by more than six months. Do not send any images with the application.

 

 Table 1. Required Materials Due Dates

 

 

 

Materials Required 

Due 

 Renewal application

 60 calendar days from date ACR sends renewal information

 Testing materials

 45 calendar days from date sent

 Repeat option forms (after deficiency)

 15 calendar days from date sent

Payment Policy

When a single practice site applies for three or more modalities, it will receive a 10% discount on the final calculated fee for that site. For example, if a site is already accredited in MRI and CT or is in the process of going through accreditation for MRI and CT, and decides to add Nuclear Medicine, it will receive the 10% discount on the initial Nuclear Medicine accreditation, as well as on the subsequent MRI and CT renewal fees. In addition, the ACR offers multi-site, multi-unit pricing discounts for large practices. 

Payment must be received with the application. Applications received without payment will not be processed and will be returned if payment is not received within 30 days. Checks should be made out to the American College of Radiology and your ACR modality identification number must be referenced on the check or check stub (please note: since sites applying for a new modality will not have a modality identification number to reference on their check, they should note the modality for which they are applying). Credit card payments using VISA, MasterCard, and American Express are accepted.

On-Site Surveys and Validation Film Checks

To verify that accredited facilities maintain consistent quality during the 3-year accreditation period, on-site surveys and mail-in film checks for each modality may also be performed at any time during the accreditation process. The ACR reserves the right to conduct on-site surveys either before or after accreditation. These surveys provide an excellent opportunity for a positive educational exchange with experts in the field, as well as validating information submitted for accreditation. Radiologist and medical physicist (if applicable) reviewers from the accreditation program will be members of the survey team along with an ACR staff person.

Personnel

Personnel interpreting or performing a given modality must meet the qualifications specific to that modality. The facility should maintain detailed supporting documentation in its files regarding its personnel’s training (e.g., the type of training, in what capacity, under whose direction, when, and at what institution training was conducted).

The practice site president/CEO or owner must agree that no imaging procedures will be performed by anyone who does not meet the qualifications described in the modality requirements.

The practice site must maintain on-site an updated personnel summary list of all physicians, medical physicists (or MR scientists) and technologists. Unannounced site visits will be conducted and all information submitted for accreditation will be verified at that time. If the practice site’s supervising physician or president/CEO or owner changes, the site must submit a new Survey Agreement to the ACR. The personnel summary list and the Survey Agreement may be obtained on the ACR accreditation website.

Peer Review of Images

Phantom and clinical images must not be submitted on the same film because different review teams will review them. The image reviewers are experts in the field and are required to participate in a training program on the image review process. Special care is taken to avoid conflict of interest by both the reviewers themselves and between the reviewers and the facilities being evaluated. Pass/fail statistics and timeliness of reviewers are monitored by the accreditation committees on a regular basis. Images selected should be reviewed by the supervising physician prior to submission and should represent the facility’s best work. All images are reviewed based on this criterion.

The ACR is currently offering an option to submit images in electronic format for facilities that are applying for Ultrasound, MRI, CT (clinical images only), Nuclear Medicine or PET module accreditation. Details regarding this method of submission will be provided to sites in the testing instructions for the aforementioned modalities.

Withdrawn, Added or Replacement Units/Modules

Facilities that withdraw, add, or replace units or modules during the accreditation process or after accreditation has been granted must submit written notification to the ACR signed by the modality-specific supervising physician. Please see the requirements for each of the modalities for additional testing of new units.

Repeat After Deficiency

The modality-specific supervising physician who receives notification of a deficiency has the option to appeal, withdraw the unit and/or module, or repeat testing. A facility that fails to satisfy the image evaluation criteria on its initial attempt will be required to resubmit only those items that were deficient (e.g., phantom or clinical images). Facilities that elect to repeat after a deficiency are required to submit their request to reapply together with the appropriate fee within 15 days of the date on the final report. Upon receipt of the request and fee, testing materials will be sent to the facility. The facility must complete and submit the testing materials to the ACR within 30 calendar days.

Accreditation Renewal

Approximately eight months prior to the expiration of each modality accreditation, the ACR will send an Accreditation Renewal Notice to the practice site. At the time of renewal, practice sites will only be required to submit updated modality information and testing materials. Information about the practice site, including personnel qualifications, a new survey agreement, and practice site data will be updated once every three years and will be associated with one of the modality accreditation renewals.

Practice Parameters and Technical Standards

ACR Practice Parameters and Technical Standards serve as the foundation for all of our accreditation programs, although accreditation criteria may be more stringent. They may be accessed by both ACR members and nonmembers through the ACR Web site at acr.org/Quality-Safety/Standards-Guidelines.

Reporting of Results

Reporting of imaging and procedure results must be in compliance with the ACR Practice Parameter for Communication of Diagnostic Image Findings.

Patient and Personnel Safety Guidelines

Policies and procedures must be in place and maintained on-site for the administration of contrast, for the recognition and treatment of adverse effects of contrast materials, and for tracking and follow-up on contrast reactions. A policy stating that radiation exposure to patient and personnel will be as low as reasonably achievable should be available. See the ACR Position Statement on Quality Control and Improvement, Safety, Infection Control, and Patient Education Concerns.

Marketing Your Accreditation

Once accreditation has been achieved, the ACR will send the facility a marketing kit to assist in promoting this success within its community. In addition, all sites fully accredited by the ACR (and those under review) will be listed by accreditation program and state on the ACR website. Access a current list of accredited facilities. The marketing tools that are included in the kit are:

For Additional Information

Modality-specific requirements, FAQs and additional information about accreditation are available in the Modalities section of this website. Please contact the ACR Diagnostic Modality Accreditation Program office in Reston, VA, at 1-800-770-0145 for more information. Each modality program has a team of professional staff including qualified technologists and sonographers who are available to answer questions and guide you through the process.