American College of Radiology… Quality Is Our Image™
ACR ACCREDITATION
Carolyn MacFarlane, MS, CNMT, RT(N)
[email protected]
What is the ACR’s Mission?
Who is the ACR? • Membership organization - 32,000 radiology professionals – Diagnostic/interventional radiologists – Nuclear medicine physicians – Medical Physicists – Radiation oncologists – Clinical Researchers
What is the ACR’s Mission? • To serve patients and society – Advance the science of radiology – Improve the quality and safety of patient care – Provide continuing education for radiology and allied health professions – Conduct research for the future of radiology
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Accreditation Statistics Modality
Accreditation Statistics Currently Active
Accredited
Breast Ultrasound
985
894
PET
875
795
3128
Stereotactic Breast Biopsy
609
569
3362
3152
Radiation Oncology
246
176
1626
1498
25184
23509
Currently Active
Accredited
Mammography
8460
8286
MR
5349
5011
CT
3672
Ultrasound Nuclear Medicine
What is ACR Accreditation?
Modality
TOTAL
ACR Practice Guidelines and Technical Standards serve as the foundation for the accreditation programs
• An educational process with self assessment and peer review – Staff qualifications – Policies and protocols – Equipment specifications – Diagnostic image quality – Therapeutic treatment quality
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Who are the Accreditation Staff? • ACR staff – Healthcare professionals – Certified imaging technologists and radiation therapist • Physicians and physicists – Accreditation committees – Reviewers
Your Role in Accreditation
Applying for and achieving ACR accreditation is a team process that involves everyone in the facility
Diagnostic Modality Accreditation Program (DMAP) • All voluntary programs are part of DMAP
How Do You Apply for Accreditation? Go to the ACR web site at www.acr.org then click on the accreditation page
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AEA – Automated Entry Application Advantages: • • • • • • •
No paperwork Save work & finish later User friendly Guides user through process No need to guess about paperwork Automatically calculates fees and deducts discounts Automatic email notifications
AEA – Automated Entry Application
Common Mistakes in AEA Application
Caveats:
• Not submitting a signed practice site survey agreement • Not clicking the submit button • Trying to submit an AEA application when the site already applied for that modality in the past • Not entering all of the modality ID numbers
• Only available to sites applying for first time or adding a new modality • Not available for renewals or adding new units • Not available for address or personnel changes
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Accreditation Fees Fees vary with the modality and number of units Facilities applying for three or more modalities will receive a 10% discount
CME Update for Accreditation All renewing sites: Physicians & physicists must have 15 CME ( half of which must be category 1) in specific modality in the prior 36-month period.
Updates • Participation in RADPEER™ or similar physician peer review program • MANDATORY CME appropriate to physician/physicist practice • MANDATORY requirements for continuing physician experience over a specified time
Nuclear Medicine & PET Accreditation Fees Facility Fee
$1200/modality
Per Module
$600 each
Each unit can have up to three modules
PET counts for NM, NM does not count for PET!!!
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Nuclear Medicine Accreditation Modules*
Nuclear Medicine Accreditation Modules
• Planar - WB and/or spot bone, hepatobiliary, lung, MUGA
New Exams!
• SPECT - Bone SPECT, liver, hepatic blood pool, brain, myocardial perfusion
• Planar - WB and/or spot Gallium, Octreotide, I131, & Thyroid
• Nuclear Cardiology – Myocardial perfusion, gated SPECT,
• SPECT – Gallium SPECT & Octreotide SPECT
MUGA
*Normal exams requested. (Facility must apply for each module that is performed on each unit)
PET Accreditation Modules • Oncology – 2 exams, one must be abnormal • Brain – 2 exams, one must be abnormal • Cardiology – 2 exams, one must be abnormal
Testing Materials • • • • • • •
Tutorial CD Quality Assurance Questionnaire Bar-coded labels with due date Clinical Test Image Data sheets Phantom testing instructions Testing Instructions Submission checklist
(Facility must apply for each module that is performed on each unit)
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Timeline
Submission of Materials Clinical Images
• Sites will have 45 days to complete the testing materials phase
Electronic Submission of Images The ACR is currently offering an option to submit images in electronic format for: – Nuclear Medicine (JPEG, TIFF, GIFF) – PET Accreditation (JPEG, TIFF, GIFF) – Ultrasound – MRI – CT (clinical images only) – Stereotactic Breast Biopsy
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No volunteers or models
•
Physician’s report for each exam
•
Written procedure
•
Clinical Test Image Data Sheet
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Original films, copies of originals or CDs
Submission of Materials Best Work???
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Clinical Image Evaluation Parameters
Clinical Image Evaluation Parameters
• Report Identification • Film Identification
Common Pitfalls • Incomplete submission of exams
• Acquisition
• Failure to read instructions
• Processing
• Incomplete clinical test image data sheets
• Display
• Not following written procedure
• Artifacts • Radiopharmaceutical distribution
#1 Reason for clinical failure…
Submission of Materials
• • • •
Physicist Report Quality assurance questionnaire NRC and/or state inspection Site Scanning Data sheets
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ACR-Approved SPECT Phantom
ACR-Approved PET Phantom
Phantom Image Evaluation Parameters
Phantom Image Evaluation Parameters
Planar
Phantom Images
• Uniformity • Spatial Resolution SPECT and PET Phantom Images • • • •
Uniformity Noise Contrast Spatial Resolution
Uniformity
Resolution
Contrast
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Phantom Image Evaluation Parameters Phantom Images
Phantom Image Evaluation Parameters
Phantom Image Evaluation Parameters Planar Images - An Example of What NOT to Submit
Phantom Image Evaluation Parameters
Another Example of What NOT to Submit
Common Pitfalls •
Incomplete submission of images
•
Failure to include rod section
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Center of Rotation
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High count floods
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Phantom mixing & positioning
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Quality Control Testing
Quality Control Testing The gamma camera evaluation should include:
• Performance tests are required at least annually • A physicist report
• Uniformity (intrinsic & system) • Spatial Resolution • Sensitivity • Energy Resolution • Count Rate Parameters
Quality Control Testing The PET evaluation must include: • ACR-approved Phantom • Dose Calibrators -Linearity
Clinical and Phantom Image Review • Clinical images are scored by two physician reviewers • Phantom images are scored by two physicist reviewers
-Accuracy
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Who are the clinical reviewers? Physician: • Board certified • Recognized expert in specific modality • In active practice with at least 50% in modality reviewed
Specific Reviewer Training • All reviewers required to complete special training – Objectivity…Standardized score sheets – Reduce variability between reviewers • Refresher training sessions • Statistics monitored
Who are phantom reviewers? • Physicist • Must Be Board Certified and in active practice with at least 25% in modality reviewed
Arbitration • If two reviewers disagree, the clinical or phantom images are sent to a third reviewer for arbitration
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Nuclear Medicine/PET Accreditation Program • Pass/Fail determined by score of each exam • All images must pass for unit to be accredited • Accreditation Granted (or not) • A certificate is issued • Accreditation is granted for three years • Final report issued to Supervising Physician
Marketing Tools for You: Sample Press Release Accreditation Seal Downloadable seal for stationery, prescription pads, etc Web site listing
www.acr.org
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If the site does not pass the first time:
If the site does not pass the second time:
• Appeal – Option to appeal the final outcome – Reviewed by a senior reviewer • Withdraw Module • Repeat
• Reinstate – Site must submit a corrective action plan – All testing to be resubmitted • Appeal
– Option to retest
If the site does not pass the reinstate cycle: • Scheduled On Site Survey (SOSS) – Physician – Physicist, if applicable – Technologist • Corrective Action Plan • Pre-test images • Reinstate
If the site does not pass the first time: • Appeal – Sites have the option to appeal the final outcome – The films are reviewed by a senior reviewer, not involved with the first review • Withdraw Module • Repeat – A facility will have the option to retest
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If the site does not pass the second time: • Reinstate – Site must submit a corrective action plan – All testing to be resubmitted • Appeal
If the site does not pass the first time:
If the site does not pass the reinstate cycle: • Scheduled On Site Survey (SOSS) – Physician – Physicist, if applicable – Technologist • Corrective Action Plan • Pre-test images • Reinstate
If the site does not pass the second time:
• Appeal – Option to appeal the final outcome – Reviewed by a senior reviewer • Withdraw Module • Repeat
• Reinstate – Site must submit a corrective action plan – All testing to be resubmitted • Appeal
– Option to retest
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If the site does not pass the reinstate cycle:
Random On Site Surveys • Survey is performed by a physician, physicist and ACR staff member
• Scheduled On Site Survey (SOSS) – Physician – Physicist, if applicable – Technologist • Corrective Action Plan • Pre-test images • Reinstate
Random On Site Surveys
• Validation process • Excellent opportunity for education and peer review
Why Seek ACR Accreditation?
Review: • • • • •
Application data Personnel qualifications Federal, state & local licensure/certification Equipment Review of annual physicist reports and corrective action • Review of all QC logs • Review protocols
# 1 Reason: AIM HIGH FOR QUALITY
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The Future of Accreditation
The Future of Accreditation
• ApplicationXtender Document Manager
Medicare Improvement for Patients and Providers Act of 2008 (MIPPA):
• Paperless
• Advanced diagnostic imaging services (ADIS) – CT, PET, MRI, Nuclear Medicine
• Reviews online
• CMS will approve by January 2010
• Compliance audits
• Hospitals not required to meet comprehensive accreditation requirements by January 2012
American College of Radiology 1891 Preston White Drive Reston, VA 20191-4397 Phone: Accreditation Hotline (800) 770-0145
www.acr.org QUALITY IS OUR IMAGE ™
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