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.
The application process for the Diagnostic Modality Accreditation Program includes eight programs:
Breast Magnetic Resonance Imaging
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET)
Stereotactic Breast Biopsy
For these programs, accreditation is a 2-step process accomplished primarily through the ACR’s online accreditation system, ACRedit, or ACRedit Plus (stereotactic and breast ultrasound only):
Step 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. There are instructions on the webpage every step of the way to assist you. There are also information buttons to give you more details. ACR staff will confirm and accept your application after we receive all required documents.
Step 2: After your application is processed, an online testing package will be activated, which will contain all forms required for accreditation review. Your facility will receive an email with a link to the online testing package. The facility user must log into the account and fill out all required forms. The testing package must be submitted online. 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.
The online testing package has the image submission due date. You must collect your test images and return them to the ACR by that date. Failure to meet this due date will jeopardize completion of your accreditation. Thus, if your facility is renewing its accreditation, we cannot guarantee completion in a timely fashion before your ACR certificate expires. If your site cannot submit the required materials by your due date, notify the ACR immediately.
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 in process. 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.
The accreditation process is conducted primarily electronically and by mail. The ACR conducts random image checks and on-site surveys to validate maintenance of accreditation criteria within the three-year accreditation period. For more information, please see our article on Validation Site Surveys.
At the completion of the accreditation review process, the ACR will issue a separate, confidential final report for each modality through the online system. A notification will be sent to the modality-specific supervising physician and administrator at the practice site when the report is available to their modality’s online user. This peer review document discusses the results of the evaluation, defines areas that can be improved, and provides recommendations for consideration by the facility.
The ACR website provides a listing of accredited facilities and facilities that have applied for accreditation and are under review. If a third-party payer requests verification of your participation in one of the accreditation programs, please refer them to the ACR website.
Successful accreditation is a team effort. Everyone at your facility is involved somewhat with accreditation, and should at least be aware of your facility’s participation. You should have one person who is “in charge” of organizing the project. You should have a “core team” made up of the personnel outlined below. This team should be agreed upon before beginning the accreditation process and should keep in close contact during the process. This will help ensure success.
Your lead technologist will be the main person we contact if necessary. This should be the primary person who completes the online accreditation application and testing package, and is the technologist contact listed on your application.
Your supervising physician is the interpreting physician responsible for your protocols. He or she approves all aspects of the application and testing materials before you submit them to the ACR for review.
Your medical physicist (does not apply to ultrasound and breast ultrasound) should be responsible for the annual system performance evaluation, supervising your facility’s QC and performing the dosimetry portion of your phantom submission, if applicable. We also strongly recommend that he or she be closely involved with the phantom portion of your testing materials submission, and assist the supervising physician and lead technologist with your routine clinical protocols to help ensure the lowest technique possible while maintaining good image quality.
Your administrative contact (e.g. manager, director) will help organize the members of your “core team” and ensure that everyone on the team has the resources necessary to successfully complete your accreditation process.
How Many Applications Should We Submit?
Under ACR accreditation policies, an accredited facility encompasses the staff, equipment, protocols, policies and procedures and physical location. In other words, all elements of the “practice” are considered. Any changes in even one major element could affect accreditation of the “facility”. ACR’s primary concern is that when patients receive imaging at an ACR-accredited facility, all aspects are in fact accredited. In situations where several businesses operate out of the same location, but have different staff, protocols etc., we must evaluate each business separately. If staff, protocols, policies and procedures, and physical location are the same, a single accreditation application is appropriate.
Please note that the Breast MRI Accreditation Program is a stand-alone program and not a module under the general MRI Accreditation Program. You must apply for accreditation in breast MRI separately. However, if you have applied for general MRI accreditation with the magnet you use for breast MRI, you are eligible for a discount on the Breast MRI Accreditation Program. Additionally, breast ultrasound facilities should check with your state’s department of radiologic health to see if your state currently requires breast ultrasound accreditation.
Revision History for this Article
Description of Revision(s)
Article created; FAQs incorporated; No criteria changes
|9-17-2020||Added link to Accreditation Process flowchart|