General Personnel Requirements: Supervising Physicians (Revised 8-22-2022)
Modified on: Thu, 26 Jan, 2023 at 8:49 AM
Note: Requirements for Lead Interpreting Physicians in Mammography and Managing Physicians in Radiation Oncology differ and are presented separately.
Facility (Practice Site) Supervising Physician: This is the physician responsible for the entire facility location. This person ensures that all terms stated in the Survey Agreement are met. They are in charge of the entire practice site and responsible for the overall management and quality assurance standards of the facility. In addition, this physician can be a facility officer or CEO; and this same physician can be - but is not required to be - a modality supervising physician.
In the event that a Practice Site Supervising Physician leaves his or her position, a new one must be designated and reported to the ACR using the online account profile. Once this information is updated, the new Practice Site Supervising Physician and the Practice Site Officer and Owner must read and sign the conditions for accreditation in the online Practice Site Accreditation Survey Agreement.
Modality Supervising Physician: This is the physician responsible for the individual modality (e.g., nuclear medicine) at your practice site. This physician must oversee the clinical exam selection for the accreditation and review all testing materials relating to that modality before they are sent to the ACR. The modality-specific supervising physician may or may not be the same as the Facility (Practice Site) Supervising Physician.
In addition complying with all modality-specific requirements for interpreting physicians, the modality supervising physician is also responsible for the development, implementation and enforcement of policies and procedures regarding the following:
Assurance of safety, including, as relevant: contrast use (including assuring that a radiologist provides direct or general supervision of intravenous contrast administration), sedation, and reduction of exposure as much as reasonably appropriate for pediatric patients.
Identification of pregnant or potentially pregnant patients
Oversight and submission of all materials, including clinical images, phantom images as relevant, quality control data and other information as required by the modality-specific accreditation program.
Notifying the ACR within 15 days of any changes in imaging equipment (units) or changes in the use of equipment that could affect clinical or phantom images (For example: in CT, using an adults-only approved scanner to scan pediatric patients; in MR, using the magnet for a module that is not accredited).
Ensuring that all accreditation criteria are met and that the same standard of performance is maintained during the 3-year accreditation period.
Providing immediate written notice to the ACR upon the termination of any accredited services provided by the Practice Site or a change in ownership of the operating location.
Ensuring that all physicians providing services at the facility are actively participating in a formal peer review program that meets the stated accreditation requirements (for breast MRI, and stereotactic breast biopsy, the facility must participate in a medical outcomes audit program in order to meet the requirement). The following articles provide additional information regarding peer review and audit requirements:
Links to QA Articles for Specific Peer Review Requirements by Modality
MRI and Breast MRI: Compliance with the ACR Manual on MR Safety. Note: Staffing is not directly evaluated during the ACR MR Accreditation review. However, if there is a question of inadequate staffing or safe practices of an ACR Accredited facility, the ACR reserves the right to request a response from the facility to ensure appropriate safety procedures are being followed and performed for that facility.
CT, Nuclear Medicine and PET: Assurance of radiation protection, protection against the hazards of radiation exposure to both patients and radiological personnel, and compliance with appropriate monitoring requirements.
Compliance with the recommendations of the medical physicist (for Nuclear Medicine and PET, the supervising physician must also review the laboratory safety manual at least annually with the radiation safety officer and medical physicist).
Revision History for this Article
Description of Revision(s)
Article created; FAQs incorporated; No criteria changes
Updated link from ACR Guidance Document on MR Safe Practices: 2013to ACR Manual on MR Safety
Added clarification about staffing for MRI and Breast MRI
New sections to clarify Facility and Modality supervising physician roles
Modality Supervising Physician
Updated supervision of contrast administration requirement
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