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American College of RadiologyAmerican College of Radiology……Quality Is Our ImageQuality Is Our Image™™

ACR ACCREDITATION

Who is the ACR?• Membersh ip organizat ion - 32,000

radio logy professionals– Diagnostic/interventional radiologists– Nuclear medicine physicians– Medical Physicists– Radiation oncologists– Clinical Researchers

• To serve patien ts and society– Adv ance the scie nce of radiology

– Impro ve the quality and safety ofpatient care

– Provide conti nuing educ atio nfor radiolo gy and allied healthprofess ion s

– Cond uct research for thefuture of radio logy

What is the ACR’s Mission?

What is the ACR’s Mission?

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What is ACR Accreditat ion?• An educational process wi th self

assessment and peer review

– Staff qualifications

– Policies and protocols

– Equipment specifications

– Diagnostic image quality

– Therapeutic treatment quality

ACR Practice Guid elines and Techn ical Stand ardsserve as the found ation for the accred itation progr ams

Who are the Acc reditati on Staff?

• ACR staff– Healthc are professionals– Certified imaging technologists and radi ation

therapist• Physician s and

phy sicists– Acc reditation

com mittees– Reviewers

Diagnos tic Modal ity Accredi tatio n Program (DMAP)

• All voluntary pro gram s are part of DMAP

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Your Role in Acc redi tatio n

Applyi ng for and achievingACR accreditation is a

team proces s that inv olv eseveryo ne in the fac ility

How Do You Apply for Accreditation ?

Go to the ACR web siteat www.acr. org then

click on theaccredit ation page

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Accre ditation Fees

Fees vary with the modality and number ofunit s

Facilities applyi ng for three or moremodal itie s wil l receiv e a 10% discount

Miss ing Items

• The ACR canno t pro cess inco mplete applications orprovide testing materials until all requir ed info rmationis recei ved.

• Incomplete Applicatio n email or letter to facilit y

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July 2007

• Participation in RADPEER™ or similar physicianpeer review program

• MANDATORY CME appropriat e tophysician/physicist practice

• MANDATORY requ irem ents for cont inuingphy sician experien ce over a specified time

CME Update for Accredi tatio n

Sites renewing in Ju ly 2007:• 5 CME (category 1) hours in specif ic modalit y in

the prior 12-month period .

Sites renewing in Ju ly 2008:• 10 CME (catego ry 1) hours in specif ic modality in

the prior 24-month period

Sites renewing in Ju ly 2009:• 15 CME hours (category 1) in specif ic modality in

the prior 36-month period

Nuclear Medicine & PET Accreditation Fees

Facil ity Fee $1200/modality

Per Module $600 each

Each uni t can have up to three mod ules

Nuclear Medic ine Accreditation Modu les*

• Planar - WB and/or spot bone, hepatobiliary, lung, MUGA

• SPECT - Bone SPECT, liver, hepatic blood pool, brain,myocardial perfusion

• Nuclear Cardiolo gy – Myocardial perfusion, gated SPECT,

MUGA

*Normal exams requested.

(Facility must apply for each module that is performed on each unit )

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PET Accreditation Modul es

• Oncolo gy – 2 exams, one must be abnormal

• Brain – 2 exams, one must be abnormal

• Cardio logy – 2 exams, one must be abnormal

(Facility must apply for each mod ul e that is per for med on each uni t)

Testing Materi als

• Tutorial CD• Quality Assurance Questionnaire• Bar-coded labels with due date• Clinical Test Image Data sheets• Phantom testing instructions• Testing Instructions• Submission checklist

Timeline

• Sites will have 45 daysto complete the testin gmateri als phase

Submission of MaterialsClinica l Images

• No volunteers or models

• Physician’s report for each exam

• Written procedure

• Clinical Test Image Data Sheet

• Original films, copies of originals or CDs

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Submission of Material s

Best Work???

Clinical Image Evaluati on Parameters

• Report Identification

• Film Identification

• Acquisition

• Processing

• Display

• Artifacts

• Radiopharmaceutical distribution

Clinic al Image Evaluation Paramet ers

Common Pitfalls

• Incomplete submission of exams

• Failure to read instructions

• Incomplete clinical test image data sheets

• Not following written procedure

#1 Reason for cli nical fai lure …

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Submission of Material s

• Physicist Report• Quality assurance questionnaire• NRC and/or state inspection

• Site Scanning Data sheets

ACR-Approve d SPECT Phantom

ACR-Appr oved PET Phantom Phantom Image Evaluation Parameters

Planar

• Uniformity• Spatial Resolution

SPECT and PET Phantom Images

• Uniformity• Noise• Contrast• Spatial Resolution

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Phantom Image Evaluati on Parameters

Phantom Images

Uniform ity Resoluti on Contrast

Phantom Image Evaluati on Parameters

Phantom Images

Phantom Image Evaluation Parameters

Planar Images - An Example of What NOT to Submit

Phantom Image Evaluation Parameters

Another Example of What NOT to Submit

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Phantom Image Evaluati on Parameters

Common Pitfa lls

• Incomplete submission of images

• Failure to include rod section

• Center of Rotation

• High count floods

• Phantom mixing & positioning

Quality Control Testi ng

• Performance tests are required at least annually

• A physicist report

Quality Contr ol Testing

The gamma camera evalu atio n shou ld include:

• Uniformity (intrinsic & system)

• Spatial Resolution

• Sensitivity

• Energy Resolution

• Count Rate Parameters

Quality Control Testing

The PET evaluation must inclu de:

• ACR-approved Phantom

• Dose Calibrators

-Linearity

-Accuracy

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Clinic al and Phantom Image Review

• Clinical images are scored by two physicianreviewers

• Phantom images are sco red by two physicistreviewers

Who are the clini cal review ers?Physician:

• Board certifi ed• Recogni zed expert in specific modal ity• In act ive practice with at least 50% in modal it y

reviewe d

Who are phantom revi ewers?

• Physicist

• Must Be Board Cert ified and in active pract icewith at least 25% 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

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Arbitrat ion

• If two revi ewersdisagr ee, the cli nicalor phantom imagesare sent to a thi rdreviewe r forarbitration

Accreditati on Granted

• Pass/Fail determined

• All images must pass for site to be accredited

• A certificate is issued

• Accreditation is granted for three years

• Final report issued to Supervising Physician

Marketing Tools for You:

� Sample Press Release

� Acc reditation Seal

� Downloadable seal forstationery, prescrip tion pads,etc

� Web site listing www.acr.o rg

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• Appe al

– 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

If the site does not pass the first time:

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 sit e does not pass the reinstate cycle:

• Scheduled On Site Survey (SOSS)– Physician– Physicist, if applicable– Technologist

• Corrective Action Plan• Pre-test images• Reinstate

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Random On Site Surveys• Survey is performed by

a physician, physicistand ACR staff member

• Valida tion process

• Excell ent opportu nityfor education and peerreview

Random On Site Surv eys

• The ACR reser ves the right to perform an onsite survey at any time duri ng the three yearaccredita tion cycle

• The faci lity receives 2 weeks notice

Random On Site SurveysReview:• Application data• Personnel qualif ication s• Federal, state & local licensure/cert ification• Equipment• Review of annual physicist report s and corr ective

action• Review of all QC log s• Review protocols

Why Seek ACR Accreditation?

AIM HIGH

# 1 Reason is QUALITY

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Why Seek ACR Accreditat ion?

Plus:• Patient Confiden ce• Payer Conf idence• Expert assessment of imag e quality• Formal review may be used to meet

cr iteria of state or federalgovernment , or thir d party payers

• Marketi ng tool – set your practiceapart

Americ an Colle ge of Radiology

1891 Preston White DriveReston, VA 20191-4397

Phone: Accreditatio n Hotline (800) 770-0145www.acr.org

QUALITY IS OUR IMAGE ™