CBH's Accreditation with American College of Radiology
What Does It Mean for a Facility to be Accredited by the ACR?
The ACR awards accreditation to facilities for the achievement of high practice standards after a peer-review evaluation of its practice. Image quality and procedure evaluations are conducted by board-certified radiologists and medical physicists who are experts in the field. The program also evaluates personnel qualifications, adequacy of facility equipment, quality control procedures and quality assurance programs. All findings are reported to the practice via a comprehensive report that includes recommendations for improvement.
The ACR accredits facilities in: Breast ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), mammography, nuclear medicine, positron emission tomography (PET), stereotactic breast biopsy, ultrasound, and radiation oncology.
When you choose an ACR-accredited facility, you know:
- Your hospital, clinic or health center has voluntarily gone through a rigorous review process to be sure it meets nationally-accepted standards
- The personnel are well qualified, through education and certification, to perform and interpret your medical images and administer your radiation therapy treatments
- The equipment is appropriate for the test or treatment you will receive, and the facility meets or exceeds quality assurance and safety guidelines
Radiation Oncology Accreditation Program Requirements:
Introduction
The radiation oncology accreditation program provides radiation oncologists with third party, impartial peer review and evaluation of patient care. The facility’s personnel, equipment, treatment planning and treatment records, as well as its quality control measures are assessed and compared to the ACR accredited facilities database, the ACR Practice Guidelines and Technical Standards for Radiation Oncology, and guidelines such as the American Association of Physicists in Medicine (AAPM) reports.
The Committee for Radiation Oncology Practice Accreditation of the ACR Commission on Quality and Safety directs the program. The accreditation process, designed to promote quality and be educational in nature, includes an on-site survey performed by board certified radiation oncologists and board certified medical physicists.
The Radiation Oncology Physicist is responsible for the design and implementation of the physics quality management program. A comprehensive review of the facility’s physics program will be included as part of the application process and verified during the on-site survey. The following areas will require documentation submitted with the application:
- Documentation of compliance with AAPM TG-40, TG-21 or TG-51 (required for accreditation)
- Documentation of treatment planning system quality assurance program TG- 53
- Independent Verification of Output of each beam
In addition, during the on-site survey, the qualified medical physicist’s documentation of the following will be reviewed:
- Procedures for instrument calibration and periodic instrument constancy checks
- Procedures to verify the manufacturer’s specifications and to establish baseline performance values for radiation therapy equipment
- Quality management program for radiation therapy equipment, simulators, treatment planning systems, and monitor unit calculation algorithms
- Monitor units calculation procedures and protocols
- Physics chart check protocol for reviewing treatment delivery
- Procedures for checking the integrity of mechanical and electrical patient care devices
- Radiation protection program as it pertains to radiation oncology
- Calculations related to patient dosimetry and/or physics measurements when such needs arise or per clinician’s requests
Personnel Qualifications:
Radiation Oncologist
- Satisfactory completion of radiation oncology residency in an American Council of Graduate Medical Education (ACGME) approved program
- Certification in Radiology by the American Board of Radiology (ABR) of a physician who confines his/her practice to radiation oncology or certification in Radiation Oncology or Therapeutic Radiology by the ABR, the American Osteopathic Board of Radiology, or the Royal College of Physicians and Surgeons of Canada may be considered proof of adequate physician qualifications.
Qualified Medical Physicist
The ACR recommends that the individual be certified in the appropriate sub fields by the American Board of Radiology. The appropriate sub fields of medical physics for Radiation Oncology are Therapeutic Radiological Physics and Radiological Physics.
Radiation Therapists and Simulation Staff
Radiation therapists and simulation staff must fulfill state licensing requirements and should have American Registry of Radiologic Technology (ARRT) certification in radiation therapy.
Dosimetrist
Certification by the Medical Dosimetrist Certification Board is recommended.