Revision History


To help your facility avoid common pitfalls, the table below outlines deficiencies that are frequently found during the accreditation process. These deficiencies must be addressed before a facility will be granted accreditation. Please note that other serious deficiencies not frequently seen and therefore not listed here may also require corrective action and documentation prior to accreditation.


 

Clinical Images

Phantom Images

Nuclear Medicine

  • Failure to label for laterality and orientation
  • Failure to read instructions
  • Incomplete submission of exams
  • Failure to follow written procedure
  • Information on Clinical Data Sheet does not correspond to Physician Report
  • Failure to send quality images
  • Incomplete dataset
  • Failure to submit composite of rods
  • Center of rotation
  • High-count flood
  • Phantom mixing and positioning

PET

  • Failure to label for laterality and orientation
  • Failure to read instructions
  • Submitting only fused images
  • Not sending coronal images for oncology, both AC and NAC
  • Not submitting testing package
  • Failure to send quality images
  • Incomplete dataset
  • Failure to include rods
  • Failure to remove spheres
  • Phantom mixing and positioning
  • SUV values now pass/fail

CT

  • Scanning through orbits/lens on brain CT
  • Not submitting required series (i.e. contrast enhanced)
  • Not reviewing the CT Testing Instructions before choosing exams for submission
  • Selecting examinations your site does not usually perform
  • Supervising physician not reviewing images before they are sent to the ACR
  • Techniques listed in Phantom Site Scanning Data Form do not match techniques used to scan the ACR or dosimetry phantoms
  • Parameters given to physicist are not parameters used for clinical exams
  • Not checking images for correct protocol
  • Not submitting dose images
  • Incorrect size chosen for pediatric abdomen phantom in data form

MRI

  • Not reviewing testing instructions before choosing exams for submission  
  • Not reviewing instructions located on the first page of each module in the Testing Instructions
  • Not submitting entire exam  
  • Not submitting required sequences
  • Not submitting ADC map
  • Poor SNR
  • Incomplete anatomical coverage                  
  • Supervising physician not reviewing images before they are sent to the ACR
  • Not following instructions provided in guidance documents
  • Physicist not reviewing images/data before sending to the ACR

Mammography

  • Positioning

  • Compression

  • Anonymizing images

  • Failure to read instructions

  • Phantom images do not meet criteria for fibers, specks and masses

  • Failure to read instructions

  • Not choosing best tomosynthesis slice for DBT units

  • Choosing wrong size phantom in testing package

Breast MR

  • Low SNR
  • Artifacts
  • Parameters for pre- and post-contrast T1 images do not match

Breast Ultrasound

  • Correlating mammogram was not performed within 60 days prior to sonogram
  • CC and MLO images not submitted
  • Sonogram discordant with mammogram
  • Distance from nipple to abnormality not measured on images
  • Pre-fire or post-fire images labeled incorrectly

Stereotactic Breast Biopsy

  • Correlating mammogram was not performed within 60 days prior to stereo biopsy
  • Calcifications not seen on both stereo pair views
Radiation Oncology
  • Insufficient information in consultative note
  • Incomplete patient history and physical examination
  • Incomplete treatment prescriptions
  • Lack of defined goals and requirements of treatment plan by radiation oncologist (i.e., dose constraints)
  • No formal treatment planning quality assurance plan
  • Lack of dose volume histograms
  • Lack of proper treatment quality assurance prior to patient treatment (i.e., no IMRT QA)
  • No written directive for brachytherapy procedure(s)
  • Insufficient radiation oncologist coverage during patient treatment
  • Lack of port film verification
  • Lack of documented weekly patient visits
  • No documented patient follow-up plan
  • No formal quality assurance and improvement program documented (e.g., outcome studies, focus studies)
  • No physician or physicist peer-review documented
  • End-of-treatment physics check not performed within a week
Ultrasound
  • Failure to read accreditation instructions
  • Submitting studies that do not meet the Exam Requirements
  • Failure to meet Exam Requirements with static imaging (cine loops submitted are disregarded for the review process)
  • Inadequate documentation of required anatomy 
  • Submitting post-surgical studies
  • Improper technical settings
  • Improper scanning technique
  • Poor image quality


 


Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes

2-3-2020UltrasoundAdded frequent Ultrasound deficiencies



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Passing Results

Options Following Failure/Deficiency

Passing Results: Mammography

Options Following Failure/Deficiency: Mammography

Passing Results: Radiation Oncology

Options Following Failure/Deficiency: Radiation Oncology