Revision History


If a facility does not pass accreditation:

  • The ACR’s final report will provide specific recommendations for improvement.

  • If this is a unit’s first attempt, the facility should take corrective action on its own.

  • Facilities may appeal any denial of accreditation.


After a failed outcome, the facility has the opportunity to submit an option form to proceed with accreditation through a repeat, reinstatement with corrective action, appeal or to withdraw the module or patient type in question, or to withdraw from the accreditation process entirely. These options are described in detail below.


To access your option form, go to “My Final Reports” and click “Select Option” under the option status column.



For uploaded submissions, the option form is available 48 hours after the final report is issued.

For CD or film submissions, the option form is available 48 hours after images are returned to your facility. 


Option forms are due 15 days after the date they are sent. Please review your final report and options with your supervising physician before completing your option form. Your final report must be viewed before the option form is available.


Facility options after unsuccessful attempts at accreditation are outlined here:


Attempt

Accreditation Not Granted

Facility Options

1st

1st Deficiency

  • REPEAT ‘not acceptable’ area(s)  

  • APPEAL 

  • WITHDRAW

2nd

2nd Deficiency (= 1st failure)

  • REINSTATE after corrective action is approved and must retest all areas applied for in the original application

  • APPEAL 

  • WITHDRAW

3rd

3rd Deficiency (= 2nd failure)

  • REINSTATE after participating in scheduled on-site survey

  • APPEAL 

  • WITHDRAW



Mammography and Radiation Oncology: The available options after accreditation failures and deficiencies, as well as the appeal and repeat procedures for mammography and radiation oncology differ from those for other modalities. Information and instructions for mammography and radiation oncology are provided separately.



Appeals

Appeals are typically made due to disagreement with the assessment of image quality and/or missing images or incorrect data forms. Facilities that disagree with a deficiency or failure may appeal the determination within 15 days of the final report. 


If you did not pass accreditation because the wrong images were selected, required images were omitted, and/or insufficient information was provided with the images submitted, you may appeal the decision; however, you may not submit new cases. During accreditation review, the ACR reviewers assume that the submitted cases were reviewed by the modality’s supervising physician and are examples of your best work. Consequently, during an appeal, only the original exam will be reviewed. If some sequences from the original exam were not included, you may be able to submit those sequences.


To appeal, complete the option form in the online accreditation system:

  1. Go to “My Final Reports”

  2. Click “Select Option”

  3. Select “Other Options”

  4. Select “Appeal”

  5. Check the attestation box at the bottom of the screen. Do NOT check any modules or patient types on this screen unless you wish to withdraw them from the accreditation process.

  6. Click “Submit”


Appeal submissions must be completed the same way as the original submission. If you submitted on CD, you must appeal on CD; if you submitted electronically, you must appeal electronically.


Appeals on Electronic Submissions: When completing the option form as outlined above, please have all materials outlined below available, and proceed as follows:

  • Upload appeal letter signed by supervising physician (if clinical) or medical physicist (if phantom).

  • Upload any supporting documentation such as corrected phantom data forms. Do NOT upload the images with the appeal letter.

  • If additional images are required, select “yes” for submission of additional images; select “no” if no additional images need to be uploaded.

  • Submit the options form online.

  • Upload the missing images in the testing package; Do NOT re-upload the entire exam.

  • Submit the online testing package in the accreditation system.


Your images will be forwarded to an arbitrator (a reviewer who did not participate in the initial review) with a copy of the previous reviews and the appeal letter written by the facility. The arbitrator's determination will be final.


You should receive the appeal results within 30 to 45 days of the date all required appeal materials were received by the ACR.


If the appeal outcome following the first deficiency is a fail, you may choose to repeat, withdraw the module/patient type, or withdraw from accreditation. 


Appeals on CD or Film: Contact the ACR for further instructions.



Repeats

If your facility does not pass accreditation on the first attempt, you must repeat the exam(s) that were found not acceptable. Exam changes are not permitted in a repeat cycle.  For clinical examinations, repeat must be from a different patient. For phantom images, repeat the phantom scans, ideally with the assistance and supervision of a qualified medical physicist or MR scientist, as applicable.


Requests for repeat should be submitted within 15 days of receiving the report. To choose this option:

  • Complete the option form in the online accreditation system

    • Go to "My Final Reports", click "Select Option"

    • Go to "My Final Reports" and click "Select Option"

    • Select "Other Options"

    • Select “Repeat”

    • Check the attestation box at the bottom of the screen. Do NOT check any modules or patient types on this screen unless you wish to withdraw them from the accreditation process.

    • Click “Submit”

  • Submit the repeat application and payment

  • You will receive your testing package and due date after the repeat application is accepted

 

If the repeat does not pass, you may choose to appeal the repeat images only, reinstate with corrective action, withdraw the module/patient type, or withdraw from accreditation.

 


Reinstatement with Corrective Action

PLEASE NOTE: DO NOT submit any type of protected health information (PHI) when submitting Reinstatement with Corrective Action documentation. The ACR will not accept any form of PHI during the corrective action documentation review process. 


Reinstatement requires the facility to address all deficiencies noted in previous reports. An appropriate corrective action plan must be approved by the ACR before continuing with the reinstatement. The ACR may also direct the facility to make some specific corrective action. Once all corrective actions are completed and supporting documentation has been forwarded to the ACR, the facility may go through the accreditation process again. All areas originally applied for must be retested (i.e., all clinical and phantom images appropriate to the modality).


If the facility fails again, it will have to participate in a Scheduled On-Site Survey. The Scheduled On-Site Survey is conducted so that an ACR review team (consisting of a radiologist, a medical physicist and an ACR staff technologist) can review the facility’s progress and provide on-site training in areas where help may be needed. This process takes time, and the facility is responsible for payment of a base site-visit fee in addition to all travel expenses incurred by the ACR team.  



Withdraw Module/Patient Type

If your facility does not perform the recommended minimum number of exams within a failed module, you may be able to drop the module. Please refer to the Emergency Use Clause in your modality’s program requirements for more information. Some modalities require all patient types to be accredited and may not have an emergency use clause. Although accreditation is voluntary, all ACR accredited sites must comply with ACR program requirements.


Please note that some third-party payers may have stricter minimum requirements for reimbursements. The ACR does not maintain a list of these payers and their requirements; you may want to check with the payer before dropping a module.


To choose this option:

  • Complete the option form in the online accreditation system

    • Go to “My Final Reports”, click “Select Option”

    • Select “Other Options”

    • Check all modules or patient types you wish to withdraw from the accreditation process

    • Check the attestation box at the bottom of the screen.

    • Click “Submit”

  • Submit the Withdraw Module/Patient Type Form signed by the listed supervising physician. Forms may be faxed to 703-295-6776. 

 


Withdraw


Choose this option if you wish to withdraw from the accreditation process entirely. Should you withdraw, you must remove any ACR accreditation signage on display.  


A Note Regarding Equipment Performance/Protocol Problems: If you did not pass accreditation on your first attempt, and ACR reviewers noted potential performance problems associated with your equipment or your choice of protocol, you should contact your medical physicist/MR scientist for assistance. When ACR reviewers report image quality problems on cases submitted for accreditation, it is not always possible to exactly identify the cause of the deficiencies. Reviewers will provide “possible” causes to help direct the facility in correcting the problem. Your medical physicist/MR scientist can be invaluable in helping you identify and eliminate problems that are technical in nature by reviewing your protocols and/or conducting focused tests on the equipment.





Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes

09-21-2020Appeals on Electronic SubmissionsAdded reminder not to upload images in the field for appeal letter. 
9-21-2020RepeatsUpdated example of cases to repeat.
03-08-2021Introduction, ReinstateAdded details regarding facility options, the reinstatement process
10-1-2021
Added yellow highlighted note regarding PHI



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