Options Following a Failure or Deficiency (Revised 11-9-2022)

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 and/or submit supplemental information if applicable.

After a failed outcome, the facility has the opportunity to submit an option form to proceed with accreditation through the following options: 

• Appeal

• Supplemental Review

• Repeat

• Reinstate with Corrective Action

• Withdraw the module/patient type/isotope/trimester/vascular submodule

• Withdraw unit

• Withdraw from the accreditation process entirely 

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

For uploaded submissions, the option form is available after the final report is viewed.

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:

Appeals

Appeals are typically made due to disagreement with the assessment of image quality. Facilities that disagree with a deficiency or failure may appeal the determination within 15 days of the final report. An appeal letter must be uploaded at the time of the appeal option selection describing the reasons your supervising physician disagrees with the final outcome. 

Supplemental Review

If you did not pass accreditation because you inadvertently omitted some information (images or data) from your accreditation submission and would like to have the same examination re-evaluated using supplemental information, you may request a supplemental review; 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 supplemental review, 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. A supplemental review letter must be uploaded at the time of the supplemental review option selection. A testing packet will be generated allowing your site to edit the data form, upload additional images and/or upload additional documentation. If uploading additional images, do not re-upload the entire exam. 

Appeal and supplemental review submissions must be completed the same way as the original submission. If you submitted on CD, you must appeal or request a supplemental review on CD; if you submitted electronically, you must appeal or request a supplemental review electronically.

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 and supplemental review letter's written by the facility. The arbitrator's determination will be final.

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

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

Appeals or supplemental reviews 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 final report and the repeat application and payment must be submitted within 30 days of the request to repeat. You will receive an online testing package and due date after the repeat application is accepted.  To choose this option:

If the repeat does not pass, you may choose to appeal or request a supplemental review of the repeat images only, reinstate with corrective action, withdraw the module/patient type/isotope/trimester/vascular submodule, or withdraw from accreditation.

Reinstatement with Corrective Action

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 unless they were withdrawn (i.e., all clinical and phantom images appropriate to the modality).

If the facility fails again, it will have to participate in an Accreditation Consultation.. The Accreditation Consultation 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/Isotope/Trimester/Vascular Submodule

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.

Withdraw Module/Patient Type/Isotope/Trimester/Vascular Submodule forms signed by the listed supervising physician may be uploaded in the accreditation system. 

Withdraw Unit

You may withdraw a unit from use if it will no longer perform modality examinations. Please refer to the Emergency Use Clause in your modality's program requirements for more information. Some modalities require all imaging types performed 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. 

Withdraw unit forms signed by the listed supervising physician may be uploaded in the accreditation system. 

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.