Personnel: Radiation Oncology (Revised 7-22-2020) : Accreditation Support

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Personnel: Radiation Oncology (Revised 7-22-2020) Print

Modified on: Wed, 22 Jul, 2020 at 9:00 AM

Revision History

Role	Personnel Requirements/Recommendations
Medical Director	Each program must have a medical director who is a radiation oncologist as described below. He/she is responsible for oversight of the department, including policies, procedures, and personnel. He/she is also responsible for instituting and supervising the CQI program through direct or delegated leadership.
Radiation Oncologist (one of these)	Board Certified in Radiology or Radiation Oncology: ABR certification in radiology (for a physician who confines his/her professional practice to radiation oncology) or certification in radiation oncology or therapeutic radiology by the ABR, AOBR, RCPSC or CMQ is considered proof of adequate qualification. Radiation oncologists with time-limited board certification must be enrolled in the certifying board’s MOC program and must satisfactorily renew certification in a timely fashion. Those with non-time-limited certificates are strongly encouraged to voluntarily participate in the MOC program.	Board Eligible: Satisfactory completion of a radiation oncology residency program approved by the ACGME, RCPSC, CMQ, or AOA. For those who are eligible but not yet certified by the date of initial employment, a pathway and timeframe would be defined by the individual for him/her to become licensed and certified in accordance with the requirements for board certification at left.
Qualified Medical Physicist	The ACR strongly recommends certification in therapeutic medical physics by the ABR, CCPM or ABMP. Previous medical physics certification categories, including radiological physics and therapeutic radiological physics, are also acceptable.
Radiation Therapists & Simulation Staff	Should fulfill state licensing requirements and be certified or eligible for certification by the ARRT in radiation therapy (radiation therapists or simulation staff) or diagnostic imaging (simulation staff).
Dosimetrist	Should fulfill state licensing requirements and be certified or eligible for certification in medical dosimetry by the MDCB.
Patient Support Staff	Should have appropriate nursing credentials (oncology nursing certification is encouraged), appropriate experience in the care of radiation therapy patients, and access to qualified nutritionists or social workers.
Physician Assistant	Has completed postgraduate education, is currently certified by NCCPA, and has obtained specified licensure in accordance with the state(s) in which he/she practices. CME should be in accordance with NCCPA and state guidelines.
Nurse Practitioner	Has completed postgraduate education in nursing; currently licensed/certified as a nurse practitioner in accordance with the state(s) in which he/she is practicing.
Administrative Support	Administrative staff are valuable for budgeting and managing resources that enable the facility to acquire and maintain the equipment needed for standard treatment practices and QA procedures, and to achieve and sustain clinical staffing levels that assure a safe and effective treatment environment.
Explanation of Acronyms ABR: American Board of Radiology ABMP: American Board of Medical Physics ACGME: American Council of Graduate Medical Education AOA: American Osteopathic Association AOBR: American Osteopathic Board of Radiology ARRT: American Registry of Radiologic Technologists CCPM: Canadian College of Physicists in Medicine CME: Continuing Medical Education CMQ: Le College des Medecins du Quebec CQI: Continuous Quality Improvement MOC: Maintenance of Certification MDCB: Medical Dosimetrist Certification Board NCCPA: National Commission on Certification of Physician Assistants QA: Quality Assurance RCPSC: Royal College of Physicians and Surgeons of Canada

If the practice site’s medical director, president/CEO or owner changes, the site must submit a new Personnel Summary List and a new Survey Agreement to the ACR.

Staffing Levels

In the final report, the facility’s staffing levels for radiation oncologists, physicists, radiation therapists, and dosimetrists are compared to the accredited facility averages and averages for the facility’s stratum as defined in the following table (updated 7-3-2019). The table allows facilities to identify personnel and equipment utilization issues. Staffing recommendations may be part of the final report; however, variations from these levels generally do not result in the withholding of accreditation unless inadequate staffing levels result in non-compliance with ACR Practice Parameters and Technical Standards and/or compromise patient safety.

While this comparison may be instructive, note that these data are incomplete in some important aspects. The data do not account for other staff duties (e.g. simulation for therapists) nor are the data scaled for complexity or the proportion of different pathologies treated at any given clinic. Each facility should, when comparing their staffing data to stratum and national averages, consider their patient population, range, and complexity of services provided, and any staff duties outside of those assumed in this table.

		New Patients Per:					FTE Therapists Per Treatment Machine
	FACILITY STRATUM	Radiation Oncologist	Physicist	FTE Dosimetrist	FTE Therapist	Treatment Machine	FTE Therapists Per Treatment Machine
	All Accredited Facilities	208	256	259	82	226	3.1
	Academic/Comprehensive Cancer Center/Main Teaching Hospital of a Med School	190	195	262	77	281	4.1
Hospital-Based	600 or more patients	272	297	314	100	303	3.1
	201-599 patients	222	256	255	82	225	2.9
	200 or fewer patients	139	211	186	65	145	2.6
Free-Standing	600 or more patients	300	298	345	101	327	3.4
	201-599 patients	230	305	306	94	255	3.0
	200 or fewer patients	144	238	212	71	143	3.8

Revision History for this Article
Date	Section	Description of Revision(s)
12-12-19	All	Article created; FAQs incorporated; No criteria changes
4-1-2020	Staffing Levels	Updated data as of July 3, 2019
7-22-20	Staffing Levels	Updated data as of July 2020

Next: QC/QA: Radiation Oncology

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