Revision History


ACR CT, MR, NM/PET, Breast MR and Stereotactic Breast Biopsy accreditation is unit-based; therefore, facilities must notify the ACR if a unit is added, replaced with a new one, or permanently withdrawn from service.


Adding a New or Replacement Unit


These instructions do not apply to ultrasound/breast ultrasound. For information specific to mammography, please see Adding a New, Replacement, Repaired or Loaner Unit, or Withdrawing a Unit: Mammography


For accreditation purposes, a “new” unit is any unit that is new to the facility. This includes previously owned units, previously accredited units moved from one site to another, and new units replacing previously accredited units. To apply for a new unit under your existing accreditation, add the unit to your account by going to “My Modalities.” Click on “Units/Modules,” then on “Add New Unit” under the list of units; this will add the unit to the Modality ID for that location.


The accreditation options available for a new unit depend upon the amount of time the facility has left on its current accreditation certificate:


Over 13 months: The facility may submit a new unit addendum or a new unit reinstate

New Unit Addendum: The facility will submit complete phantom and clinical testing for the new unit(s) and pay a reduced accreditation fee. The added unit(s) will receive the same expiration date as currently approved units for this modality.

New Unit Reinstate: The facility will submit complete phantom and clinical testing for all active units, existing and new, and will pay the full application fee. The expiration date will be three years from the first approval report date.

Fewer than 13 months: The facility will start an early renewal

The facility must renew accreditation for all units at the facility, including the new one. Early renewal requires full application fees and complete phantom and clinical testing. Once approved, all of the units at the facility will have an expiration date that is 3 years from the old expiration date.


Units that receive replacements or upgrades to any of the major subassemblies after accreditation is granted will be treated as new units and follow the procedures above. Minor modifications, such as replacing the detector on a stereo unit or replacing an Xray tube, do not require notification.


The majority of software-only upgrades do not require testing as a new unit. Major hardware upgrades that require the physicist to perform acceptance testing and/or establish new baselines for technologist QC require new unit accreditation testing. Major upgrades include but are not limited to: replacing the magnet or gradient coils; new gradient drivers/RF transmitter; or replacing all/the majority of imaging coils. 


If a unit is moved to a new room in an existing accredited facility, additional accreditation testing may be required. If a unit is moved to a new address, please see the guidelines for changes in facility, personnel and modality .


Loaner Units 

Accredited facilities may use a “loaner” unit to temporarily replace an accredited unit that is out of service for repairs, etc., for up to 6 months without submitting images for evaluation. The accredited facility must immediately notify the ACR of the installation date, manufacturer, and model of the loaner. Any loaner unit that is in use for more than 1 month will be required to submit evidence of testing by a qualified medical physicist/MR scientist within 90 days of installation. If the loaner is in place for longer than 6 months, the facility must submit an application to accredit the unit, including clinical and phantom images as relevant, as well as the corresponding fee.

 

Withdrawing a Unit

If a unit is no longer used for imaging, the facility must withdraw the unit from the accreditation system. Go to “My Modalities”, click on the “Units/Modules” link under the action column, and then click the “Withdraw” link under the action column. The facility must complete and submit the Withdraw Unit Application (available within ACRedit) to the ACR. If your account is due for renewal, the unit may be withdrawn in the renewal application.



Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes



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