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The Accreditation Process: Radiation Oncology (Revised 6-2-2021)

Revision History

The radiation oncology practice accreditation (ROPA) program provides radiation oncologists with a third party, impartial peer review and evaluation of patient care. The facility’s personnel, equipment, treatment planning and treatment records, as well as patient safety policies and quality control/quality assessment (QC/QA) activities, are assessed. Recommendations for improvement are based on nationally-recognized parameters, including ACR and American Society for Radiation Oncologist (ASTRO) parameters, ACR and American Association of Physics in Medicine (AAPM) technical standards, and AAPM Task Group reports and Practice Guidelines.

The ACR Committee for ROPA directs the program. The accreditation process, designed to promote quality and be educational in nature, includes an on-site survey performed by board-certified radiation oncologists and board-certified medical physicists.


Each facility applying for accreditation must submit an application through the secure Radiation Oncology Practice Accreditation website. The application consists of:

Business Associate Agreement: The ACR understands that as providers, facilities are subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and that is why the ACR executes a HIPAA business associate agreement (BAA) with facilities. This agreement allows the collection of patient information in the performance of ACR accreditation activities that are specifically mentioned in the HIPAA regulations. If the facility has a BAA with ACR, they are covered under HIPAA. If not, contact the ACR to obtain an agreement for signature.

Accreditation Process Flowchart

Requirements for Accreditation

If a facility does not meet the requirements outlined below, accreditation may be deferred or denied until a corrective action plan is submitted and approved by the ROPA Committee. The following are required:

Radiation Oncologist Availability: A radiation oncologist should be available for direct care and quality review and should be on the premises whenever radiation treatments are being delivered. The radiation oncologist, facility, and support staff should be available to initiate urgent treatment within a medically appropriate response time on a 24-hour basis or refer to a facility that is available to treat on a 24-hour basis. When unavailable, the radiation oncologist is responsible for arranging appropriate coverage.

Medical Physicist Availability: The medical physicist must be available when necessary for consultation with the radiation oncologist and to provide advice or direction to technical staff when a patient’s treatments are being planned or patients are being treated. The center should have written policies specifying any special procedures (e.g., high-dose-rate brachytherapy, stereotactic radiosurgery, or stereotactic body radiation therapy) that require the presence of the medical physicist. When a medical physicist is not immediately available on-site during routine patient treatment, clinical needs should be met by using documented procedures. Authority to perform specific clinical physics duties must be established by the medical physicist for each member of the physics staff in accordance with his or her competence. The radiation oncologist should be informed of the clinical activities authorized for each member. Refer to the ACR Technical Standard for the Performance of Radiation Oncology Physics for External Beam Therapy for minimal requirements for physics support.

Staffing for Radiation Therapy Treatment Delivery: Two registered radiation therapists per patient per treatment unit is the minimum standard for safe and efficient delivery of radiation therapy. Please refer to the ASRT position statements on Staffing for Radiation Therapy Treatment Delivery.

The process of radiation therapy should include the following:

  • Each patient chart should contain a documented, comprehensive history and physical examination performed by the radiation oncologist, including a comprehensive history of the present illness, past medical history, review of systems, review of imaging studies and laboratory data, histopathology diagnosis and recommendations for treatment, and signed and dated consent form. Consultation/History and physical should include:

    • Overall stage grouping and TNM classification of tumor in the consult note and staging sheet

    • Performance classification (Karnofsky or ECOG)

    • Chemotherapy information (Drugs, schedule, etc. - If applicable

    • Documentation of physical examination done by a radiation oncologist

  • Treatment prescriptions should include: volume (site) to be treated, description of ports (i.e., AP, PA, lateral, etc.), radiation modality, dose per fraction, number of fractions per day, number of fractions per week, total number of fractions, total tumor dose and prescription point or isodose.

  • Simulation of treatment: A simulation order should be signed and dated by the radiation oncologist and include the following:

    • Treatment site

    • Treatment position

    • Immobilization devices (if applicable)

    • Use of contrast (if applicable)

      • Simulation and treatment photos should include the following:

        • Patient’s name

        • Date of the photo

        • Treatment set-up information (immobilization devices, position, tattoos, etc.)

Treatment Planning:

  • Documentation of delivered doses to volumes of the target and non-target tissues, in the form of dose volume histograms and representative cross-sectional isodose treatment diagrams, should be maintained in the patient’s written/electronic record.

  • Treatment prescription and isodose plan must be signed or electronically approved by the radiation oncologist and medical physicist prior to the initiation of radiation therapy.

  • Patient-specific goals and requirements of the treatment plan, including specific dose constraints for the target(s) and nearby critical structure(s), should be documented.

Patient Evaluation: Patient evaluation and, when appropriate, physical examination by a radiation oncologist during treatment should be performed weekly, and more often when warranted.

Treatment Summary: After a course of treatment is completed, the radiation oncologist should document a summary of the treatment delivered including site treated, modality used, dose per fraction, total dose, elapsed time, treatment response (if applicable), relevant side effects (if applicable) and other observations.

Follow-Up: At the completion of treatment, a follow-up plan should be documented in the patient chart, and the radiation oncologist should see patients at regular, on-going intervals. If direct follow-up is not possible or practical because of issues such as patient medical condition, patient choice or unreasonable travel, the radiation oncologist should review follow-up documentation provided by other pertinent medical providers regarding the patient’s condition.

General Brachytherapy Requirements:

  • Written directive should be signed and dated by a physician prior to the procedure.

  • Complete documentation should be included in the patient record when brachytherapy is performed. Written directives documented for each procedure should include the treatment site, isotope, number of sources, and the planned dose to designated points. After brachytherapy is completed, a written summary of treatment delivery should include a total dose of brachytherapy and external beam therapy, time of source insertion and removal and documentation of a radiation safety survey of the patient and room.

  • A policy requiring two forms of patient identification as well as verification of treatment parameters prior to each treatment must be documented.

Policy and Procedures: The following policies and procedures should be in place:

  • Timeout policy for simulation and treatment

  • Administration of contrast (if applicable)

  • Image guidance and port film policy: a set of patient positioning or target localization images should be taken at least weekly and for any new fields. The radiation oncologist should then review verification images prior to the next treatment.

  • Disaster plan: the facility should have a written disaster plan based on an assessment of contingencies appropriate for the local practice environment. The disaster plan should be designed to ensure that the facility staff could respond to patients and other care providers within 24 hours of the contingency condition, with plans for resuming or transferring patient care within 5 days of the contingency condition, and should incorporate plans for:

    • Prolonged power failure

    • Prolonged information system failure, with provisions to address operational continuity including data redundancy and recovery

    • Loss or release of radioactive materials

    • External threats including natural disasters

  • Infection Control

  • Radiation Safety 

Revision History for this Article



Description of Revision(s)



Article created; FAQs incorporated; No criteria changes

Added link to the Accreditation Process Flowchart
6-2-2021Requirements for AccreditationAdded statement and link regarding staffing for radiation therapy treatment delivery

Previous: Relationship Between Accreditation Requirements, Practice Parameters, Technical StandardsNext: Questions About Accreditation?

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