The medical director (chair, chief) of the radiation oncology facility must request the survey by submitting a completed on-line application, survey fee, and signed survey agreement and release (consent) forms from each physician in the practice. If deficiencies are noted or missing items identified in the application, the facility will be contacted so that any missing items can be submitted before the site survey is scheduled. When the application is complete, your facility will receive an email confirming the date(s) of the survey, introducing the ACR team members, and asking that you submit cases (Census Data Form) from which 10 (or more) will be selected for review during the site visit (for more information, please see our article on Radiation Oncology Patient Census Forms). An ACR staff member will contact you prior to the survey for details such as parking, directions to the site, the day of survey agenda, etc.
The toolkit attached below will help your practice prepare for your site survey. The data collection forms (physician and medical physicist) for preliminary self-assessment will be available on the ROPA website after the application has been accepted. The intention for the data collection forms is to prepare the practice for the site survey. Ten cases should be reviewed for the self-assessment activity. Cases should be representative of your patient mix (e.g., breast, prostate, lung) and should include treatment modalities such as IMRT, prostate seed implant, stereotactic radiosurgery, etc. A radiation oncologist who did not provide the patient’s care should complete the self-assessment forms. These data collection forms should be completed prior to your site visit. Please make sure the self-assessment cases are different from the cases requested by the ACR for the surveyors to review.
This self-assessment activity is an excellent tool for physicians and medical physicists to use as part of their internal peer review activities and the facility is encouraged to use these forms as part of their Continuous Quality Improvement (CQI) program. Completing these forms is optional; however, it is recommended you review and complete the forms before your site survey. These forms will no longer be available after your site survey is complete.
A survey can usually be scheduled 30 to 90 days after the completed application is submitted. The scheduled dates are based on the available dates submitted by the facility.
Your preparation for the survey may be assisted by reviewing the following and incorporating them into your facility’s operational policies and procedures:
AAPM Task Group Reports (in particular TG-51, TG-40/TG-142, and TG-53)
The on-site survey is conducted over one business day (multi-site surveys will require more days, based on the number of sites, geographic locations, and practice patterns). During the visit, the surveyors will:
Tour the facility
Verify the information submitted in the facility’s application
Conduct an interview with the Chief/Medical Director of Radiation Oncology, the chief physicist, department administrator/chief therapist, dosimetrist, nurse, and other key personnel
Collect information about the facility’s patient treatment policies and procedures and safety initiatives
Review the selected cases
The radiation oncologist and medical physicist review charts and complete a set of questions developed by the ROPA Committee. Chart reviews include components such as complete and signed prescriptions, consent forms, pathology reports, history and physical, physician management during treatment and follow-up, appropriateness of treatment, simulation/treatment planning, and dosimetry activities.
The following items are required during the survey:
If paper charts, a list of physician, physicist, and dosimetrist with their signatures and initials found in the patient records with printed identification beside each signature
CVs for all physicians and physicists
Quality Control and improvement documents, including:
Hospital, department, and physics policy and procedure manuals
Radiation safety program documentation
Physics Quality Control documentation
Quality Assessment and Improvement meeting minutes
Focus Study and internal outcome documentation
Physician Peer Review documentation
Physicist Peer Review documentation
Continuing Medical Education (CME) credits for all staff
Licenses and/or certification for all staff
Please arrange for the following (If your site cannot comply with the necessary items specified here, you will need to contact an ACR staff member):
A quiet room to work located within the radiation oncology department
A table surface large enough to review several charts/films/scans
Chairs for two surveyors
Two or more view boxes (if applicable)
Two computers with dual monitors and wired internet access for each computer
Workstations with access to record and verify system, hospital/facility electronic medical records (EMR)
Two facility staff members who can assist surveyors during the site visit
At the end of the day, the surveyors will again meet with the group for a brief “exit” interview. This is primarily to clarify any issues prior to their departure. For multi-site surveys, ACR and facility staff will determine the exit interview time and place.
The surveyors act as data collectors only; all data from the application and the survey are compiled and submitted to the ACR Committee on Radiation Oncology Practice Accreditation, who make the final recommendations regarding accreditation. The team will not provide their recommendations at the end of the survey, as this is a Committee decision made following a review of the results of the survey. Any questions or concerns about your survey should be referred to ACR staff. Surveyors should not be contacted directly by any members of the facility staff.
A practice that has multiple sites may be eligible for a single survey, with a limited case review from each additional site. Criteria to determine eligibility include but are not limited to:
The physician group has a single medical director
The physicist group has a single director
Physicians’ peer review includes all the practice sites
All practice sites utilize uniform treatment methods
All practice sites have uniform chart organization and forms
Geographic accessibility (site(s) is within one-hour drive of the main site)
If the practice does not meet the criteria, a full survey will be required for each site.
Random On-Site Surveys
In order to verify that accredited facilities maintain consistent quality during the three–year accreditation period, on-site surveys may also be performed at any time during the accreditation period. These surveys provide an excellent opportunity for a positive educational exchange with experts in the field, as well as providing validation of continued compliance with ACR parameters and technical standards. Radiation oncologists and medical physicists from the ROPA program will conduct these surveys. Any facility chosen for a random on-site survey will be notified in advance. There is no additional cost to the facility for the random survey. The practice site must maintain on-site an updated personnel summary list of all radiation oncologists, medical physicists, and therapists.
Revision History for this Article
Description of Revision(s)
Article created; FAQs incorporated; No criteria changes
Added note regarding ROPA virtual surveys
Updated note about virtual site surveys
Attached ROPA Brochure
|Previous: PQI: Radiation Oncology||Next: Mini-Audit and Consultative Surveys: Radiation Oncology|