Examinations should be systematically reviewed and evaluated as part of the overall quality improvement program at the facility. Monitoring should include evaluation of the accuracy of interpretation as well as the appropriateness of the examination. Complications and adverse events or activities that may have the potential for sentinel events must be monitored, analyzed and reported as required, and periodically reviewed in order to identify opportunities to improve patient care. These data should be collected in a manner that complies with statutory and regulatory peer-review procedures in order to ensure the confidentiality of the peer-review process. The ACR's Breast Ultrasound Quality Assurance Questionnaire is attached below.
Physician Peer-Review Requirements
All sites initially applying for ACR accreditation and all sites renewing their accreditation must actively participate in a physician peer review program. Sites may develop their own peer review program, use a vendor product, or use RADPEER, a peer review process developed by the ACR. Sites not using RADPEER must use a program that includes the following:
A double reading (2 MDs interpreting the same study) assessment
Allows for random selection of studies to be reviewed on a regularly-scheduled basis
Reviews exams and procedures representative of the actual clinical practice of each physician
Reviewer assessment of the agreement of the original report with subsequent review (or with surgical or pathological findings)
Classification of peer review findings with regard to level of quality concerns (one example is a 4-point scoring scale)
Policies and procedures for action to be taken on significantly discrepant peer review findings for the purpose of achieving quality outcomes improvement
Summary statistics and comparisons for each physician by imaging modality
Summary data for each facility/practice by modality.
The Ultrasound-Guided Breast Biopsy Module is exempt from this requirement because outcomes are monitored as part of accreditation and physician peer review applies only to review of image interpretation.
Outcome Data – Ultrasound-Guided Breast Biopsy Accreditation Module Only
Each facility applying for the Ultrasound-Guided Breast Biopsy Module must submit outcome data. Although the ACR does not currently use this information as pass/fail criteria, it may be used in the future to help set criteria. The minimum data elements to be collected are:
Total number of procedures
Total number of cancers found
Total number of benign lesions
Total number of ultrasound-guided biopsies needing repeat biopsy, categorized by reason and type of biopsy (i.e., CNB, FNAC):
Reason for Repeat Biopsy
Discordance with Imaging
Cellular Atypia, Radial Scar
Complications categorized by type of biopsy (i.e., CNB, FNAC)
Number with hematoma (requiring intervention)
Number with infection
Number with pneumothorax (CNB only)
The ACR strongly recommends that the biopsy report include a statement referring to the pathology results, imaging/pathologic concordance, and follow-up recommendations based on pathology results. The ACR will review a facility’s biopsy reports as part of a validation site visit.
Revision History for this Article
Description of Revision(s)
Article created; FAQs incorporated; No criteria changes
Added QA Questionnaire attachment
Updated QA Questionnaire attachment
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