Revision History


Policies and procedures related to quality, patient education, infection control, and safety should be developed and implemented in accordance with the ACR Position Statement on Quality Control and Improvement, Safety, Infection Control and Patient Education.


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. 

All sites initially applying for ACR accreditation and all sites renewing their accreditation must actively participate in a physician quality assurance program. There are two pathways an accredited facility can meet the physician quality assurance requirement. Validation that the minimum requirements are met for either pathway will occur during Validation Onsite Surveys. 



Physician Score-Based Peer Review

A physician score-based peer review program must perform the following functions:

  • 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

There are several options available to meet this requirement. Sites may develop their own peer review program, use a vendor product, or use RADPEER, a peer review process developed by the ACR.



Peer Learning Program

A peer learning program must include a written policy and annual documentation with the following minimum requirements:

Written Policy

Culture

  • Program description that emphasizes supporting a culture of learning and minimizing blame

Goal

  • The goal of improvement of services by relying on the establishment of trust and free exchange of feedback in a constructive and professional manner

Definition of peer learning opportunities

  • Definition of peer learning opportunities that includes submissions and review of peer learning cases that address actual or potential performance issues, including both discrepancies and “great calls”

  • Description of case identification (routine work, case conferences, event reports or other sources) rather than  randomly selected cases

Description of program structure and organization

  • Definition of the roles of physician and non-physician leader(s)

  • Description of responsibilities and the amount of time or the percentage of full-time equivalent (FTE) hours to be dedicated to managing the peer learning program

  • Definition of the workflow of the peer learning opportunity submission including the workflow for review of peer learning submission communication with the interpreting radiologist as appropriate and designation of the peer learning submission for group sharing

Definition of targets

  • Definition of targets by defining expectations for minimum participation by radiologists in peer learning submissions and in learning activity participation

  • Minimum standards for peer learning program activities (defined as in-person or online conferences or other virtual learning formats)

Quality Improvement 

  • Outline of the process for coordination with appropriate practice and administrative personnel to translate findings from peer learning activities into dedicated quality improvement efforts

Reporting

  • Statement of commitment to sequestering peer learning activity content from individual practitioner’s performance evaluation 

Annual documentation

  • Total number of case submissions to the Peer Learning program

  • Number and percent of radiologists meeting targets as defined in the facility practice policy

  • Determination of whether peer learning activities met the minimum standard as defined by the facility practice policy

  • Summary of related quality improvement efforts and accomplishments

Additional peer learning resources can be found on the Peer Learning Resources webpage including:

  1. ACR’s Minimum Requirements for Peer Learning Physician Quality Assurance Pathway for Accreditation 

  2. Peer Learning Program Checklist for ACR Accredited Facilities


 

MRI Safety: Safety guidelines, practices, and policies must be written, enforced, reviewed, and documented at least annually by the MR supervising physician. For additional information, see the ACR Guidance Document on MR Safe Practices, 2013 and the ACR Manual on Contrast Media. The annual medical physicist/MR scientist performance evaluation must include an assessment of the MRI safety program (signage, access control, screening procedures and cryogen safety), in addition to an inspection of the physical and mechanical integrity of the system.



Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes

6-30-2021TitleChanged title from QA/Peer Review to Physician QA Requirements
9-7-2021
Added Physician Peer Learning section



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