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.


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 that performs 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.


 

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



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