The Accreditation Process: Mammography (Revised 9-21-2020)
Modified on: Mon, 21 Sep, 2020 at 11:46 AM
For information on other modalities, please see our article on The Accreditation Process.
Developed in 1987 by the ACR Task Force on Breast Cancer, the accreditation program is the country’s first and the largest for mammography. The program is directed by radiologists and medical physicists on the Committee on Mammography Accreditation of the ACR Commission on Quality and Safety. The ACR Mammography Accreditation Program offers radiologists an opportunity for review and evaluation of their mammography facility, personnel qualifications, image quality, equipment, quality assurance and quality control procedures through a constructive peer review mechanism. As an ACR peer-review program, all reports, documentation, correspondence (including e-mail) between the ACR and the facility undergoing accreditation, and any information provided by the facility to evaluate its imaging services is privileged and confidential under the Code of Virginia 8.01-581.17. (The facility name, address, phone number, and listed contact personnel are not considered privileged and confidential). The program is consistent with all Food and Drug Administration (FDA) regulations under the Mammography Quality Standards Act (MQSA) and administered by the ACR Committee on Mammography Accreditation.
Please review all ACR Mammography Accreditation Program articles before submitting your online application.
A facility must have a current and valid MQSA certificate (or “interim notice") to legally perform mammography. Any facility performing mammography without this certificate is subject to sanctions under MQSA.
A new facility must apply for accreditation of all mammography units and receive a provisional MQSA certificate from the FDA (or state certifying body) before performing mammography.
Before a new facility applies for accreditation:
Contact the state radiation control agency for any state-specific requirements for new facilities.
Schedule the medical physicist’s survey at least 1 week before the “applications” training to allow time for corrective action of potentially non-compliant tests. Contact the medical physicist early, especially if he/she is a consultant.
Schedule the manufacturer’s “applications” training accordingly (the facility must have this provisional MQSA certificate before imaging human subjects as part of this training).
Submit the online accreditation application after the medical physicist survey, allowing time to receive the MQSA certificate prior to applications training.
Accreditation is a 2-step process accomplished primarily through the ACR’s online accreditation system, ACRedit.
Step One: Provide the ACR with the following information.
Information regarding your practice site characteristics (facility, equipment and personnel). A practice site is defined as each different geographical location where imaging is performed. You must apply for all mammography units in use. New facilities must also submit the MQSA Requirements for Mammography Equipment Checklist and Medical Physicist's Mammography QC Test Summary Form as well as corrective action documentation if any measurements failed.
There are instructions on the webpage every step of the way to assist you. There are also information buttons to give you more details. ACR staff will confirm and accept your application after we receive all required documents. The ACR notifies the FDA (or state certifying body) to fax the facility a 6-month provisional MQSA certificate or “interim notice”. The facility should expect to receive its provisional MQSA certificate within two business days of the day the ACR confirms and accepts the application. If you do not receive it within this timeframe please contact the ACR.
Step Two: After your application is processed, an online testing package is activated, which will contain all forms required for accreditation review. Your facility will receive an email with a link to the online testing package. The facility user must log into the account and fill out all required forms. The testing package must be submitted online. Submit the following information:
Policies and procedures
Patient outcome data
Personnel (radiologists, medical physicists and radiologic technologists)
Images (submitted electronically; hard-copy submission is available only for screen-film units, or through special permission from the ACR)
The online testing package has the image submission due date. Extensions on the due date of images is not permitted for mammography.
The ACR will provide you with a link to The ACR Digital Mammography Quality Control Manual.
At the completion of the accreditation review process, the ACR will issue a separate, confidential final report for each unit through the online system. A notification will be sent to the lead interpreting physician when the report is available to the modality’s online user. You will also receive an accreditation certificate and a decal for each passing unit at your facility. The name of your accredited facility will be listed on the ACR website as well as the FDA’s website.
The ACR website provides a listing of accredited facilities and facilities that have applied for accreditation and are under review. If a third-party payer requests verification of your participation in one of the accreditation programs, please refer them to the ACR website.
Successful accreditation is a team effort. Everyone at your facility is involved somewhat with accreditation and should at least be aware of your facility’s participation. You should have one person who is “in charge” of organizing the project. You should have a “core team” made up of the personnel outlined below. This team should be agreed upon before beginning the accreditation process and should keep in close contact during the process. This will help ensure success.
Your contact technologist
Your lead interpreting physician
Your medical physicist
For more information on passing results, please see our article on Passing Results: Mammography.
The ACR will conduct random site visits and random image checks to validate consistent maintenance of accreditation criteria within the three-year accreditation period. For more information, please see our article on Validation Cycles: Mammography.
How Many Applications Should Be Submitted?
Under ACR accreditation policies, an accredited facility encompasses the staff, equipment, protocols, policies and procedures, and physical location. In other words, all elements of the “practice” are considered. Any changes in even one major element could affect accreditation of the “facility”. ACR’s primary concern is that when patients receive imaging at an ACR-accredited facility, all aspects are in fact accredited. In situations where several businesses operate out of the same location but have different staff, protocols, etc., we must evaluate each business separately. If staff, protocols, policies and procedures, and physical location are the same, a single accreditation application may be appropriate. Please contact the ACR for guidance.
The following mammography sites must apply separately for accreditation and obtain unique facility MAP IDs and MQSA certificate numbers:
A new site, not associated with an existing mammography facility, opening with new equipment and personnel
A new site associated with an existing mammography facility, opening at a separate physical location with new equipment
A new site at a separate physical location, with a previously-accredited unit from a sister site (the sister site remains in operation with other units under its current MQSA certificate)
If you are accrediting a mobile mammography unit, please see our article on mobile mammography.
The Committee on Mammography Accreditation recognizes that the accreditation process involves a significant investment in time and effort on the part of your facility. Thank you for demonstrating your interest in providing quality mammography services by accrediting with the American College of Radiology. Please visit our website or call the Mammography Accreditation Program at (800) 227-6440 if you have any questions.
Revision History for this Article
Description of Revision(s)
Article created; FAQs incorporated; No criteria changes
|9-21-2020||Added link to Accreditation Process Flowchart|
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