Frequent Deficiencies (Revised 8-2-2024)

Katie Albus

Modified on: Fri, 2 Aug, 2024 at 10:43 AM

Revision History

To help your facility avoid common pitfalls, the table below outlines deficiencies that are frequently found during the accreditation process. These deficiencies must be addressed before a facility will be granted accreditation. Please note that other serious deficiencies not frequently seen and therefore not listed here may also require corrective action and documentation prior to accreditation.

	Clinical Images	Phantom Images
Nuclear Medicine	Failure to label for laterality and orientation Failure to read instructions Incomplete submission of exams Failure to follow written procedure Failure to send quality images Submitting only fused images	Incomplete dataset Failure to submit composite of rods Center of rotation High-count flood Phantom mixing and positioning Not applying required attenuation correction (if available in the processing software)
PET	Failure to label for laterality and orientation Failure to read instructions Submitting only fused images Not sending coronal images for oncology, both AC and NAC Not submitting testing package Failure to send quality images	Incomplete dataset Failure to include rods Failure to remove spheres Phantom mixing and positioning SUV values now pass/fail
CT	Scanning through orbits/lens on brain CT Not submitting required series (i.e. contrast enhanced) Not reviewing the CT Testing Instructions before choosing exams for submission Selecting examinations your site does not usually perform Supervising physician not reviewing images before they are sent to the ACR	Techniques listed in Phantom Site Scanning Data Form do not match techniques used to scan the ACR or dosimetry phantoms Parameters given to physicist are not parameters used for clinical exams Not checking images for correct protocol Not submitting dose images Incorrect size chosen for pediatric abdomen phantom in data form
MRI	Not reviewing testing instructions before choosing exams for submission Not reviewing instructions located on the first page of each module in the Testing Instructions Not submitting required sequences Not submitting ADC map Poor SNR Incomplete anatomical coverage Supervising physician not reviewing images before they are sent to the ACR	Not following instructions provided in guidance documents Physicist not reviewing images/data before sending to the ACR
Mammography	Positioning Compression Anonymizing images Failure to read instructions	Phantom images do not meet criteria for fibers, specks and masses Failure to read instructions Not choosing best tomosynthesis slice for DBT units Choosing wrong size phantom in testing package
Breast MR	Low SNR Artifacts Parameters for pre- and post-contrast T1 images do not match
Breast Ultrasound	Correlating mammogram was not performed within 60 days prior to sonogram CC and MLO images not submitted Sonogram discordant with mammogram Distance from nipple to abnormality not measured on images Pre-fire or post-fire images labeled incorrectly
Stereotactic Breast Biopsy	Correlating mammogram was not performed within 60 days prior to stereo biopsy Calcifications not seen on both stereo pair views
Radiation Oncology	Insufficient information in consultative note Incomplete patient history and physical examination Incomplete treatment prescriptions Lack of defined goals and requirements of treatment plan by radiation oncologist (i.e., dose constraints) No formal treatment planning quality assurance plan Lack of dose volume histograms Lack of proper treatment quality assurance prior to patient treatment (i.e., no IMRT QA) No written directive for brachytherapy procedure(s) Insufficient radiation oncologist coverage during patient treatment Lack of port film verification Lack of documented weekly patient visits No documented patient follow-up plan No formal quality assurance and improvement program documented (e.g., outcome studies, focus studies) No physician or physicist peer-review documented End-of-treatment physics check not performed within a week
Ultrasound	Failure to read accreditation instructions Submitting studies that do not meet the Exam Requirements Failure to meet Exam Requirements with static imaging (cine loops are permissible for some exams; details of which exams allow cine clips are included in the specific Exam Requirements) Inadequate documentation of required anatomy Submitting post-surgical studies Improper technical settings Improper scanning technique Poor image quality

Revision History for this Article
Date	Section	Description of Revision(s)
12-12-19	All	Article created; FAQs incorporated; No criteria changes
2-3-2020	Ultrasound	Added frequent Ultrasound deficiencies
2-26-20	NMAP	Under phantom added: "Not applying required attenuation correction (if available in the processing software)" Under clinical added "Submitting only fused images"
5-2-2023	Ultrasound	Updated Ultrasound deficiencies
2-23-2024	MRI	Removed "not submitting entire exam"
8-2-2024	NMAP	Updated reasons for deficiencies for Clinical Images

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Passing Results	Options Following Failure/Deficiency
Passing Results: Mammography	Options Following Failure/Deficiency: Mammography
Passing Results: Radiation Oncology	Options Following Failure/Deficiency: Radiation Oncology