Quality Assurance: Breast MRI (Revised 12-12-19)

Revision History

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.

Each facility must establish and maintain a medical outcomes audit program to follow up positive assessments and to correlate pathology results with the interpreting physician’s findings. (If the facility does not perform MRI-guided intervention, it must be able to obtain the correlative pathology results from the accredited facility with which they have a referral arrangement.) The audit must include evaluation of the accuracy of interpretation as well as appropriate clinical indications for the examination. Facilities must use the Breast Imaging Reporting and Data System (BI-RADS) final assessment codes and terminology for reporting and tracking outcomes. The BI-RADS® Atlas contains guidance on monitoring outcomes and conducting the audit.  Summary statistics and comparisons generated for each physician and for each facility should be reviewed annually by the lead interpreting physician.

It is not necessary to have a physician peer-review program in place for Breast MRI Accreditation. The medical outcomes audit program fulfills this requirement.

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