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.
* Solo nuclear medicine or PET cardiology sites are permitted to use a cardiac catheterization correlation process.
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:
ACR’s Minimum Requirements for Peer Learning Physician Quality Assurance Pathway for Accreditation
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.
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