Testing Overview: Mammography (Created 11-20-2024)

There are three portions to your ACR Mammography Accreditation submission:

1. Quality Control/Annual System Physicist’s Survey
2. Clinical Testing
3. Phantom Testing

To achieve ACR accreditation, a mammography unit must pass both the clinical and phantom image quality tests.

The ACR will not confirm your testing package if any items are missing. Be sure to keep copies of the completed application, any additional submitted information, and know what images you submitted in case there are future questions.

Successful accreditation is a team effort involving the lead supervising physician, mammography technologist, and medical physicist . Other personnel (administrators, managers, etc.) may also be a part of your team, depending on your facility. 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.

After your new or renewal application is processed, an online testing packet will be activated which will contain all clinical and phantom data forms required for accreditation review. Your facility will receive an email with a link to the online testing packet as well as a link to the electronic PDF version of the ACR Digital Mammography Quality Control Manual. Your facility user must log into the account and fill out all forms required in the online Testing Package and upload your accreditation images.

For renewal and reinstate cycles, the online testing packet has the image submission due date, 45 calendar days from the online testing packet link was emailed to the facility. You must collect your test images and submit the testing packet by that date. Failure to meet this due date will jeopardize completion of your accreditation. If your facility is renewing its accreditation, we cannot guarantee completion in a timely fashion before your ACR accreditation certificate expires. If your site cannot submit the required materials by your testing package due date, contact the ACR immediately.

Prior to submission, your lead interpreting physician must ensure that all of your facility’s images meet the minimum requirements listed in the Clinical Image Testing and Phantom Testing.

You may use this checklist to assist in completing your online testing package:

• Personnel Forms No Longer Required – Effective 11-18-2024, you are no longer required to upload the completed and signed forms. The ACR is in the process of updating our online accreditation system. Until the changes are made, please upload a non-completed form or blank sheet up paper in a PDF format in each required field
  • Interpreting Physician – No longer required
• Medical Physicist – No longer required
• Radiologic Technologist – No longer required 
• Mammography Quality Control Checklists – New Units Only (complete and send checklists; do not send your QC forms)

• Daily and Weekly Checklist or DM Unit Checklist– send 1 month of QC, data must include the dates that the accreditation clinical and phantom images were taken (send all available)
• Monthly, Quarterly and Semi-Annual Checklist or DM Display Checklist– send previous calendar 12 months (if this is a new unit, send all available)

• Most recent medical physicist’s survey report – Upload a copy of the entire report for each unit to include ancillary equipment, such as review workstations, even if located offsite. All reports must be complete and include:

• Medical Physicist’s Mammography QC Test Summary form (signed by the medical physicist)
• “Evaluation of Site’s Technologist QC Program” page (even for new units)
• All data pages (not just the summary forms)
• Corrective action taken for failures of MQSA regulations identified on the medical physicist’s report

• Clinical images

• 4-views only, appropriately labeled that are:
• BI-RADS^® category 1 (negative)
• Of interpretive quality
• Must be labeled with the MQSA-required image identification information (Do not anonymize your images)
• Reviewed and approved by the lead interpreting physician

• Phantom image (appropriately labeled; only 1 phantom image for each unit module)

• FFDM module: 2D DICOM
• DBT module: a single best-slice 3D tomosynthesis image 

• Online testing packet completed and submitted

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