Accreditation Overview. Presented by: Dina Hernandez, BSRS, RT(R)(CT)(QM) ACR Quality & Safety November 11, 2015
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1 Accreditation Overview Presented by: Dina Hernandez, BSRS, RT(R)(CT)(QM) ACR Quality & Safety November 11, 2015
2 Topics: Who is the ACR? What is ACR accreditation? Why get ACR accreditation? General accreditation processes Validation site surveys Diagnostic center of excellence (DICOE)
3 American College of Radiology Professional Medical Organization founded in 1923
4 American College of Radiology ACR is at the forefront of the radiology evolution ACR represents more than 37,000 diagnostic radiologists, nuclear medicine physicians, radiation oncologists, interventional radiologists and medical physicists. ACR improves, promotes and protects the practice of radiology to ensure the quality and safety of patient care.
5 ACR Core Purpose To serve patients and society by empowering members to advance the practice, science and professions of radiological care
6 ACR Core Values Leadership Integrity Quality Innovation
7 7 William T. Thorwarth, Jr., MD, FACR ACR CEO
8 The College is organized around Five Pillars Advocacy Economics Quality & Safety Clinical Research Education 8
9 ACR Nationally Recognized Accreditation Programs:
10 ACR s accreditation history 1986 Radiation Oncology Mammography Accreditation 1992 FDA adopts ACR s mammography accreditation program 1995 Ultrasound 1996 Stereotactic Breast Biopsy 1996 MRI 1998 Breast Ultrasound 1999 Nuclear Medicine 2002 CT, radiography/fluoroscopy, and PET CMS accepts ACR as accrediting organization for MIPPA & Breast MRI program launched 10
11 MODALITY ACCREDITED FACILITIES MAMMOGRAPHY 8020 MRI 7021 CT 6798 ULTRASOUND 4837 Nuclear Medicine 3468 Breast Ultrasound 2158 PET 1516 Stereotactic Breast Biopsy 1427 Breast MRI 1397 Radiation Oncology 646 Total 37,288
12 ACR Practice Parameters & Technical Standards Foundation of Accreditation Programs
13 Practice parameters & technical standards Educational tool designed to assist in providing appropriate radiologic care for patients. Not inflexible rules or requirements of practice Not intended, nor should they be used, to establish a legal standard of care.
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16 ACR accreditation An educational process of self assessment and peer review - Modality based - Diagnostic image quality - Staff qualifications - Policies and protocols - Equipment specifications - Therapeutic treatment
17 Goals of ACR accreditation Set quality standards for imaging practices Provide recommendations for improvement Help sites improve quality of patient care Recognize quality imaging practices
18 Why seek ACR accreditation? Validate good practice through peer-review May document need for new or dedicated equipment, continuing education or qualified personnel Expert assessment of image quality Formal review may be used to meet criteria of state government, federal government or third party payers
19 MIPPA Medicare Improvements for Patients and Providers Act (MIPPA) passed July 2008 Providers of advanced diagnostic imaging services (ADIS) that bill under Part B of the Medicare Physician Fee Schedule must be accredited by January 1, 2012 to receive payment for the technical component of these services Beginning January 1, 2012, payment will only be made if your facility is fully accredited
20 Accreditation Process
21 How to prepare for accreditation
22 Available resources Path to Quality Improvement Dedicated Accreditation webpage Quality & Safety - Practice Parameters/ Technical Standards - QC manuals Education catalog
23 St Available resources f ACR staff Healthcare professionals Certified technologists & rad therapist Physicians and physicists Accreditation committees Reviewers
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28 Lead technologist should be account login!
29 ACRedit database Start by reading the Home page Read each screen completely before continuing to the next Pay ATTENTION to everything in RED Extra information by clicking on the icon
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31 Online application Application includes: Facility information Modality information CMS information Medicare ID number National provider identifier EIN Payment options
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33 Facility and modality information Facility information Facility name and address Facility supervising physician Mailing address Peer review Other accredited modalities Modality information Modality name Modality supervising physician Number of units Unit specific information
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35 Transfer of Images and Data
36 How Does it Work?
37 1. Web client choose images 2. Windows client choose folders Three choices to upload images! 3. Windows client connect to your PACS 37
38 Web Client 1. Choose images directly through ACRedit 2. No software downloads 3. Can view thumbnail images of what you ve uploaded 4. Print patient summary 38
39 Windows Client - Folders or PACS 1. Small download/install 2. Choose entire folders of images 3. Can view full images using ClearCanvas DICOM viewer 4. See your images just as our reviewers see them 5. Print patient summary 39
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44 Where are the images stored? TRIAD central server Secured server ACR supported Files encrypted TRIAD
45 Why electronic image submission? Cuts cost of shipping Shortens turn around times
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48 Timeline Sites have 45 days to complete and submit testing materials Extensions considered - case by case
49 Accreditation review Materials submitted for accreditation review are sent to volunteer reviewers Clinical images 2 radiologist reviewers Phantom images 1 or 2 physicist reviewers
50 Achieving accreditation Pass/Fail determined All images/unit must pass Accreditation granted Certificate issued Accreditation granted for 3 years Final report (with link) issued to Supervising Physician & Administrator Technologist notified
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52 Marketing tools for you: Sample Press Release Accreditation Seal Downloadable seal for stationery, prescription pads, etc Web site listing
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55 First deficiency: Appeal Withdraw module/isotope Repeat Second deficiency: Appeal Reinstate CAP & retest Fail reinstate: Accreditation consultation CAP Pre-test images Reinstate -
56 Compliance Monitoring After Accreditation Granted Validation site surveys 56
57 Validation site survey (VSS) If a facility bills under Medicare Part B, they must comply with these new requirements, regardless of where the service is provided (e.g., outpatient office, hospital, etc.) A facility that bills under Part B is subject to an unannounced site visit.
58 Unannounced validation site surveys (VSS) The ACR conducts validation site surveys on accredited facilities to monitor compliance with accreditation standards and to meet the requirements of MIPPA Each accredited facility will go through a site visit within the three year accreditation period
59 Validation site surveys Unannounced Site s can be visited by an ACR representative and/or CMS at any time during 3 year accreditation period Toolkit designed to assist gathering and maintaining documentation that is required for accreditation Toolkit can also be used to prepare preaccreditation and/or post-accreditation on-site surveys
60 How to prepare for site visits
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62 Outcomes
63 Outcomes (Through 2014)
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66 Other items found Information not on site, held at main office Units not accredited Units that have been removed from service Not having access to QC Closed facilities
67 Diagnostic Center of Excellence
68 Diagnostic Imaging Center of Excellence (DICOE) Provides a comprehensive assessment of the entire medical imaging enterprise including structure and outcomes
69 DICOE: basic eligibility ACR accreditation in all modalities provided Dose Index Registry (DIR) and General Radiology Improvement Database (GRID) participation Image Gently and Image Wisely pledges Site survey
70 DICOE: benefits Comprehensive assessment of the medical imaging facility, including structure and outcomes Participation in ACR registries at no cost Ongoing process for self-assessment Recognition that distinguishes your facility to providers, payers, patients and administrators Three-year status Customizable materials for local public relations and marketing
71 Areas of assessment Governance Personnel Facility organization and management Physical environment Equipment and IT infrastructure Radiation and general safety Quality management Policies and procedures Patient rights Medical records
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75 Accreditation contact information American College of Radiology 1891 Preston White Drive Reston, VA Accreditation Hotline:
ACR NUCLEAR MEDICINE & PET ACCREDITATION. Presented by: Carolyn Richards MacFarlane, MS, CNMT, RT(N) ACR Quality & Safety November 12, 2015
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