Preparing for an ACR On-Site Validation Site Survey

One of the aspects of accreditation that is often overlooked by medical physicists, particularly those of us in the consulting world, is the MIPPA-mandated on-site visit by the ACR. The ACR has been performing these visits since 2013 as required by CMS. This on-site Validation Site Surveys is required for facilities accredited in advanced modalities. Sites accredited in advanced modalities should expect an on-site survey during their three-year accreditation period. This applies particularly to all CT, MRI, Breast MRI, PET, and Nuclear Medicine facilities. There are other ACR surveys outside of the MIPPA-mandated visit, which will not be covered in this article.

The facility administrator will receive an email notifying them that a reviewer, an ACR staff person, will arrive for an unannounced survey in the next 90 days. Many facilities have not experienced other ACR surveys. Now, all facilities will have a survey during their accreditation period. During this survey, all accredited modalities at the facility will be visited.

Surveys will focus on policies and procedures, CME and Continuing Experience records, physicist annual surveys, and QC practices. The ACR has provided excellent guidance for preparing for an onsite survey. On this page, the Toolkit for Practice Sites details all the areas surveyors will look at and detail the documentation that should be available.

While many in-house physicists are familiar with the survey process and may be in the department during the survey, many of us in the consulting world may only get a frantic phone call when the surveyor arrives, asking for documentation, CEU's, or reports. Familiarity with the ACR requirements and making sure that annual surveys include all necessary documentation for every client will help to minimize these frantic phone calls and help facilities successfully complete an on-site survey.

The following items will be reviewed by the surveyor regarding the medical physicist's qualifications: copy of board certification or documentation of alternate pathway and documentation of participation in MOC, continuing experience, and continuing medical education. As per CMS, ACR surveyors cannot accept self-attested CME documentation: they will ask to see certificates or transcripts from CAMPEP showing the number of CME's earned and the date they were earned. Additionally, facilities must verify that all personnel, including consulting physicists, are not on the Office of Inspector General exclusion list. This can be done by visiting the website and searching for an individual or company. As of October 2017, there are more than 68,000 individuals or businesses on this list.

The Toolkit also provides details of each test that must be performed per modality. These are all listed in the details for each program, but the Toolkit summarizes the tests for every modality very succinctly. It has been very helpful for my practice to use the ACR-provided summary pages for each modality because the tests correspond exactly to what the inspectors are looking for. Surveyors will want to see the most recent annual evaluation as well as the previous year's evaluation. If any deficiencies are noted, the surveyor will want to see documentation of corrective action from the facility.

Surveyors will also review the most recent three months of technologist QC. During annual inspections, it is important to review and sign QC records, but surveyors will focus on the most recent three months. Therefore, for facilities where a physicist may only visit once per year, it is vital to carefully review the program and make sure the technologists are performing the test appropriately.

Additional documentation of policies and procedures, patient reports and communication, physician peer-review, and image labeling are also reviewed during the survey. These items are generally the responsibility of the facility manager and radiologist, but physicists should have a working knowledge of the process and what's required so that we can serve as a resource to facilities. At the least, we should be able to point facility managers and radiologists to the Toolkit and help to explain the program and how the surveys are generally performed.

Finally, it is important to remember that an on-site Validation Site Survey is not a punitive measure. Surveyors are not visiting because they want to make your life difficult: they want to verify that the requirements of the accreditation programs are being followed so that patients receive the best quality of care.

For additional questions or information on the validation site surveys, you can contact the ACR directly.