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ACR Accreditation
Scott Dube, M.S.Queen of the Valley Medical Center
Napa, CA
ACRASTROAAPM
Performance Standards
ACR Guidelines and Standards
“Each practice guideline and technical standard, representing a policy statement by
the College, has undergone a thorough consensus process in which it has been subjected to extensive review, requiring
approval of the Commission on Quality and Safety as well as the ACR Board of
Chancellors, the ACR Council Steering Committee, and the ACR Council”
Agency will perform survey to review program on a
broad scope
(voluntary)
ACR, ACRO
Evidence of Compliance
Began in 1986 as extension of Patterns of Care Study sponsored
by National Cancer Institute
Today317 Facilities
121 under review
ACR Accreditation
ACR ROPA Surveys
July 2011
DepartmentPhysicianPhysics
Dosimetry
Potential Deficiencies
CQI MeetingMorbidity and Mortality Conference
Internal Outcome StudyStaffing Levels
Department
Staffing
30 patients/day ~ 300 patients/year1.5 Radiation Oncologists
1 Physicist1 Dosimetrist
adjust for Special Procedures
Hospital Based
Peer Review of PlansPeer Review of Charts
Site Specific Consent Forms
Physician
Physics QA ManualEnd to End Testing
TG 40/142 DocumentationTreatment Device Evaluation
Peer Review for Solo Physicist
Physics
Plan Check (at some point)
Weekly Chart Check (can be delegated)
Final Chart Review (timely)
Physics
IMRT Plan EvaluationPeer Review of Plans
Treatment Planning Manual
Dosimetry
“No Fly Policy”
Morning Huddle
Dosimetry Time Out
Extra Credit
American College of Radiation Oncology
Began in 1996
142 Facilities Today
106 under review
ACRO Accreditation
Will accreditation ever be required for radiation oncology
services?
1987 - ACR Mammography Accreditation
1992 - Congress enacts MQSA law
1994 - All facilities must be certified
No certification means no payments
Mammography
PayersPatients
Referrals Regulators
Administrators
Radiation Oncology
