Accreditation 101: How ACR Accreditation Impacts Equipment Maintenance and Service


EDITOR’S NOTE: This is an excerpt from an in-depth article about accreditation submitted by the experts at the American College of Radiology (ACR). To access the complete article, visit

With today’s focus on patient-centered care, accreditation programs for diagnostic imaging have emerged as vital initiatives to enhance quality and safety, especially for modalities that depend on advanced technologies such as CT, MRI, nuclear medicine, and PET.

The gold seal of the American College of Radiology (ACR) — ACR accreditation — lets patients know that a hospital, clinic, or imaging center has gone through a rigorous review process to ensure it meets nationally accepted standards. When patients choose an ACR-accredited facility, they also know that the equipment used is appropriate for the test or treatment they will receive, and that the facility meets or exceeds quality assurance and safety guidelines.

What Does It Mean for a Facility to Be Accredited by the ACR?
The ACR awards accreditation to facilities for the achievement of high practice standards based on peer-reviewed assessment of clinical and phantom images, as well as radiation dose. Evaluations are conducted by board-certified radiologists and medical physicists who are experts in the field.

The ACR accredits facilities in ten modalities, including CT, mammography, MRI, nuclear medicine and PET, and stereotactic breast biopsy. The educationally focused accreditation process is based on the ACR Practice Parameters and Technical Standards, which were developed to ensure appropriate radiologic care for patients.

Why Do Facilities Need to Be Accredited?
Achieving ACR accreditation is not only the right thing to do for patient quality and safety, it also helps your facility meet governmental and third-party payer criteria and protect your reimbursements.

In 2012, the Medicare Improvements for Patients and Providers Act (MIPPA) mandated that providers of CT, MRI, breast MRI, nuclear medicine, and PET exams that bill under Part B of the Medicare Physician Fee Schedule be accredited in order to receive payment for the technical component of these services.

CMS requirements for accreditation include personnel qualifications, image quality, equipment performance, safety standards, and quality assurance.

How Does the ACR Accreditation Process Work?
ACR accreditation is an educational process of self-assessment and peer review. The ACR accreditation process documents that your facility meets accreditation requirements for equipment, medical personnel, and quality assurance.

Critical elements of the process include clinical and phantom image quality review, as well as radiation dose assessments. The ACR streamlined application process has cut approval time in half, with accreditation evaluation typically completed within 90 days of image submission. Here’s how it works:

Materials submitted for accreditation review are sent to volunteer reviewers. For clinical images, the ACR requires evaluation by two radiologist reviewers. For phantom images, one or two medical physicists provide evaluation.

If you receive a deficiency, you will have a dedicated ACR support team to discuss your options to appeal, withdraw, repeat, reinstate, retest, etc. And, you can contact ACR if you have any questions throughout the accreditation process.

What You Need to Know About Phantoms
ACR phantoms are scanned by a technologist or physicist. If performed by a technologist, a medical physicist should check all images and data forms. Depending on the modality, ACR phantom measurements may include:

  • CT number calibration
  • Low-contrast (CNR)
  • Spatial resolution
  • Uniformity
  • Artifacts

For dose testing on CT units, the dosimetry must be performed by a medical physicist. Dose testing includes:

  • CTDIvol
  • Reference values and pass/fail criteria

Phantom submissions may include:

  • CT ACR phantom (Gammex) and dosimetry phantom images
  • MR phantom (JM Specialty Parts), including:
    • Large phantom for whole body magnets
    • Small phantom for extremity magnets
  • NM and PET ACR-approved phantoms (Data Spectrum)

Why Quality Control?A key aspect of achieving accreditation rests in the proper maintenance and functioning of imaging equipment to ensure quality and safety. Routine QC can help ensure that your equipment operates appropriately to achieve the necessary image quality. A continuous QC program is essential to identify problems before the diagnostic utility of the equipment is significantly impacted.

The evaluation of equipment performance as part of an ongoing QC program can also be instrumental in building a business case to justify improved service contracts or the purchase of new equipment. What’s more, documentation of QC—including acceptance testing, annual survey, routine QC tests, and preventive maintenance—is often a governmental regulation.

How to Prepare for Accreditation
The ACR has dedicated and readily accessible resources to help sites prepare for accreditation. Start with ACR accreditation website (, where you’ll find a wealth of easy-to-access online information that serves as a comprehensive guide to the requirements for each program. For each modality, you can also find all the latest articles, announcements, and frequently asked questions (FAQs) regarding accreditation.

The Quality and Safety section ( of the ACR website also provides access to Practice Parameters and Technical Standards, Appropriateness Criteria, the National Radiology Data Registry, the Education Catalog, and numerous other resources.

What Happens After Accreditation?
Imaging facilities are accredited for three years. For MIPPA modalities, each accredited facility will go through an unannounced site visit during the three-year accreditation period. Sites can be visited by an ACR representative and/or CMS at any time during the three-year accreditation period.

How can you prepare for unannounced site visits? The ACR provides a detailed toolkit designed to assist gathering and maintaining documentation that is required for accreditation. The toolkit can also be used to prepare pre-accreditation and/or post-accreditation onsite surveys.

Expert Help to Guide You
Along the path to accreditation, ACR experts are standing by to guide you every step of the way. With our expert staff of experienced technologists and the assistance of more than 250 board-certified radiologists and qualified medical physicists, the ACR has provided successful and timely accreditation for nearly 40,000 facilities nationally.

American College of Radiology
1891 Preston White Drive
Reston, VA 20191
Accreditation Hotline: 800-770-0145


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