By Beth Allen
Banner Imaging is accredited with the ACR as is required by CMS for outpatient facilities. This is an ongoing process since we always have a renewal due somewhere or a new piece of equipment being added. Our team has become very proficient at submitting the application, gathering the required images and documents, and receiving approval.
I have seen questions about what to expect out of an ACR survey on the AHRA Forum. Most responses direct folks to the ACR website and the toolkit that is set up there. Everything necessary is laid out on the site, but sometimes it is nice to have a little bit more detail so I thought I would share our experience.
Recently, four of our centers were selected for a virtual accreditation survey. We felt prepared for this, as we have experienced several in-person surveys prior to the pandemic but decided this would be a great time to refine our information and educate other team members. Our modality managers handle the details of the ACR process, so site managers are not as up to speed on the requirements and the specifics of each modality in their center.
Things have changed a bit since the pandemic and a virtual survey is slightly different. Previously, we had all our site information in an ACR Toolkit physical binder, which we updated every 6 months. We began building an online toolkit in Teams about a year ago that includes all the required information for each of our sites but is all in one place. We were very happy we had already started this when we received notification that we were going to be surveyed, especially since it was at four sites.
The electronic binder is set up just like the physical binder with the tabs suggested on the ACR website. We have tech information split by modality instead of by site, which makes them all easier to manage. The same is true for radiologists and physicists. Our policies are listed in a spreadsheet with links to our policy software.
Being that the surveyor is not physically onsite, we were asked to present a video or PowerPoint presentation of our center. We provided a floor plan of our space to begin the presentation. It is important to include the waiting room and appropriate signage, including the notice to patients regarding the process to submit a complaint to the ACR. The surveyor also needs to see MRI zone signage, in use light for CT and hot lab signage. We presented pictures of our emergency kit and the daily log.
Our surveyor did a review of the physical space; policy and procedure review; personnel, physician and physicist credentials and continuing education; physicist reports; peer review, and daily QC logs. We then went through image verification for each modality. The surveyor viewed PACS images to verify that specific information was included either on the screen or in the DICOM header.
We had the same surveyor for all our visits, but all were scheduled separately. She was very patient and easy to work with. She even allowed team members from all four sites to be included on the first survey so they could be prepared when it was their turn. This helped us immensely for the proceeding surveys since everyone knew what to expect. We also had the same point person navigate the toolkit for each of the surveys that had helped to build it. This allowed us to move from one section to the next quickly and efficiently.
If I was to give any advice, I would say be prepared by following the toolkit. Go into the survey seeking to understand areas that can be improved. Be friendly with your surveyor since this is a joint effort. Do whatever possible to make their job easier by knowing and understanding your information. Prepare ahead of time and have an internal mock survey to find anything that may have been missed before the real deal.
We did learn that we had not been good about updating contact information when we had a site manager change. The ACR uses this information to contact the site to set up the survey. We also will be updating personnel and physician information more frequently.
All in all, the experience was interesting and painless. I was so happy that we had prepared as a team, and I was proud of our performance. We will keep our toolkit up to date and should be ready for the next one.
Beth Allen, RT(R)(CT), CRA, is the director, clinical operations at Banner Imaging.
