Initial outcomes from federally mandated accreditation site surveys of advanced diagnostic imaging facilities performed by the ACR.
OBJECTIVE
The aim of this study was to evaluate the findings of the first year of validation site surveys performed by the ACR pursuant to new federal accreditation requirements for nonhospital advanced diagnostic imaging (ADI) facilities.


METHODS
In the first year of validation site surveys (November 2012 to November 2013), the ACR surveyed 943 ADI facilities across 21 states. Data were extracted from these site survey reports and analyzed on the basis of the survey outcomes and the frequency and type of deficiencies and recommendations. Follow-up data were obtained from the ACR for facilities deemed noncompliant on the site survey to determine if these facilities adequately took the corrective actions necessary to maintain accreditation.


RESULTS
Of the 943 ADI facilities surveyed, 45% (n = 421) were deemed compliant with the ACR accreditation standards, and 55% (n = 522) had one or more deficiencies. Failure to produce the required personnel documentation and absence of mandatory written policies were the two most common causes of deficiencies. Facilities accredited in more modalities tended to fare better in the site surveys, with the number of accredited modalities at a facility negatively associated with the likelihood of a deficiency (P = .007). Of the facilities with deficiencies, 73% (n = 382) took the necessary corrective actions to maintain accreditation, 27% (n = 140) were in the process of taking corrective actions, and no facility has lost accreditation because of an inability to adequately address the deficiencies. Nonbinding recommendations were made to 37% (n = 346) of facilities, and facilities with deficiencies were statistically more likely to receive recommendations (P < .001).


CONCLUSIONS
Initial site surveys of ADI facilities demonstrated a high proportion of deficient facilities, but no facility has lost accreditation because of an inability to correct these deficiencies. Knowledge of the most common sources of deficiencies and recommendations can assist ACR-accredited ADI facilities in better preparing for validation site surveys, reducing the likelihood of facility noncompliance.
Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts. Electronic address: hbharvey@partners.org.
H Benjamin
HB
Harvey
Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
David
D
Chow
Department of Quality and Safety, American College of Radiology, Reston, Virginia.
Marion
M
Boston
Harvard School of Public Health, Cambridge, Massachusetts.
Jing
J
Zhao
Department of Quality and Safety, American College of Radiology, Reston, Virginia.
Leonard
L
Lucey
Scott and White Department of Radiology, Texas A&M College of Medicine, Temple, Texas.
Debra L
DL
Monticciolo
D000068:Accreditation / Q000592:standards* / Q000706:statistics & numerical data*; D003952:Diagnostic Imaging / Q000592:standards* / Q000706:statistics & numerical data*; D035082:Federal Government; D033161:Government Regulation; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D008485:Medical Audit / Q000592:standards / Q000706:statistics & numerical data*; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care / Q000592:standards; D011871:Radiology / Q000592:standards* / Q000706:statistics & numerical data; D012955:Societies, Medical
Accreditation; advanced diagnostic imaging; deficiency; site survey