Full text of DOI:10.1053/cn.2001.v25.acn0250113

Part III. The American College of
Radiology Accreditation Program for
Radiation Oncology
The concept of reviewing the care given to patients in a radiation oncol-
ogy practice became a reality in 1973 with the establishment of the Pat-
terns of Care Study, which was sponsored by the National Cancer Insti-
tute and administered by the American College of Radiology (ACR). By
gathering information about the practice patterns of hundreds of radiation
oncology facilities in the United States, a comparison of the performance
of the practices could be made. The patterns that were found to be present
in what were judged by a panel of experts to be the most ideal practices
provided a means of evaluating the quality of a practice.1 An accreditation
program was a logical extension of this National Cancer Institute initia-
tive and was authorized by the ACR’s board of chancellors in 1986.
Accreditation of radiation oncology practices by the ACR became avail-
able later that same year.
The Commission and the Committee
The Radiation Oncology Practice Accreditation Committee is a com-
mittee of the ACR Commission on Standards and Accreditation. This
commission has oversight and coordination authority over all 11 ACR
accreditation committees. These accreditation committees also address
many other radiologic disciplines such as ultrasonography, nuclear medi-
cine, magnetic resonance imaging, mammography, radiologic physics,
and quality assurance. The Commission on Standards and Accreditation
and its committees also interact with the other ACR commissions and
with committees of the ACR that deal with radiation oncology, such as the
Commission on Radiation Oncology and the Commission on Medical
Physics. Although the authority of the accreditation committees ulti-
mately is derived from the ACR board of chancellors and the entire ACR
membership, individual decisions made by the accreditation committees
are not subject to their review. The accreditation committees therefore are
able to remain free of direct influence in their accreditation decisions.
Members of the Radiation Oncology Practice Accreditation Committee
are appointed by the Board of Chancellors for 1 or 2 terms of 3 years
each. They serve in a voluntary capacity and receive no pay for doing so.
The ACR organizational structure is illustrated in its resource guide.2 The
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113

ACR Commission on Standards and Accreditation usually meets at least
once per year, often coincident with the annual meeting of the Radiolog-
ical Society of North America. The Radiation Oncology Practice Accred-
itation Committee conducts its annual meeting just before the annual
meeting of the American Society for Therapeutic Radiology and Oncol-
ogy (ASTRO) and commonly holds a midwinter meeting at the ACR
office in Reston, Virginia. Both the ACR Commission on Standards and
Accreditation and the Radiation Oncology Practice Accreditation Com-
mittee hold conference calls throughout the year as needed.
The Radiation Oncology Practice Accreditation Committee has 3 major
functions. First, it reviews current published standards and medical liter-
ature to define a body of scientific knowledge to be used when evaluating
a practice as it undergoes an accreditation survey. This information
becomes incorporated into a data collection tool that is used during site
visits for the objective gathering of data about the practice being sur-
veyed. These collection tools are revised regularly as medical knowledge
evolves. The second major function of the committee is to review survey
reports and make decisions as to whether the surveyed practice has earned
accreditation. The formulation of recommendations, which may be
implemented to bring the practice into fuller compliance with the stan-
dards by which it has been judged, is included in the report decision
process. Third, the Accreditation Committee sets the policy of the accred-
itation program. In performing these 3 functions, the committee receives
advice from the legal department of the ACR in an attempt to be aware of
legislation that could influence the accreditation process and accredita-
tion decisions. Members of the committee are not responsible for writing
standards used to measure a facility’s performance. However, they must
be aware of such standards, and they often interface with the Standards
Committee. Many current standards are the result of a need that has been
identified by members of the Accreditation Committee.
The Surveyors
A site visit for accreditation purposes is conducted by 3 surveyors: a
data manager, a radiation oncologist, and a physicist.
The data manager is an employee of the ACR and usually has a back-
ground in radiation therapy, general oncology, or nursing. Data managers
are trained in the accreditation process. They coordinate the site visit with
the facility, the other surveyors, the report writers, and the accreditation
committee. Data managers carry with them the data collection tools to be
used during the site visit and all preliminary materials supplied by the
facility being surveyed that were submitted as part of the application
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process. They also arrange for the survey team to arrive at the assigned
time and location, and they gather all report materials from the other sur-
veyors. These are later distilled into a draft report, which is submitted to
the accreditation committee for its review and decision.
The physician and physicist surveyors are members of the ACR. They
are currently in active practice and serve in a voluntary capacity. Nearly all
have undergone an accreditation survey at the facility in which they work.
At each annual meeting of ASTRO and the American Association of
Physicists in Medicine (AAPM), training sessions are conducted for new
surveyors; these sessions also serve as a refresher opportunity for survey-
ors who have been trained in previous years. The training session is a 2-
hour program during which the candidate surveyors receive an overview
of the program, review copies of the data collection tools, and engage the
instructors and current surveyors in discussions about conducting a site
visit. The program includes remarks by a member of the ACR legal staff
and lectures by the ACR Accreditation Program staff, a senior radiation
oncology surveyor, and a senior physicist surveyor. In addition, issues
such as confidentiality are addressed. Each physicist and physician can-
didate surveyor is subsequently required to participate in a training sur-
vey as a participating observer of a site visit team before conducting a sur-
vey “solo” as a member of a 3-person team. During site visits, the ACR
accreditation staff in Reston is constantly available to answer questions
that may arise while on site. Surveyors are asked to participate in at least
2 surveys per year to remain current. If they are unable to do so, atten-
dance at a refresher training class is requested. At the conclusion of each
site visit, surveyors are asked to comment on each others’ performance
and demeanor, and the ACR staff member who uses the surveyor’s report
to draft the committee’s report is requested to comment on the surveyor’s
thoroughness and timeliness of reporting. Surveyors who retire from
active practice may continue to perform site visits for a limited amount of
time. Surveyors commonly become candidates for appointment to the
Accreditation Committee. For each site visit, each physicist and physician
surveyor is reimbursed for travel expenses and receives a modest hono-
rarium to cover incidental expenses.
Program Activity
Since its inception in 1986 through the fiscal year that ended Septem-
ber 30, 2000, the ACR has conducted 393 surveys as illustrated in Table
1. Of these, 361 have been for accreditation and 32 for consultative pur-
poses. During the most recent fiscal year ending September 30, 2000,
there were 46 surveys. During this same time period, as the initial out-
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TABLE 1. ACR practice accreditation activity
Year
Accreditation surveys Consultative surveys
Total surveys
To 1992*
1993
1994
1995
1996
1997
1998
1999
2000
Total
60
15
38
43
32
43
47
40
43
361
10
3
2
0
3
8
1
2
3
70
18
40
43
35
51
48
42
46
393
32
*Totals for 1986 through 1992 are approximate and may be underestimated.
come of their survey, 11 facilities have received full 3-year accreditation;
5 have not received accreditation; 11 have received 1-year accreditation
with the probability of receiving an additional 2 years pending receipt of
further documentation of compliance. Twenty have received the remain-
der of a full 3-year accreditation after having received only a partial
accreditation during a previous year. The totals do not coincide because
outcomes of surveys are often reported in a different fiscal year than the
one in which the survey was undertaken. The average failure rate is
approximately 15%; however, every facility that fails is given advice on
the steps to be taken to achieve full accreditation before a subsequent
visit. If it is thought that this can be accomplished within 1 year of the sur-
vey, then the facility is given the option of doing so and earning accredi-
tation without another site visit. On certain occasions, a surveyor will
revisit a facility to verify that promised changes have been implemented.
Since the program’s inception, 256 facilities have had a site visit per-
formed. The survey was repeated in 101 facilities after conclusion of the
initial 3-year accreditation process, resulting in a 39% rate of repetition to
date. Twenty-four facilities are on their third accreditation cycle, and one
is in its fourth. Since inception, 70% of surveys were conducted on hospi-
tal-based practices. Thirty percent were at freestanding centers. As of Sep-
tember 30, 2000, there are 154 accredited facilities. Ninety-two percent of
surveys are requested with the intent of achieving accreditation. Eight per-
cent are requested for consultative purposes. Consultative requests are usu-
ally made for the purpose of reviewing a facility that has significant issues
to be resolved. In the application process, the facility will identify those
issues, and a fourth team member will be assigned. This additional mem-
ber may be a radiation oncologist or a physicist, depending on the nature
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of the specific critical issue. For all consultative surveys, at least one of the
surveyors will be a senior surveyor who has several years of accreditation
experience and commonly will have been in practice for many years. By
definition, a consultative survey does not lead to accreditation. It may be
requested as a problem-solving process or as a means of conflict resolu-
tion between or among members of the radiation oncology staff, the
administration, department physicists, or the medical staff.
Virtually all accreditation surveys have been conducted in the United
States. There are accredited facilities in 31 states. NewYork has the most;
Florida ranks second. A list of currently accredited facilities will soon be
maintained on the ACR Web site at http://www.acr.org.
Standards, Appropriateness Criteria,
and Task Group Reports
In addition to historical information provided by the Patterns of Care
Study, there are several other documents used by the Accreditation Com-
mittee as a reference against which a practice is judged. These include ACR
Standards, ACR Appropriateness Criteria,* and AAPM Task Group Reports.
The literature is filled with information regarding the options of man-
agement of patients with cancer. When a certain level of commonality
develops regarding management of certain types of cases, that common-
ality often results in a standard. The ACR has published 91 standards.
Twenty-six deal with diagnostic radiology; 8 deal with interventional
radiology; 7 deal with medical physics; 17 deal with nuclear medicine; 10
deal with radiation oncology; 15 deal with ultrasonography; 3 deal with
magnetic resonance imaging; and 1 deals with credentialing. Four are col-
laborative standards that were developed with other societies to address
specific disease processes, such as the Standard for Diagnosis and Man-
agement for Invasive Breast Carcinoma.
Standards first come into existence when they are proposed and eventu-
ally adopted by the ACR Council during an annual meeting. Proposal of
a standard may come from a number of sources, including specialty orga-
nizations; ACR state chapters; individual practicing radiologists, physi-
cists, or radiation oncologists; or “any other appropriate entity related to
the specialty of radiology.”3 A proposed standard travels along a very
thorough review path that includes an ACR Specialty Commission, the
ACR Standards and Accreditation Committee, the ACR Board of Chan-
cellors, and the ACR Council Steering Committee. Each draft standard is
then circulated for comments to ACR state chapter presidents, councilors,
*Appropriateness Criteria is a trademark of the American College of Radiology.
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alternate councilors, all members of the Board of Councilors, all mem-
bers of the Board of Chancellors, and the Council Steering Committee.
Each proposed standard has its own ad hoc committee whose members
write the draft version, make revisions based on comments that have been
received, and include advice from legal counsel who sit on the commit-
tee. The proposed standard is then assigned to an ACR Reference Com-
mittee at the annual ACR meeting for proposal, revision, adoption, or
rejection by the council. During the annual meeting, any ACR member
may comment on the proposal. On approval, all standards are mailed to
all ACR members. The process takes about 14 months. On a 5-year cycle,
adopted standards are reviewed and undergo reevaluation and reapproval
after a similar process. As new and revised standards are received each
year, the members of each practice should review them and incorporate
them into their practice behavior.
The ACR has also published a compendium of Appropriateness Criteria
that addresses clinical situations often faced by a radiologist or radiation
oncologist. Scores are assigned to various options of management, with
the highest score assigned to those options deemed most appropriate.4
More than 150 topics have been published in this format, including 31
directly involving radiation oncology. These are developed under the over-
sight of the ACR Appropriateness Criteria Task Force, which includes 8
diagnostic radiology and 2 radiation oncology consensus panels.
Physics issues are commonly addressed by task groups of the AAPM and
are published for the AAPM by the American Institute of Physics. Task
group reports are regarded by the physicist members of the Accreditation
Committee as the standard of practice for physics in radiation oncology.
At the Accreditation Committee level, decisions regarding a practice’s
activity and accreditation status are largely drawn from these 3 sources of
standards. If none are pertinent, the committee must draw on general
medical literature, recognizing and allowing for a lesser degree of con-
sensus in many cases.
The Survey Process
The survey process includes submitting a completed application, con-
ducting a site visit, drafting a report, and completing a postsurvey review
that leads to a decision regarding accreditation. The process is protected
as a peer review activity by the Medical Malpractice Act of Virginia,
under section 8.01-581.17 of the Code of Virginia. All information
learned through the process is regarded as privileged and confidential. To
be eligible for an accreditation visit, the facility should have been in oper-
ation for a minimum of 6 months.
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A practice that wishes to receive accredited status does so on a volun-
tary basis and requests an application in writing. An information packet
and an application are then sent by ACR staff to the facility. The submit-
ted application includes
• A letter of application
• A completed structure form that describes the facility’s physical aspects
and enumerates its staff and their qualifications
• Curriculum vitae and documentation of continuing medical education of
all physicians and physicists in the practice
• Enumeration of dosimetrists and radiation therapists with supporting
documentation of licensure and continuing medical education activity
• Reports documenting testing and calibration of each linear accelerator,
including outside Radiological Physics Center thermoluminescent
dosimetry comparisons
• Census information regarding caseload of the facility organized by
disease site
• A consent form to allow the ACR to conduct the accreditation process
signed by each radiation oncologist in the practice
• A survey agreement signed by the chief of radiation oncology
• Payment of the survey fee
The facility is requested to submit a list of cases managed during a ref-
erence year, which is usually the calendar year immediately before the sur-
vey. From these, review cases are selected for audit during the site visit.
After the application has been submitted and found to be complete, a
survey team is assembled and a mutually convenient date is established
for the site visit. Team members are excluded from a survey if they are
located in close geographic proximity to the facility being surveyed. In
addition, each team member is asked to withdraw voluntarily from a sur-
vey if a conflict of interest exists because of any close association with
the facility or its staff; in the case of such a withdrawal, a replacement will
be found. It is recognized that radiation oncology is a small specialty and
that it is sometimes difficult to find surveyors who are completely
unknown to those at the facility. Special attention is given to match the
surveyors to the survey so that any potential conflict is avoided. During
the on-site survey the 3-member team tours the facility, interviews key
staff members, collects information about the quality assessment and
improvement programs, and evaluates peer review activity. Using the
ACR proprietary data collection tools, the surveyors collect medical and
physics data from at least 25 patient charts and evaluate the charts for
organization and completeness. A focus is placed on cases of breast can-
cer, prostate cancer, cervical cancer, rectal or rectosigmoid cancer, and
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Hodgkin’s disease. Five cases from each category are requested for
detailed review. This includes a review of the chart, simulation films, por-
tal films, and all dosimetry records. For certain cases all diagnostic imag-
ing studies that were available to the radiation oncologist during manage-
ment are also requested. If a facility does not have a minimum of 5 cases
from each category, cases of other types of cancer (“generic cases”) are
requested. A small number of charts of patients currently receiving treat-
ment may be reviewed.
The data collection tools are copyrighted, proprietary materials owned
by the ACR. There is a tool for each of the diseases mentioned earlier and
another more generic tool for all other disease sites. There are several
dozen questions on each. Some questions are unique to the disease
process, for example, questions regarding prostate-specific antigen for
prostate cancer. Most questions represent a defined standard or are trace-
able to the Patterns of Care Study. The responses to each question are tab-
ulated and reported back to the facility in the report, with a comparison to
findings obtained from facilities in a similar stratum. The data collection
tools accommodate patients who may have been enrolled in national pro-
tocols and check for basic elements that should be present in all charts,
such as the elements of a treatment prescription.
For a one-facility survey, the data manager and physicist are on site for
2 consecutive business days, and the radiation oncologist is present for the
second of those 2 days. For multilocation surveys, another day is added for
each survey team member for each additional location being surveyed.
For a practice to be eligible for a multisite survey, the following criteria
must be met. Every physician must be a member of the single group prac-
tice. The physician group must have a single medical director, and the
physicist group must have a single physics director. Physician peer review
must include all practice sites. All practice sites must use uniform treat-
ment methods and must have uniform chart organization and forms.
The surveyors act as the eyes and ears of the Accreditation Committee
and pass no judgment while visiting the facility. Their individual reports
are combined into a draft report by ACR staff and evaluated by members
of the Accreditation Committee. Historical data from previous accredita-
tion surveys and Patterns of Care Study surveys are used as a comparison.
The candidate facility is compared with facilities of its own size and type,
as well as with all facilities in the ACR database. If the facility has been
surveyed earlier, the current survey of the candidate facility will also be
compared with the facility’s earlier surveys.
On review of the information gathered by the surveyors, members of the
Accreditation Committee then vote on accreditation status. Surveyors’
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opinions are solicited. The committee’s decision is forwarded to the can-
didate facility after being reviewed by the chairman of the Accreditation
Committee. A decision can be any of the following: full 3-year accredita-
tion; 1-year accreditation pending receipt of a schedule of implementa-
tion of recommendations, followed by the remainder of a full 3 years on
actual implementation of those recommendations; or no accreditation. An
appeal process exists if the facility disagrees with the outcome. The report
is issued to the radiation oncologist who submitted the original request
for the survey to be conducted. To have accreditation continue without
interruption, the facility should submit a completed application for its
next survey before the expiration period.
The survey report contains background information regarding the
ACR’s accreditation process. It describes the process according to which
data were collected. Emphasized is the fact that it is a peer review process
that is protected by law. Tables are included that describe the facility’s
physical plant and personnel, with comparisons to all other facilities that
have been surveyed. Ratios are drawn between caseload, equipment, and
staffing levels and are compared with those of other facilities of similar
size and type of practice. A narrative report describes the facility, its staff,
and all pertinent observations made by the surveyors. Noteworthy obser-
vations about the cases that were reviewed are included. Observations that
were offered by the facility’s staff may be included. The committee is
usually able to offer specific recommendations for improvement on the
basis of the information that was supplied by the facility, verified by the
surveyors, and learned on site. These are commonly grouped according to
significance, with those most critical to achieving accreditation clustered
first. After the list of recommendations, the accreditation decision is
stated and explained. In those cases in which more documentation is
needed, this information will be requested, and the decision may be post-
poned. It is not unusual that a facility can achieve full accreditation by
documenting a process that is in place but has not been heretofore incor-
porated into an official policy and universally followed. The facility may
be given a conditional accreditation status with a requirement that the
appropriate documentation be forwarded to the ACR within a specified
time period of 6 or 12 months. When the documentation has been
received, it is reviewed by the committee and, if satisfactory, full accred-
itation is awarded.
It should be noted that it is the entire practice that is accredited. This
includes the facility, staff, and process of delivering care. Any substantial
change in a program should be reported to the Accreditation Committee
for comment regarding continuation of accredited status. Examples of
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such changes include changes in leadership, loss of key personnel, major
equipment changes, or sale or change of ownership or governance.
Reasons for Wanting a Survey
The ACR has taken the position that accreditation should be required of
all radiation oncology facilities. In some states, such as New York [New
York State Sanitary Code 10 NYCRR 16.24(a)(4)(I)] and New Jersey
[New Jersey Register, Monday, December 20, 1999 Subchapter 28], reg-
ulations exist that require an external review on a regular basis. Accord-
ing to Trudie Cushing, MS, RN, manager of the ACR’s radiation oncol-
ogy and nuclear medicine accreditation programs, “The ACR’s
accreditation program provides medical directors and administrators with
valuable benchmarking data and recommendations for quality improve-
ment of that care.”5 Other reasons for requesting a survey vary broadly.
Surveys are commonly requested purely to demonstrate that an external
review has been performed to validate a practice’s quality. Other facilities
cite marketing advantage. Some facilities anticipate that payment will
someday be tied to accreditation. Public demand is also commonly cited.
Accreditation has been said to be a source of pride by those facilities that
achieve it, and the process often proves to be very satisfying, especially
on favorable culmination. In fact, the process of preparing for an accred-
itation survey commonly involves a thorough self-inspection that would
not have been done if a survey had not been requested. Because the
accreditation process provides an overview of how the components of the
facility operate with respect to one another and with respect to the hospi-
tal or network in which the facility resides, the different sections of the
facility may learn from the survey better ways of interrelating with one
another. Effective September 1, 1998, a cooperative agreement between
the ACR and the Joint Commission for the Accreditation of Healthcare
Organizations (JCAHO) provides that accreditation decisions rendered by
the ACR Radiation Oncology Practice Accreditation Committee will be
accepted by JCAHO for those facilities that are part of a health plan or
managed care organization. Further negotiations between ACR and
JCAHO are being conducted in an attempt to broaden this acceptance pol-
icy to all radiation oncology surveys conducted by the ACR.
Top 10 List of Recommendations
For 1999 the committee tabulated the most common recommendations
it had made to facilities that were surveyed that year. In order of fre-
quency, these recommendations included:
1. Elements of the radiation prescription. According to the ACR Stan-
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dard for Radiation Oncology, “The prescription should include: volume
(site) to be treated, description of portals (e.g., AP, PA, lateral, etc.),
radiation modality, dose per fraction, number of fractions per day, num-
ber of fractions per week, total number of fractions, total tumor dose,
and prescription point or isodose.” For patients receiving both external
beam therapy and an implant, all prescriptions should be maintained in
the patient’s chart (ie, a prescription for external beam, as well as one
for each implant). As treatments become more complex and different
fractionation schedules are used, it is not always universally understood
what simple abbreviated prescriptions mean. This necessitates a strict
definition of prescription to minimize the likelihood of error.
2. Portal verification films. According to the ACR Standard for Radi-
ation Oncology, portal verification films should be taken at the begin-
ning of therapy, with field changes, and at least every other week. All
portal verification films should be labeled with the patient’s name, the
date they were taken, the field size, and the direction of the beam; the
label should also include the radiation oncologist’s signature and date
signed. The physician approving simulation or portal verification films
or recommending a change must initial the films and indicate the date
of approval and suggested modification.
3. Physics completion check. According to the ACR Standard for
Radiation Oncology Physics for External Beam Therapy, at the com-
pletion of treatment the radiation oncology physicist shall review,
sign, and date the entire chart to affirm the fulfillment of the initial or
revised prescription dose.
4. Elements of a history and physical examination. All patients who
are evaluated should have a comprehensive history and physical exam-
ination in the chart. This should include a comprehensive history of the
present illness, medical history, review of symptoms, physical exami-
nation, review of imaging studies and laboratory data, histopathologic
data, and diagnosis and recommendations. For example, charts of
patients with breast cancer should include information on pertinent
aspects of breast cancer, such as estrogen and progesterone receptor
status, menopausal status, chemotherapy, and hormone therapy status.
5. Quality assurance for treatment planning system. The quality
assurance plan for each treatment planning system should be formally
documented. The element of periodic confirmation of the treatment
planning system consistency should be included.
6. Brachytherapy documentation. More complete brachytherapy
documentation is recommended. The written directive should include
the treatment site, isotope, number of sources, and the planned dose to
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designated points. The planned total dose should be documented in all
brachytherapy cases. Any changes in the brachytherapy prescription
should be documented. In addition, the brachytherapy sources used
should be documented in the physician treatment summary. After the
brachytherapy is completed, a written summary of treatment delivery
should include total dose of brachytherapy and total dose of external
beam, time of source insertion and removal, and documentation of a
radiation safety survey of the patient and his or her room.
7. Physician peer review. Current physician peer review activities
should be formalized and documented. If a more formal process were
put in place, it would be likely that the quality of documentation would
be improved. According to the ACR Standard for Radiation Oncology,
“It is recognized that the peer-review process for the radiation oncolo-
gist in solo practice presents a unique and difficult situation; however,
the practitioner should institute a documented peer-review mechanism
for review of the appropriateness of given treatment.”
8. On-treatment visits. According to the ACR Standard for Radiation
Oncology–Medicare requirements, on treatment patients should be
evaluated weekly and notes documented. It is recommended that a con-
sistent place for all on-treatment progress notes be designated and used.
9. Follow-up. According to the ACR Standard for Radiation Oncol-
ogy, “At completion of irradiation and periodically after treatment,
assessment by the radiation oncologist of tumor response and possible
sequelae of treatment is essential. Early detection of post-treatment
tumor progression may permit additional, potentially beneficial treat-
ment. Early detection and treatment of radiation-induced sequelae may
avoid serious problems later.” A follow-up plan needs to be documented
by the radiation oncologist; obtaining correspondence from the refer-
ring physicians would be helpful in determining eventual outcomes.
10. Quality assurance and improvement. A formal, documented qual-
ity assurance and improvement program should be established. This
should include regularly scheduled department quality assurance and
improvement meetings with documented minutes. According to the
ACR Standard for Radiation Oncology, the Medical Director of Radi-
ation Oncology will be responsible for the institution and ongoing
supervision of the Continuing Quality Improvement (CQI) Program. It
will be the responsibility of the director to identify problems, to see
that actions are taken, and to evaluate the effectiveness of the actions.
The director will select appropriate personnel to constitute the CQI
Committee, which will meet on a regular basis. This review will be
documented as the minutes of the CQI Committee. Problems that are
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recognized will be addressed and any special studies or further in-depth
analysis required will be outlined and undertaken. CQI records should
be maintained in a manner that would protect the confidentiality and
discoverability of these records to the extent permitted by state and fed-
eral law. Formal, documented chart rounds, new patient rounds, and
morbidity and mortality conferences should be regularly conducted.
Quality Control, Quality Improvement, and Peer Review
The subjects of quality control, quality improvement, and peer review
deserve special comment, because they are often confused or lacking in a
practice. For these to be recognized as taking place, they should be per-
formed and carefully documented.
It is a rare practice that does not continually make improvements. It is
a natural phenomenon in the practice of radiation oncology.5 Better visu-
alization and localization of tumors, better patient satisfaction, better
tumor control rates, more efficient processes, and better sparing of nor-
mal tissues always appear to be the goal. Outcome studies are perhaps the
most commonly employed demonstration of quality improvement. If data
are gathered and reported in aggregate in a retrospective manner, it is a
good starting point for the demonstration of quality improvement. It is
common that conclusions drawn from such a study may lead to improve-
ment. To convert such a study to a quality improvement endeavor, the out-
come should be remeasured after instituting those ideas and learning
whether the improvement has taken place. A controlled clinical trial that
prospectively compares the outcome by means of more than one method
of management is another way to perform quality improvement.
On the other hand, quality control implies that a process is in place
that attempts to control individual case management so that errors are
not made. For example, routine inspection of all charts for proper inclu-
sion of all elements of a radiation treatment prescription constitutes
quality control. As this is done and as omissions are found and cor-
rected, there is potential for quality improvement. This takes place
when remeasuring proves that the rate of incomplete prescriptions has
decreased as a result. Reviewing all portal verification films for accu-
racy constitutes quality control. Monitoring how frequently portal veri-
fication films are necessary, devising methods to minimize the need for
corrections, and then remeasuring to demonstrate improvement consti-
tute quality improvement.
Ideas for improving quality are all around us. They can come from any
observer of the practice. Staff should be encouraged to “think outside of
the box” and to imagine ways that changes may lead to improvement.
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Patient and staff satisfaction surveys should be conducted periodically to
tease out such ideas. The facility’s quality improvement committee
should discuss such ideas, test whether the improvements can be made,
and document the process in either a formal report or in the committee’s
minutes. Quality improvement activities do not need to be grand or broad.
Small steps can make real progress.
Peer review is also commonly performed without the participants real-
izing it is being done. On survey visits, it is rare to find a practice that
does not have some informal means of reviewing performance. Unfortu-
nately, documentation is often lacking, although it is required for accred-
itation. In a solo practice, true peer review is often more conspicuously
difficult. However, it can be very simply performed. Assuming that the
solo radiation oncologist has a coverage arrangement when he or she is
on vacation or absent to attend a meeting, the covering peer can be
assigned the task of peer review. By being specific with instructions, a
covering physician can provide valuable feedback. For example, on
departure for a vacation, the host solo physician can provide a list of
patients currently receiving treatment and request the covering physician
to answer a few basic questions about the management of each case.
Questions like “Was the patient staged correctly?,” “Were the history and
physical examination complete?,” “Was my radiation treatment prescrip-
tion complete and clear?,” and “Was my management of the case appro-
priate?” are examples. It is suggested that the covering physician’s
answers to these questions be recorded and kept on file. If any of the
questions receives a negative reply, the solo physician can either remedy
the deficiency or justify the deficiency in a subsequent note. At the end of
the year, the reports can be tallied and the number of deficiencies can be
examined in aggregate. The natural tendency would be to avoid making
the same errors in the future. If this is proven on remeasuring next year,
the peer review process has also become quality improvement. If the
questions that are asked do not receive any negative replies, more difficult
ones should be devised; otherwise the opportunity for improvement will
be lost. It is suggested that the process of this activity be documented in
an explanatory note that is kept in a peer review activity file.
In practices with more than one physician, the process can be similar
and can be incorporated into the normal work that is performed when
vacation absences are covered. By working this process into a regular
work schedule, it becomes less burdensome.6 Group practices have the
advantage of offering the opportunity for more frequent peer review. If
each physician examines the other’s patients on a regular basis, peer
review can be built into the normal schedule. Because the examination of
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trends that are observed over time leads to opportunities for improvement,
it is important to remember to document deficiencies that are noted. Chart
rounds can serve as a valuable peer review, but demonstration of improve-
ment becomes difficult if behavior modification is not documented and
trends tracked as a result of the discussions.
Practices should not overlook the importance of peer review of non-
physician staff. Solo physicists are in need of similar review, and the med-
ical director of a facility is entitled to know peer review initiatives and to
receive documented reports of that activity. In practices with multiple
physicists, evidence of cross review is more easily achieved and should
be formally documented. The physicist staff should be charged with
devising a peer review process and reporting its outcome regularly to the
facility’s performance improvement committee. Peer review of staff tech-
nologists, nurses, and clerical employees is less commonly performed.
Supervisory review is a frequently used substitute.
The initiatives of quality control, quality improvement, and peer review,
when taken in aggregate, monitored, and documented by facility leader-
ship, constitute a total quality management program. If these initiatives are
performed on a regular basis and incorporated into everyday life, a facility
does not need to scurry to do these in preparation for an accreditation visit.
Fees
The current fee for an accreditation survey is $8500 for a one-site facil-
ity. Each additional site costs an additional $6000. In cases of multiple
satellite offices, a fee reduction may be granted in some circumstances.
The travel expense of the surveyors is in addition to the survey fee and
should not be overlooked in budgeting. ACR staff can provide estimates
of expenses. In response to requests by practices that have been surveyed,
the ACR is developing a method whereby the fee can be paid on a yearly
basis, rather than in a single lump sum during the year of survey.
How to Prepare for an Accreditation Survey
Since 1999 the ACR has presented a refresher course at the annual
ASTRO meeting entitled “How to Prepare for ACR Accreditation.” The
syllabus from this course can serve as an overview for facilities that are
interested in applying for an accreditation survey. The 2000 version of the
syllabus is available from the author. An audiotape of the presentation is
available through ASTRO. Knowing the characteristics of a practice that
achieves accreditation can help other facilities take the steps to achieve
accreditation also. Those characteristics are
1. The physicians, physicists, and staff follow ACR standards.
Curr Probl Cancer, March/April 2001
127

2. They have in place a mechanism of peer review, quality control,
policy development, and policy adherence.
3. They perform appropriate documentation of the care that is given.
That is, they have a complete chart documenting the evaluation that
has been performed of the patient, the radiation treatment prescription
made, the execution of the plan, and the provision of follow-up care.
4. They address the outcome of their efforts in at least one disease
site approximately once a year. This outcome should also be reported,
preferably to colleagues via distribution or publication.
5. They take seriously the recommendations received during any
prior survey.
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therapy. Semin Radiat Oncol 1997;7:95-182.
2. American College of Radiology. American College of Radiology resource guide
2000. Reston (VA): American College of Radiology; 2000.
3. American College of Radiology. American College of Radiology standards manual
1999-2000. Reston (VA): American College of Radiology; 1999.
4. American College of Radiology. American College of Radiology Appropriateness
Criteria 2000. Reston (VA): American College of Radiology; 2000.
5. Cushing T. Accredit where it’s due. ADVANCE Admin Radiology Radiat Oncol
2000;10:85-6.
6. Johnstone PA, Rohde DC, May BC, Peng YP, Hulick PR. Peer review and perfor-
mance in a radiation oncology clinic. Qual Manag Health Care 1999;8:22-8.
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