Marion Boston, Presenter: Nothing to Disclose

Priscilla Fay Butler MS, Abstract Co-Author: Nothing to Disclose

Judy M. Destouet MD, Abstract Co-Author: Nothing to Disclose

To evaluate trends in the Scheduled On-Site Survey (SOSS) process and corrective action requested by American College of Radiology (ACR) surveyors to improve quality at mammography facilities.

In order to legally perform mammography in the U.S., the Mammography Quality Standards Act requires each facility to pass accreditation once every three years. As of January 1, 2005, the ACR accredited 12,919 mammography units at 8431 facilities. If a mammography unit cannot pass ACR accreditation after three attempts, the facility must participate in a SOSS. During the SOSS, the ACR team (a radiologist reviewer, a medical physicist reviewer and an ACR staff technologist) reviews all aspects of the mammography practice with the facility’s radiologists, medical physicists and technologists. The ACR team provides detailed recommendations for corrective action that the facility must implement before the facility is allowed to reapply for accreditation.

Between 1996 and 2004, the ACR conducted 165 SOSSs. The number of SOSSs has dropped dramatically since 1996 when 32 SOSSs were performed. In 2004, only four were necessary. The ACR has analyzed the recommendations from 162 of the SOSS reports. Each facility received multiple recommendations for quality improvement. The mammography unit required service at 55% of the facilities visited. Technologists were instructed to obtain hands-on positioning training at 54% of the facilities due to continued poor clinical image quality. Fifty percent of the facilities continued to have quality control problems. Improving communication between the radiologists and technologists was recommended in 44% of all the visits. Patient follow-up or medical audit analyses were inadequate in 38% of the facilities. The processor required service in 34%. After taking corrective action and reapplying for accreditation, virtually all of the facilities participating in the SOSS passed.

The ACR’s SOSS process has been successful in helping facilities with repeated, serious problems meet quality standards. In addition, the number of SOSSs necessary since 1996 has dramatically decreased indicating that image quality has improved over that time.

To evaluate trends in the Scheduled On-Site Survey (SOSS) process and corrective action requested by American College of Radiology (ACR) surveyors to improve quality at mammography facilities.

In order to legally perform mammography in the U.S., the Mammography Quality Standards Act requires each facility to pass accreditation once every three years. As of January 1, 2005, the ACR accredited 12,919 mammography units at 8431 facilities. If a mammography unit cannot pass ACR accreditation after three attempts, the facility must participate in a SOSS. During the SOSS, the ACR team (a radiologist reviewer, a medical physicist reviewer and an ACR staff technologist) reviews all aspects of the mammography practice with the facility’s radiologists, medical physicists and technologists. The ACR team provides detailed recommendations for corrective action that the facility must implement before the facility is allowed to reapply for accreditation.

Between 1996 and 2004, the ACR conducted 165 SOSSs. The number of SOSSs has dropped dramatically since 1996 when 32 SOSSs were performed. In 2004, only four were necessary. The ACR has analyzed the recommendations from 162 of the SOSS reports. Each facility received multiple recommendations for quality improvement. The mammography unit required service at 55% of the facilities visited. Technologists were instructed to obtain hands-on positioning training at 54% of the facilities due to continued poor clinical image quality. Fifty percent of the facilities continued to have quality control problems. Improving communication between the radiologists and technologists was recommended in 44% of all the visits. Patient follow-up or medical audit analyses were inadequate in 38% of the facilities. The processor required service in 34%. After taking corrective action and reapplying for accreditation, virtually all of the facilities participating in the SOSS passed.

The ACR’s SOSS process has been successful in helping facilities with repeated, serious problems meet quality standards. In addition, the number of SOSSs necessary since 1996 has dramatically decreased indicating that image quality has improved over that time.

Boston, M, Butler, P, Destouet, J, An Analysis of the American College of Radiology Mammography Accreditation Program's Scheduled On-Site Survey Process.  Radiological Society of North America 2005 Scientific Assembly and Annual Meeting, November 27 - December 2, 2005 ,Chicago IL. http://archive.rsna.org/2005/4417463.html