The short answer is: Call your NPC consultant! For nuclear medicine or PET accreditation, contact Dave Close or Sharon Long. For CT, MRI, breast MRI, mammography ultrasound, breast ultrasound, or stereotactic breast biopsy accreditation, contact Bob Kobistek.

You should also visit the website of the accrediting body, the American College of Radiology, The Joint Commission, or the Intersocietal Accreditation Commission. For ACR accreditations, you should download the program requirements documents and read them over. There are also clinical imaging guides which you should eventually also read. Be sure to contact your NPC representative early in the process. We need to schedule visits for phantom imaging, and we can help answer your questions along the way.

Direct links to the ACR Program Requirements Documents are as follows:

• Mammography
• Ultrasound
• MRI
• CT
• Nuclear Medicine and PET
• Stereotactic Breast Biopsy
• Breast MRI
• Breast Ultrasound

No. The requirements apply only to freestanding imaging centers. Off site hospital-based imaging centers are also exempt if they bill through the hospital for the technical component of the exam. For more detailed information, visit the ACR website FAQ's

CMS has approved three organizations to provide accreditation services to comply with the MIPPA requirements. These are the American College of Radiology (ACR), The Joint Commission (TJC), and the Intersocietal Accreditation Commission.

For starters, the accreditation programs involve not just the equipment and image quality, but also personnel qualifications, policies and procedures, quality assurance, etc. Taken together these requirements involve not only the equipment, but the radiologists and the facility as well. So unless the mobile company provides complete turnkey service, including image reading, billing, quality assurance, etc., the responsibility for accreditation falls on the facility. In addition, the accreditation requirements of the MIPPA fall on the entity who bills Medicare, which in most cases would be the facility, not the mobile company.

Yes. I won't go into the details of the mammography program, because it's known by the mammography techs all too well. The MRI accreditation program has had a QC manual available since the early 2000's, and the first revision of the CT QC manual was made available on December 1, 2012. Stereotactic Breast Biopsy Accreditation Program also has a manual available. These manuals are available from the ACR. Nuclear Medicine and Ultrasound also require QC, however there is no manual. QC requirements are listed briefly in the Program Requirements, also available on teh ACR website. NPC customers, of course, can count on their consultant to assist.

An NPC consultant contacted the ACR and learned that the ACR recommends retaining QC records for one year. However NPC cautions the facility to also keep in mind the requirements of other organizations and regulators who may require longer retention times. For example, state inspectors may visit the facility at intervals ranging from 2 to 5 years depending on the type of facility and the state in which it is located. The inspector will want to see the records accumulated between inspections. Also, the FDA and ACR have different requirements for mammography QC record retention: Records must be retained between inspections or until each test has been performed 2 times, whichever is longer. But again, also remember that physicists need to see the records as well, so do not throw out records after your MQSA inspection until the physicist has seen them as well.

No. In the fall of 2010, the popular TV doc, Mehmet Oz, aired a program in which he recommended to his viewers that they request thyroid shields be provided during screening mammography examinations. This is an erroneous recommendation and not based on scientific fact. The radiation dose to the thyroid from scatter and tube leakage during a mammography exam is less than 0.005 mGy. The presence of a thyroid shield could also cause image artifacts. In April 2011, the ACR and the SBI published a joint statement on the use of thyroid shields during mammography, which you can access with this link.

The most common oversights in the installation of new FFDM units relate to the hard-copy printer. Since the radiologists read mammograms on the soft copy workstations, it's common for facilities to consider of the printer as an afterthought. (See FAQ on this subject). Other items to remember:

• As in all mammography installations, everything has to pass before the physicist can provide a report to the ACR. Unlike the annual physicist survey, the testing performed after installation (called a Mammography Equipment Evaluation or MEE) does not allow for the 30 day margin in correcting deficiencies. All deficiencies must be corrected before the unit may be used clinically.
• Be sure all connectivity is enabled. The physicist must not only test the FFDM unit but also the radiologist viewing stations and the printer.
• If remote viewing stations are being installed, be sure arrangements can be made to have the physicist visit the various sites.
• Be sure the physicist has access to all pertinent QC manuals -- from the FFDM manufacturer, the soft copy workstation manufacturer and also from the printer manufacturer. Your physicist may request copies of these manuals in advance of the acceptance test in the event he is not familiar with the particular model.

Yes you need a printer. MQSA regulations require it. The printer does not necessarily have to be located at your facility, but you need to have ready access to it if it is located at another location. The printer has to be able to provide diagnostic quality images and must be QC'ed as required by the printer manufacturer and the FFDM manufacturer. And here's the most important point: The printer must pass the physicist testing before the FFDM unit can be placed into service, even if you do not plan to print mammograms right away. Be sure to have your installing engineer test the printer for artifacts and run a SMPTE pattern to test for gray scale calibration.

You must maintain QC records for all printers that you do print to, not all those that you can print to. For example, assume there are 5 mammography facilities within your group, each facility has a printer, and all are linked via a data network. If Facility 1rints its own films, but occasionally has Facility 2 print films for patients examined at Facility 1, then Facility 1 must maintain records for its own printer and that of facility 2. Facility 1 need not maintain records for facilities 3, 4, and 5.

Effective April 15, 2009, new ODH regulations require any facility who provides CT services to develop an ALARA program for CT patients. The program must be developed in cooperation with a radiation expert (medical physicist) and must be reviewed annually. That's about all the regulation says; there is not much detail, and they have not released any regulatory guidance. At this time, NPC is assisting all our CT clients with developing and maintaining the ALARA program and performing annual reviews. As our CT facilities experience ODH inspections and we gather comments from inspectors, we will continue to relay what we've learned about ODH's expectations to our clients.

The flexible, disposable, commercially available shields are placed over the breasts, thyroid, or eyes to reduce the organ dose to the specific region. Whether or not they are effective vs. simply reducing the mAs per rotation is still being debated. Of course there is a degradation in image quality, as will always be the case when radiation dose is reduced. Some researchers claim that the image quality degradation is acceptable and a worthwhile tradeoff when dose reduction is considered. Other researchers point out that although the shields attenuate the primary beam when the tube is in the anterior position, when the tube is in the posterior position, the shields attenuate radiation that has already contributed to patient dose and contains useful image information. Therefore it might be better and less expensive to reduce dose by reducing the technique or using tube current modulation. The AAPM is currently working on a position statement on the use of these shields, and NPC will post it as soon as it becomes available.

A small air bubble isn't a problem. The most obvious drawback of a bubble is that once the bubble becomes large enough, you can no longer see the top of the phantom. This prevents you from measuring the phantom diameter on slice # 5 from the top to the bottom. However, unless the bubble is huge, you can do what the ACR reviewers do. You just measure the diameter of the phantom slightly to left or the right of top dead center. Start drawing the line on the edge of the water-filled part of the phantom, avoiding the bubble. Finish the measurement on the opposite side of the phantom making sure the measurement line passes through the center of the grid. However, if the bubble becomes very large, we recommend you have the phantom refilled or topped off.

The manufacturer, JM Specialty Parts, can refill the phantom for you. Call them at 858-794-7200 for instructions on shipping the phantom.

Yes. It is very easy to top of the phantom using a syringe and distilled water. There is a commercially available refill kit. NPC does not recommend purchasing this kit. The kit costs over $200 and consists of nothing more than a few ml of distilled water and two syringes. We are currently working on written instructions on how you can top off the phantom using distilled water and a syringe. As soon as we finish these instructions they will be posted on this website. Meanwhile, if you are an NPC customer, you can call Bob Kobistek at 888-456-5255 if you need assistance with topping off your phantom. But if you'd like to give it a try, here's what you do: Set the phantom on the table with the inferior end up. Use a 5/16" nutdriver and remove the nylon plug. There are two plugs. One opens up the captive cylinder inside the phantom, which contains solution with a higher concentration of nickel ions. Do not remove that plug -- remove the other one. Tilt the phantom so the air bubble comes up to the fill opening. Use a syringe filled with distilled water to top off the phantom. I find that using a syringe with a hypodermic needle works great because you can inject the water below the surface and avoid having it bubble up and out of the phantom. When you are finished filling the phantom replace the plug and tighten gently. Over tightening will cause the plug threads to strip.

As a service to our customers we want to be sure everyone is aware of a couple of the ACR requirements for accreditation. This is from the ACR Nuclear Medicine/PET Accreditation Program Requirements, 2/6/13.

"A physics survey must be performed on each Gamma Camera or PET unit at least annually." This includes the annual camera QC tests and the annual phantom scans for both routine nuclear medicine and/or PET. All test data must be sent to a qualified medical physicist for review and report preparation. Further, "the qualified practicing medical physicist should meet with the supervising physician and the QC technologist to review the results of the survey and the effectiveness of the technologist QC program, and to recommend any corrective action or repairs that are needed." NPC will be adding signature lines for the physician and the appropriate technologist in our reports to verify that all involved are aware of the test results. For you information" The supervising physician is responsible for assuring compliance with the recommendations of the medical physicist."

Also, the ACR requires semi-annual QC testing with the SPECT/PET phantom. "At this time, the ACR strongly recommends quarterly testing of each system with an appropriate phantom in addition to other tests recommended by the vendor. At a minimum, testing with the appropriate phantom must be performed semi-annually." This requires that the phantom is imaged and evaluated. The evaluation can be by the technologist.

NPC offers programs for either information review and report preparation or on site annual ACR testing. If you would like to change any of your current programs, contact your consultant.