American College of Radiology (ACR)-accredited advanced diagnostic imaging (ADI) facilities need knowledge about the most common sources of deficiencies and recommendations to better prepare them for validation site surveys and reduce their chances of being noncompliant, according to a study published online May 14 by the Journal of the American College of Radiology.
Under the Medicare Improvements for Patients and Providers Act (MIPPA), ADI facilities that provide Medicare Part B imaging services for CT, MRI, nuclear medicine and PET need to be accredited every three years. Sites that do not receive accreditation cannot receive the technical component reimbursement for Medicare Part B ADI services.
Three organizations have approval to grant accreditation: the ACR, the Intersocietal Accreditation Commission and the Joint Commission. MIPPA site surveys, which are a part of the accreditation process, are unannounced. Lead author H. Benjamin Harvey, MD, JD, of Massachusetts General Hospital in Boston, and colleagues evaluated the findings of first-year validation site surveys performed by the ACR.
The ACR surveyed 943 ADI facilities across 21 states during the first year of validation site surveys. Data were extracted from the site survey reports and were analyzed based on the survey outcomes and frequency and type of deficiencies and recommendations. The researchers obtained follow-up data from the ACR for facilities that were deemed noncompliant on the site survey to investigate if the facilities took adequate, corrective actions necessary to maintaining accreditation.
Results indicated that of the 943 ADI facilities surveyed, 45 percent were compliant with ACR accreditation standards, while 55 percent had one or more deficiencies. The two most common causes of deficiencies were failure to produce the required personnel documentation and absence of mandatory written policies.
Facilities that were accredited in more modalities seemed to fare better in the site surveys, as the number of accredited modalities at a facility was negatively associated with the likelihood of a deficiency.
Of the facilities with deficiencies, 73 percent took necessary corrective actions to maintain accreditation, 27 percent were in the process of taking corrective actions, and no facility lost accreditation because of an inability to adequately address deficiencies.
Nonbinding recommendations were made to 37 percent of the facilities. Facilities with deficiencies were statistically more likely to receive recommendations.
"The findings of this study can provide valuable insight for the more than 6,700 facilities expected to undergo advanced imaging accreditation site surveys by the ACR," wrote the authors.