Anxiety over the unknown is normal, and most people feel uncomfortable under a microscope. You may think a “surprise” visit to evaluate your facility’s quality control policies and procedures warrants worry. When it comes to the FDA’s requirement that accredited mammography facilities be willing to undergo a random on-site survey (ROSS), the College is here to help — and it’s not scary.

Under the Mammography Quality Standards Act (MQSA), the FDA requires the ACR to conduct on-site surveys of a random sample of accredited facilities. Those facilities are notified in advance of what will be evaluated and who will be involved during the visit. A survey team consists of an ACR staff accreditation specialist (technologist), a volunteer ACR clinical image reviewer (radiologist) and a volunteer ACR phantom reviewer (physicist) for the Mammography Accreditation Program. The clinical and phantom reviewers are volunteers who take time from their own busy practices to travel the country and share their expertise.

They review a facility’s quality assurance and quality control (QC) programs, mammography policies and procedures, personnel qualifications, clinical image quality and mammography reports — and evaluate a phantom image. These site visits offer facility staff an opportunity to interact with and learn from imaging experts while validating a facility’s accreditation information.

Professional and Positive

“As an accrediting body for the FDA, this is a requirement we must perform,” says Tracy Purdie, BS RT (R)(M)(CT) CBDT, an ACR senior accreditation specialist in the ACR Quality & Safety department’s breast imaging accreditation section. “Every month a different state is selected. We send notice of the visit to the randomly selected facilities in advance with the date and the time of day, either morning or afternoon.”

“As hard as we try to make facilities comfortable, when they get the notice, I think sometimes it must feel like getting a letter from the IRS,” Purdie says. “After first contact, we ask them for some documentation prior to the visit. When I call, I try to be as upbeat and friendly and relaxing as possible.”

Performing mammography at a facility should be a team approach, Purdie says. “Everyone should be working to ensure that equipment is working well, but we’re also looking at the knowledge and expertise of the radiologists — who should be giving positive feedback when critiquing the work of their technical staff,” she says. “It often feels like the technologists get the short end of the stick if there is an issue. So, when the visit is complete, I always make sure to relay how wonderful the techs were to work with and how staff in general were pleasant and accommodating.”

Everyone should be working to ensure that equipment is working well, but we’re also looking at the knowledge and expertise of the radiologists — who should be giving positive feedback when critiquing the work of their technical staff.

The facilities are told in advance what the site visit team will need and do when we arrive, Purdie says. “The radiologist reviews random cases and other data. The medical physicist follows the mammography tech and does the phantom image with the tech,” Purdie explains. “We try to get in and out of the room as quickly as possible. We don’t want them to cancel any patients — it should pretty much be business as usual. The ROSS team is open to all questions, and this is a good time to ask ACR staff anything you may otherwise not have a chance to ask.”

Preparation and Progress

“When we received the letter about the survey, our first reaction was to start Googling if we should be worried about being underprepared,” says Brittany Carroll, RT(R), radiology manager at The Medical Center at Caverna in Horse Cave, KY. “We do our ACR accreditation, of course, but we had never had this kind of an on-site survey.”

That anxiety was quelled almost immediately through personal assurances and open lines of communication. “Everyone was so nice throughout the process,” Carroll recalls. “Tracy contacted me before the site visit by phone — even after we received a notice by mail and email — and walked us through everything that was going to happen when the survey team arrived.”

Facility staff were given ample time to ask questions of the survey team during and after the visit, Carroll says. “We really got the sense that they were there to help educate more than anything else. Everyone on the visiting team had a great deal of patience,” she says. “We did a kind of exit review where everyone — our staff, the mammography technologists and the ACR team — gathered to summarize the day and discuss what we had learned. We felt like we got great advice and were in a better position going forward.”

After the visit, the facility has time to provide anything additional that the site team requested. For example, if your technologists need more education on positioning, the ACR may recommend that they do eight hours of hands-on positioning and document that instruction. Other “fixes” may be as simple as rewording an existing policy or procedure.

“Once we received our report after the visit, if I had a question, I just shot off a quick email and found ACR staff to be very responsive,” Carroll says. There are a lot of unknown factors before and during this type of site visit — and it can be a bit stressful, she admits. “The bottom line is that the experience has led to improvements at our facility. Things that could be improved — whether image quality or process — were brought to light and we were glad to learn about them,” she says.

Process and Productivity

“I felt like the survey team supported our mission, which is to provide the highest quality healthcare to Native peoples,” says Robyn Free, JD, ARRT mammography technologist specialist/QC at Benteh Nuutah Valley Native Primary Care Center in Wasilla, AK. “We are totally tribal-based, and we also provide imaging and other services to the VA here,” she says. “During and after the facility visit, it was clear that they were there to help us improve, not put us through some painful inspection.” 

“We are a very small department and still had patients getting exams the day of the visit,” Free says. “I got the ACR radiologist surveyor set up at some Barco monitors we have. We don’t have a reading room here because the [staff] radiologists don’t come out here, so the ACR radiologist surveyor reviewed the images remotely.” 

“Our manager, Julie, who is not an imaging person, learned a lot about the equipment and the process that day,” Free says. “She and I went with the physicist to shoot the ACR-approved phantom. The physicist was so helpful and gave us a refresher on how to read and score the image. And he showed us how to magnify the phantom to do your scoring. The whole exercise is designed to ensure your image quality is top-notch and that you aren’t slipping.”

While you should always be prepared to show your work, these random surveys can really give you an upper hand, Free says. “After we had the ACR survey, we had our MQSA assessment a few months later. We sailed through it. We got zero recommendations. That’s what an ACR visit can do for you,” she says.

Learning and making improvements not only boost the quality of care for patients, but can also give staff morale a real lift. “All site visit team members take the time to let management know how responsive staff were during the visit,” says Elspeth Gates, RT(R)(M)(MR), accreditation specialist in the ACR Quality & Safety department’s breast imaging accreditation section. “They’ll say what a great job staff are doing, especially in front of management or administration — as some staff only ever hear the bad and never the good.” 

“When the visit is complete and we’re ready to walk out the door, I’ve gotten more hugs than not,” Gates says. “There is a real sense of appreciation for us being there to listen and answer questions that may improve patient care.” Facility staff will often tell members of the site visit team that the experience wasn’t as unnerving as they thought it might be. Gates says, “That’s how I know we’re doing things the right way — bolstering quality improvement efforts for better patient care while building more confident and experienced radiology teams.”