The American College of Radiology Mammography Accreditation Lawrence & Idell Weisberg Cancer Treatment Center Karmanos Cancer Center- Farmington Hills Sandra Ziaja Presentation date: June 28, 2016

Karmanos Cancer Center –Farmington Hills The Karmanos Cancer Center-Farmington Hills mammography center is located within the Lawrence & Idell Weisberg Cancer Treatment Center. The mammography center offers digital screening & diagnostic mammography services as well as diagnostic ultrasound and ultrasound guided breast biopsy procedures. The mammography center is accredited by the American College of Radiology (ACR)and the FDA. The Mammography Quality Standards Act requires facilities that perform mammography to renew their ACR accreditation every three years.

Site Supervisor: Natasha Robinette, M.D. Current position: Service Chief of Radiology for The Karmanos Cancer Center. Credentials: Dr. Robinette holds Board Certification by the American Board of Radiology in both Diagnostic and Neuroradiology. Dr. Robinette is also a Clinical Assistant Professor of Oncology, Wayne State University School of Medicine. Education: Dr. Robinette received her Baccalaureate degree from Michigan State University, and attended Medical School at Wayne State University. She completed her Diagnostic Radiology Residency at Oakwood Hospital & Medical Center Dearborn as well as a Neuroradiology Fellowship at the University of Michigan in Ann Arbor.

Practicum Overview The ACR Mammography Accreditation Program has specific outlined requirements for the following areas in order to achieve accreditation. These requirements include: Personnel: Radiologist Qualifications Medical Physicist Qualifications Radiologic Technologist Qualifications MQSA Personnel Requirements Quality Control and Equipment Evaluation: Radiologic Technologist Equipment Quality Control Medical Physicist Equipment Evaluation Clinical Image Submission Clinical mammography images must be submitted for both dense and fatty breasts. Phantom images must be submitted

Practicum Objectives The objective of my practicum is to initiate, submit, and achieve ACR accreditation for mammography at the Karmanos Cancer Center-Farmington Hills location. Action Steps: Application Gather required information for submission: Personnel documentation Equipment evaluation/reports Clinical image selection Phantom Image selection Submission of required documentation and clinical images Granting of accreditation from the ACR.

Practicum Time Line Practicum Time Line Cont. 11-12-2015 - Start initial application to the ACR 11-12-2015 to 11-24-2015 Completed application to the ACR Updated facility, contact and Lead Interpreting Physician information Obtained signatures for the Mammography Accreditation Survey Agreement from the Lead Interpreting Physician and the CEO Obtain signatures for the MQSA release authorization from the Lead Interpreting Physician

Practicum Time Line Cont. Update the Practice Information to include: Collected data for number and type of mammography exams in prior 12 month period Attest to the qualifications of staff: Radiologists, Physicist, Technologists. Validate all licenses and certifications, continuing experience, and continuing medical education on each individual Attest to the QC and QA programs that are in place. Validate that each is performing within the specifications of the ACR/MQSA Research and provide percentages of final assessment categories from mammograms for the last complete one year analysis. Review all policies that are required to assure they meet the MQSA standards. Copies, film retention, infection control, patient safety, complications and adverse events, & patient education.

Practicum Time Line Cont. Update Radiologists information Update Technologists information Update Physicist Information Update Equipment Information Request Check from Finance, obtain signatures 11-24-2015 : Completed Application Submitted to the ACR.

Practicum Time Line Cont. November 30, 2015: Testing Package Received from ACR December 1, 2015 to December 17, 2015: 406 mammography studies were reviewed for possible clinical image submission. Each exam consisted of 4 or more images per study Average time for image review per study was 20 minutes. December 18, 2015: Final image selection review with Lead Interpreting Physician Clinical Image Test Data forms completed for selected images

Practicum Time Line Cont. December 19, 2015: Met with PACS Admin to identify images for upload to the Triad program including clinical images and phantom images. All documents scanned and uploaded to computer for future ACR upload January 4, 2016: Personnel Attestations uploaded to ACR Physicist Reports uploaded to ACR All signature forms uploaded to ACR All QC data forms uploaded to ACR The Phantom image data form uploaded to ACR The Clinical image data form uploaded to ACR The Clinical images uploaded to ACR via the Triad program

Practicum Time Line Cont. January 6, 2016: Final electronic submission to the ACR Total Clock Hours =200 Hours March 14, 2016: Three Year ACR Mammography Accreditation Granted!

References: The American College of Radiology http://www.acraccreditation.org/Modalities/Mammography