1. 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

2. 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.

3. 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.

4. 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

5. 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.

6. Practicum Time Line Practicum Time Line Cont.
Start initial application to the ACR
to 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

7. 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.

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

9. 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

10. 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

11. 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!

12. References: The American College of Radiology