New Accreditation Physician Peer-Review Requirements Effective April 1, 2007


Effective April, 2007, all sites initially applying for ACR accreditation and all sites renewing their accreditation must have active participation in a physician peer-review program. RADPEER™, or an equivalent peer review program, is required for accreditation. Please note: The Mammography and Stereotactic Breast Biopsy Programs and Ultrasound Guided Breast Biopsy module of the Breast Ultrasound Program are not included in this requirement.

Examinations should be systematically reviewed and evaluated as part of the overall quality improvement program at the facility. Monitoring should include evaluation of the accuracy of interpretation as well as the appropriateness of the examination. Complications and adverse events or activities that may have the potential for sentinel events should be monitored, analyzed and reported as required, and periodically reviewed to identify opportunities to improve patient care. These data should be collected in a manner that complies with statutory and regulatory peer-review procedures to ensure the confidentiality of the peer-review process.1

RADPEER™ is a simple process that allows peer review to be performed during the routine interpretation of current images. If, during interpretation of a new examination, there are prior images of the same area of interest, the interpreting radiologist will typically form an opinion of the previous interpretation while interpreting the new study. If the opinion of the previous interpretation is scored, a peer review event has occurred. In RADPEER™, the report of the previous interpretation is scored by the reviewer using a standardized four-point rating scale

An acceptable alternative physician peer review program must include:

  • A peer review process that includes a double reading two MDs interpreting the same study) assessment;
  • A peer review process that allows for random selection of studies to be reviewed on a regularly scheduled basis;
  • Exams and procedures representative of the work of each physician's specialty.
  • Reviewer assessment of the agreement of original report with subsequent review (or with surgical or pathological findings);
  • A classification of peer review findings with regard to level of quality concerns (One example would be a 4 point scoring scale);
  • Policies and procedures for action to be taken on significantly discrepant peer review findings for purpose of achieving quality outcomes improvement;
  • Summary statistics and comparisons generated for each physician by modality; and
  • Summary data for each facility/practice by modality.

For information on RADPEER™ or e RADPEER™ please go to the ACR Web site at www.acr.org.

1 2005 ACR Guidelines and Technical Standards. ACR Position Statement on Quality Control and Improvement, Safety, Infection Control, and Patient Education Concerns. Page IV.