Due to the ongoing COVID-19 pandemic, the ACR is working hard to keep business as usual and provide support to our accredited facilities. One of the ways we’re accomplishing that goal is to convert site surveys to a virtual format. Two ACR programs are now conducting virtual site surveys: the ACR Diagnostic Imaging Center of Excellence™ (DICOE) and the ACR Radiation Oncology Practice Accreditation (ROPA).
Piloting Through Virtual DICOE Surveys
Top-quality radiology teams can receive recognition for outstanding diagnostic imaging and patient care by achieving the ACR DICOE distinction. To achieve DICOE status, radiology practices must demonstrate achievement of the highest levels of efficiency, safety and quality of patient care.
One key component of earning DICOE recognition is to undergo a site survey, assessing multiple areas of quality, safety, procedures and personnel by an ACR survey team that includes a radiologist, medical physicist and technologist working with your team members.
The COVID-19 pandemic created a major roadblock for the ACR DIOCE program. A significant part of the DICOE designation process is conducting an on-site survey. Over the last few months, the DICOE team started reaching out to prospective DICOE renewal sites to explore interest in conducting a virtual DICOE survey.
The virtual DICOE survey mimics an on-site DICOE survey. We start with introductions, using video conference, followed by a department tour, which includes a combination of sharing screens, video clips and presentations. After the tour, both teams meet through a video conference session, and the virtual site survey concludes with an exit interview to recap findings.
The ACR DICOE team started conducting virtual surveys in July of 2020; to date, we have completed a dozen virtual site surveys. We hope to continue conducting virtual surveys during these uncertain times.
Conducting Site Surveys Virtually for ROPA
COVID-19 has also affected the ACR’s ability to conduct in-person accreditation site surveys. After many months on pause, the ACR embarked on a process to conduct virtual site surveys via teleconferencing for the ROPA program. In May, the ACR successfully beta tested and conducted its first virtual ROPA site survey.
Here’s how it works: The host institution will initiate, launch and run a third-party video conferencing platform such as Zoom. Our surveyors use the Zoom links provided by the facility to access and view patient data. Our surveyors do not log into facility systems directly, but instead, a staff member logs in, shares and navigates their screens with the survey team. There may be instances where our surveyors request keyboard and mouse control to navigate through patient files. However, we prefer that the assigned navigators drive the process.
For the virtual site survey, the facility should be able to replicate everything the department does to conduct the review. Some items, such as the tour of the facility or visiting the other satellite sites, will not be an option.
For sites to qualify for a virtual site survey, they must meet specific requirements requested by the ACR. A unique aspect of the ROPA program is that practices must complete the ROPA Toolkit before scheduling a virtual visit. As part of the toolkit, all sites must complete a checklist before a virtual site survey is scheduled.
The toolkit is a self-study of the practice’s compliance with the ROPA standards. It allows the facility to implement changes or confirm their compliance with ROPA standards before the virtual visit. This process promotes quality improvement and leads to higher performance during the virtual visit.
We strongly encourage that all sites participate in a virtual site survey. If a site declines the virtual site survey, the ACR will provide a three-month extension and reschedule an on-site review once travel is safe.
The ROPA Virtual Experience
One of the first facilities to undergo a virtual site survey for ROPA was Northside Cancer Institute in Atlanta, GA. Marcia Phillips, BS, RTT, CMD, Administrative and Quality; Tomi B. Ogunleye, MS, DABR, Chief Physicist; and Dawn Hayes ,PT,PhD, GCS, Manager Oncology Quality and Accreditation, share their first-hand experiences with the ROPA virtual site survey.
“In this time of the ongoing COVID pandemic, where so many program development initiatives have had to be placed on hold and there was an unknown time frame of when we would be able to resume normal activities, it was exciting to be able to complete and an achieve our ACR Accreditation for four of our clinical locations.
Being the first survey to be completed virtually presented us with the opportunity to think outside the box and be creative in utilizing the appropriate tools for a successful survey. Northside appreciated the opportunity to work through the virtual site survey format with the ACR. I believe our success can be attributed to the following:
- All required documentation was available in an electronic format for easy review by the surveyors.
- Utilization of the GoToMeeting platform in two simultaneous virtual meeting sessions. One session was used by the physician and the other by the physicist for the introduction, documentation review and closing remarks. Surveyors were given controls and were able to navigate within our EMR systems and review documentation from remote locations.
- Testing sessions with the ACR staff and Northside Radiation Oncology staff were carried out prior to the actual survey to ensure the GoToMeeting platform would support our needs and the visualization of the EMR was sufficient for the surveyors’ review.
- Photos of clinical areas and equipment provided a visual representation of our clinics. We were also prepared to have staff perform video virtual tours or walk-throughs of our clinics’ areas in the event that more detail was needed.
- We are fortunate to have an administrative suite, which houses all of the offices of our leadership team. Having all of the necessary members of the survey team in one location allowed us to maintain the necessary social distancing requirements but afforded easy access to these individuals when they needed to interact with the surveyors during the documentation reviews.
We hope our willingness to do a virtual survey will pave the way for other institutions to achieve their ACR accreditation during these uncertain times.”