Standards and Guidelines for the Accreditation of Ultrasound Practices
Approved 11/5/2011

PURPOSE

The AIUM strives to continuously improve the quality of diagnostic ultrasound services by offering a peer review process for providers to demonstrate that they meet nationally recognized standards and guidelines.

Diagnostic medical ultrasound makes important contributions to patient care and may be used in a variety of settings. Ultrasound practice accreditation is designed to set a standard of quality for the performance of basic ultrasound procedures. These Standards and Guidelines for the Accreditation of Ultrasound Practices specify minimum training, experience, credentialing, and continuing medical education requirements for medical staff and personnel who perform and interpret diagnostic ultrasound examinations. Furthermore, these Standards specify the requirements for safety, maintenance, and calibration of equipment, staff performance, reports, record keeping, and quality assurance for clinical practices where studies are performed.

Ultrasound practices that meet the standards and guidelines described below will be eligible for ultrasound practice accreditation.

Accreditation
Accreditation may be obtained in 1 or more of the following specialties:

The completed application and supporting documents are reviewed by the AIUM's Ultrasound Practice Accreditation Program's peer reviewers. Reaccreditation is required every 3 years. In case of major changes in personnel or the practice, the AIUM's Ultrasound Practice Accreditation Department must be notified as soon as possible.

ULTRASOUND PRACTICE PERSONNEL

Physician Director of Ultrasound
The practice must designate a physician director of ultrasound who is responsible for overseeing the quality and appropriateness of ultrasound operations of the practice, including ensuring that appropriate clinical services are provided, that support services are sufficient, and for certifying that the practice continues to meet the Standards and Guidelines for the Accreditation of Ultrasound Practices. The physician director of ultrasound may supervise the entire operation of the facility or may delegate specific operations to associates and sonographers. The physician director of ultrasound must meet all additional requirements for physicians who perform and/or interpret ultrasound examinations.

Interpreting Physicians
All practice physicians who perform and/or interpret ultrasound examinations must meet the following requirements:

SONOGRAPHERS AND OTHER NONPHYSICIANS WHO PERFORM ULTRASOUND EXAMINATIONS

Chief Sonographer
A qualified chief sonographer may be designated for the facility. The chief sonographer will report to the physician director of ultrasound and will be responsible for those tasks specified by the physician director of ultrasound for the day-to-day operation of the facility and the maintenance and operation of the equipment. The chief sonographer must meet all additional requirements for sonographers and other nonphysicians who perform ultrasound examinations.

Sonographers and Other Nonphysicians Who Perform Ultrasound Examinations
Qualified sonographers and other nonphysicians who perform ultrasound examinations (hereto referred to as sonographers) will be responsible for those tasks specified by the physician director of ultrasound and the chief sonographer. Sonographers must have appropriate training for the performance of the sonographic examinations they perform. Requirements for sonographers and other nonphysicians who perform ultrasound examinations are as follows:

POLICIES AND PROCEDURES SAFEGUARDING PATIENTS, ULTRASOUND PERSONNEL, AND EQUIPMENT

Patient Identification

Precautions for Invasive Procedures

TIMELY REPORTING OF ULTRASOUND FINDINGS

If physicians are not immediately available for the patient at the time of the sonogram, the sonographer must be registered in the specialty area; a mechanism must be in place to address unexpected or emergency findings; sonograms must be finally read within 24 hours, and if the patient is not kept until the physician reviews the images, a callback mechanism must be described.

FINAL REPORTS

A final report is a written report that has been signed and dated by the interpreting physician. Findings must be recorded and results communicated in a timely fashion to the physician responsible for care.

Reports must specifically address the indication for the study and findings. The final report must meet the requirements specified in the AIUM Practice Guideline for Documentation of an Ultrasound Examination.

PRELIMINARY REPORTS

A preliminary report is a written or verbal report released before being signed by the physician responsible for giving the final interpretation.

INCIDENT REPORTING

A policy/procedure must exist for responding to and reporting any accidents or complications that occur in the facility.

PATIENT CONFIDENTIALITY

All practice personnel must adhere to Health Insurance Portability and Accountability Act regulations and professional ethics and behavior to ensure patient confidentiality.

POLICIES ON PREVENTION OF INFECTIOUS DISEASES

The practice must have procedures and policies on the protection of patients and practice personnel from the transmission of infectious disease as well as the cleaning and disinfection of ultrasound equipment and transducers.

ALARA PRINCIPLE

Personnel must be familiar with and show evidence of practicing the ALARA (as low as reasonably achievable) principle.

QUALITY ASSURANCE

The practice must show ongoing monitoring of the clinical practice's personnel performance, including all physicians and sonographers.

DOCUMENT STORAGE AND RECORD-KEEPING GUIDELINES AND REQUIREMENTS

POLICIES PROTECTING PRACTICE PERSONNEL

The practice must be in compliance with all US Occupational Safety and Health Administration regulations.

ULTRASOUND EQUIPMENT MAINTENANCE AND QUALITY ASSURANCE

The ultrasound equipment must meet all state and federal guidelines.

Studies must be conducted with real-time equipment, and transducers must be available with a frequency range that will optimize beam penetration and resolution.

Practices must meet or exceed the quality assurance guidelines specified in Routine Quality Assurance for Diagnostic Ultrasound Equipment.



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