Standards and Guidelines for the Accreditation of Ultrasound Practices
Approved 11/2/2014

PURPOSE

The American Institute of Ultrasound in Medicine (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 (CME) 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 (QA) 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 and/or staff 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 all correspondence with the accreditation department and must sign all required accreditation correspondence. The physician director of ultrasound is responsible for overseeing the quality and appropriateness of ultrasound operations of the practice, including ensuring that appropriate clinical services are provided and that support services are sufficient, and for attesting 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 requirements for physicians who perform and/or interpret ultrasound examinations.

Interpreting Physicians

Ultrasound studies must be supervised and interpreted by a physician or chiropractor with training and experience in the specific area of sonography and meet the following requirements:

Reaccreditation:

At reaccreditation, all physicians who were on the previous application must have documentation of appropriate CME: CME must be in the area that physicians interpret and/or perform. Physicians who perform and/or interpret ultrasound examinations in multiple specialties must have a representative sample of CME credits from each area of specialty for the 3-year cycle.
Refer to the above links for AIUM Training Guidelines, which designate appropriate CME requirements.

Yearly Volume Requirements:

Physicians must meet procedure volume requirements on the type(s) of accreditation for which the practice is applying.*
Refer to the above links for AIUM Training Guidelines, which designate appropriate yearly volume requirements.

*Physicians who do not meet the minimum volume of ultrasound procedures on an annual basis can participate in a QA program designed to increase their exposure to ultrasound examinations and ensure quality ultrasound care. Physicians who do not meet the minimum annual ultrasound volume requirements can meet the case study requirements in any 1 of the following ways:

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. 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:

The following certifications are acceptable:

Although a sonographer may play a critical role in extracting the information essential to deriving a diagnosis, the rendering of a final diagnosis from ultrasound studies represents the practice of medicine and, therefore, is the responsibility of the supervising physician.

FINAL REPORTS

Final reports must meet the requirements specified in the AIUM Practice Guideline for Documentation of an Ultrasound Examination: http://www.aium.org/resources/guidelines/documentation.pdf

PRELIMINARY REPORTS

A preliminary report is a written or verbal report released before being signed by the physician responsible for giving the final interpretation. Refer to "Nonroutine Reporting" in the AIUM Practice Guideline for Documentation of an Ultrasound Examination: http://www.aium.org/resources/guidelines/documentation.pdf

If an interpreting physician is not immediately available at the time an ultrasound examination is being performed:

POLICIES AND PROCEDURES SAFEGUARDING PATIENTS, ULTRASOUND PERSONNEL, AND EQUIPMENT

Patient Identification

Patients must be identified by 2 separate identifiers before a study is performed: for example, name, date of birth, address, or medical record number.

Precautions for Invasive Procedures

Time-outs

Specimens

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. http://www.aium.org/officialStatements/57

ALARA PRINCIPLE

Personnel must be familiar with and show evidence of practicing the ALARA (as low as reasonably achievable) principle. Medical Ultrasound Safety can be purchased at the AIUM Online Store. Refer to the official statement: http://www.aium.org/officialStatements/39; and the Journal of Ultrasound in Medicine article on biosafety: http://www.jultrasoundmed.org/content/28/2/139.full

QUALITY ASSURANCE

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

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 QA guidelines specified in Routine Quality Assurance for Diagnostic Ultrasound Equipment.



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