Standards and Guidelines for the Accreditation of Ultrasound Practices

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 represent an overview of 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 set requirements for safety, maintenance and calibration of equipment, staff performance, reports, record keeping, and quality assurance (QA) for clinical practices where studies are performed.

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.

Accreditation is offered in the following specialties:

  • Abdominal/General Ultrasound
  • Breast Ultrasound (diagnostic only, or diagnostic and interventional; accreditation may not be sought in interventional breast only)
  • Female Pelvic Floor (Urogynecology)
  • Fetal Echocardiography
  • Gynecologic (with or without Adjunct Competence in 3D)
  • Musculoskeletal - Diagnostic
  • Musculoskeletal - US-Guided Interventional Procedures
  • Point-of-Care Ultrasound
  • Reproductive Endocrinology & Infertility (with or without Adjunct Competence in 3D)
  • Standard Obstetric Ultrasound (all trimesters or "trimester-specific": a single trimester/combination of any 2 trimesters)
  • Standard Obstetric with an Adjunct in Detailed Fetal Anatomic Ultrasound Examination (CPT 76811)
  • Limited Obstetric Ultrasound (for Advanced Clinical Providers)
  • Thyroid, Parathyroid, and Neck
  • Ultrasound-Guided Regional Anesthesia
  • Urologic Ultrasound

 

ULTRASOUND PRACTICE PERSONNEL


Director of Ultrasound

The practice must designate a director of ultrasound, who is responsible for all correspondence with the accreditation department and must sign all required accreditation correspondence. The director of ultrasound must be a licensed medical provider who meets the training guidelines in the specific area of sonography. The director of ultrasound is responsible for overseeing the quality and appropriateness of ultrasound operations of the practice. This includes ensuring that appropriate clinical services are provided and that support services are sufficient, and for attesting that the practice continues to follow requirements in The Manual for Ultrasound Practice Accreditation. The director of ultrasound may supervise the entire operation of the facility or may delegate specific operations to associates and sonographers.

Interpreting Providers

Ultrasound studies must be supervised and interpreted by a licensed medical provider with training and experience in the specific area of sonography and meet the following requirements:

  • They must have a current state license.
  • They must meet the AIUM Training Guidelines linked below in the specific area of sonography for which they perform and/or interpret diagnostic ultrasound examinations.
    • CME must be AMA PRA Category 1 Credits™ or AOA Category 1A Credits specific to ultrasound unless otherwise specified.
    • If interpreting in multiple specialties, a representative sample of CME credits must be obtained in specialties for which they are applying.

AIUM Training Guidelines:

At reaccreditation, all interpreting providers who were on the previous application must have documentation of the appropriate number of CME and procedure volume requirements. CME credits must be AMA PRA Category 1 and in the ultrasound specialty area that the interpreting provider has designated for the practice. Providers 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. Following initial accreditation, each year, 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.

Non-Physicians Including Sonographers

Non-physician practitioners who perform ultrasound examinations and sonographers will be responsible for those tasks specified by the physician director of ultrasound.

Non-physician practitioners must have appropriate training and meet the training guidelines for the performance of the ultrasound examinations they perform or be certified by one of the organizations listed below and in each specialty in which they perform ultrasound evaluations (one per cycle if multiple is required).

All sonographers must be certified by one of the organizations listed below and in each specialty in which they perform ultrasound evaluations (one per cycle if multiple is required).

The following certifications are acceptable for sonographers:

 

FINAL REPORTS


Final reports (separate from other clinical notes) must meet the requirements specified in the AIUM Practice Parameter for Documentation of an Ultrasound Examination. If a preliminary report, either written or verbal, is released this should be documented on the final report and any discrepancies noted. For additional information review the AIUM Practice Parameter for Documentation of an Ultrasound ExaminationFor all practices accredited by AIUM, the final report must be signed and available to the relevant clinicians within two business days or as dictated by local policy (documentation required if local policy is longer than 2 business days).

 

POLICIES AND PROCEDURES SAFEGUARDING PATIENTS, ULTRASOUND PERSONNEL, AND EQUIPMENT


Policies must be available for review and in compliance with all local, state, and federal regulations as applicable. Policies for the following area are recommended and may be reviewed at the time of application for Accreditation and Re-accreditation:

  • Patient identification
  • Time-out for invasive procedures
  • Specimen handling
  • Incident reporting
  • Patient confidentiality
  • Infection prevention
  • Ultrasound safety
  • Ergonomics
  • Quality assurance and improvement for personnel and equipment

 

Invasive Procedures

Before beginning an ultrasound-guided invasive procedure, the practice must take steps to verify the correct patient, correct procedure, and correct location. If specimens are collected, the practice must take steps to ensure that specimens are correctly labeled, personnel responsible is clearly defined, and the steps required to hand off each specimen are followed.

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. Refer to the ALARA official statement. Medical Ultrasound Safety can be purchased at the AIUM Online Store.

Quality Assurance Program

The practice must show ongoing monitoring of the clinical practice's ultrasound personnel performance, including all physicians and sonographers through regular, retrospective review. A record of quality assurance (QA) activities must be maintained and kept current. The ultrasound equipment must meet all state and federal guidelines and testing must be maintained in good operating condition and undergo routine quality assurance at least once a year or more frequently if problems arise and must meet or exceed the recommendations specified in Routine Quality Assurance of Clinical Ultrasound Equipment: Version 2.0.

Refer to The Manual for Ultrasound Practice Accreditation for further information on QA activities.

Document Storage and Record-Keeping Guidelines and Requirements

There must be provisions for the retrieval and storage of examination records of all studies performed. Appropriate documentation of every study must include permanent ultrasound images stored on suitable recording media and adhere to the AIUM Practice Parameter for Documentation of an Ultrasound Examination.

 


Approved: 03/13/2002; Reapproved: 11/10/2002, 11/13/2005, 11/14/2009, 03/27/2010, 12/17/2010, 11/05/2011, 04/02/2014, 11/02/2014, 10/31/2015, 06/16/2020

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