Standards and Guidelines for the Accreditation of Ultrasound Practices

Purpose

• Abdominal/General Ultrasound
• Contrast-Enhanced 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 - Peripheral Nerve
• Musculoskeletal - US-Guided Interventional Procedures
• Point-of-Care Ultrasound
• Reproductive Endocrinology & Infertility (with or without Adjunct Competence in 3D)
• Standard Obstetric Ultrasound (all 3 trimesters)
• Trimester-Specific OB Ultrasound (a single trimester/combination of any 2 trimesters)
• Detailed Second Trimester OB Ultrasound (CPT 76811)
• Detailed First Trimester OB Ultrasound
• 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.

• The Director of Ultrasound must be a licensed medical provider who meets the AIUM training guidelines specific to their scope of practice.
• The Director of Ultrasound is responsible for:
• All correspondence with the accreditation department and must sign all accreditation-related documents.  
• Overseeing the quality and appropriateness of ultrasound operations of the practice, including ensuring that appropriate clinical services are provided and that support services are available.
• Delegating specific operations to associates and sonographers.
• Attesting that the practice continues to follow requirements listed in The Manual for Ultrasound Practice Accreditation. 

Interpreting Providers (Full Time, Part Time, Locums)

AIUM Training Guidelines:

• Training Guidelines for Physicians Who Perform and/or Interpret Diagnostic Ultrasound Examinations
• Training Guidelines for Licensed Medical Providers Who Perform and Interpret Ultrasound-Guided Procedures
• Training Guidelines for Licensed Medical Providers (PA, NP, CNM/CM, DPT, and DC) Who Perform and/or Interpret Diagnostic Ultrasound Examinations

At reaccreditation, all interpreting providers must meet the following requirements:  

• Documentation of required CME credits and procedural volume.
• CME
• CME must be AMA PRA Category 1 Credits^TM or AOA Category 1A Credits specific to the ultrasound studies performed.
• Providers interpreting in multiple specialties must have a representative sample of credits in each specialty for which reaccreditation is sought.
• Procedural Volume
• Providers must meet yearly procedural volume for the accreditation specialty being sought. These may be found in the AIUM Training Guidelines listed above.

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 all practices accredited by the AIUM, the final report must be signed and available to the clinicians within two business days.

For additional information, review the AIUM Practice Parameter for Documentation of an Ultrasound Examination.

POLICIES AND PROCEDURES SAFEGUARDING PATIENTS, ULTRASOUND PERSONNEL, AND EQUIPMENT

Policies must be readily available for review and must comply with all local, state, and federal regulations as applicable.

Policies covering the areas listed below 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 clinician must take steps to verify the correct patient, correct procedure, and correct location.
• If specimens are collected, the clinician must ensure that each specimen is correctly labeled and that the personnel responsible for labeling and hand-off of the specimen are clearly identified, and the required steps for transferring the specimen are followed. 

Incident Reporting

A policy/procedure must exist for responding to and reporting any incidents, 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

All clinicians performing and interpreting the ultrasound examinations must be thoroughly familiar with and consistently demonstrate adherence to ALARA (as low as reasonably achievable) principle. Refer to the ALARA official statement.

Quality Assurance Program

• The practice must show ongoing monitoring of all ultrasound personnel. Including physicians, non-physicians, and sonographers, through regular, retrospective, performance reviews. Written documentation of these reviews should be maintained to verify ongoing quality and compliance with established standards. AIUM Personnel Performance Quality Assurance.

• The ultrasound equipment must comply with all state and federal guidelines, be kept in optimal operating condition and undergo documented quality assurance testing at least annually, or more frequently if issues arise.
• Machine maintenance 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.

On-site, Remote, or Virtual Audit

The AIUM may, with notice, conduct an on-site, remote, or virtual audit of the “practice” to assess quality measures, including case and image review, assess equipment maintenance, and adherence to safety protocols. The inspection date and time will be mutually agreed upon. If the AIUM, in its sole discretion, deems an on-site audit necessary, the ‘practice’ must accommodate the request.

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 media and adhere to the AIUM Practice Parameter for Documentation of an Ultrasound Examination.