| Categories: MRI Accreditation | Author: Resonant Healthcare Imaging Solutions | 0
For many medical professionals, “audit” can be a scary word. However, with proper preparation and the right plan in place, your facility can pass an onsite MRI accreditation audit with flying colors.
During the MRI accreditation process, your facility had to demonstrate that it was compliant with the standards established by the accreditation organization. Now that your facility has obtained its MRI accreditation, it is your facility’s job to maintain compliance with those standards during the three-year accreditation period. One of the main ways that accreditation organizations ensure ongoing compliance is through random onsite audits.
Onsite audits typically are conducted by a team of board-certified radiologists and medical physicists.
Facilities are typically chosen at random for onsite MRI accreditation audits. However, MRI accreditation organizations reserve the right to conduct unannounced site visits at any time. Depending on your accreditation organization, you may or may not receive advanced notification if your facility is selected for a site audit. Your auditors will tour your facility, interview key team members, and verify that the information submitted in your facility’s application is still accurate. They also will review:
The best preparation for an onsite MRI accreditation audit begins immediately after you are notified that your facility received its MRI accreditation. Many facilities choose to continue to work with their MRI accreditation consultant / coordinator to develop an audit readiness plan right away, which should address the following key areas:
1. Record-keeping
Your facility should keep records of quality control tests, performance improvement activities, and other mandatory actions onsite in an easily accessible place. Several key staff members should have access to these records. According to the Intersocietal Accreditation Commission’s (IAC) website, the following documentation may be requested during your facility’s audit:
Because it can be easy to lose track of documents and emails when things get busy, your MRI accreditation consultant / coordinator will work with your staff to develop a record-keeping system that will help your facility meet all audit requirements.
2. Safety
You need to make sure your facility’s MRI system and environment adhere to the safety standards set by your accreditation organization and will pass all safety tests. Your facility should have records of all weekly, quarterly, annual, and ongoing safety-related activities.
Your MRI accreditation coordinator / consultant will help you determine the frequency and type of safety activities your facility needs to perform and will work with you to develop appropriate safety policies and procedures. Whether your facility is audited or not, it is important to stay vigilant to ensure that all safety policies and procedures are followed. Also, it never hurts to stress the importance of safety with staff whenever possible.
3. Policies & Procedures
Your facility should have a well-organized file that includes up-to-date copies of all relevant MRI policies and procedures. If your facility receives notice from your accreditation organization about changes to the MRI accreditation standards, it is your facility’s responsibility to implement the changes by the effective date and update your policies accordingly. Your MRI accreditation consultant / coordinator can help your facility determine the best, most efficient way to implement changes and update policies and procedures, as needed.
4. Personnel
You should be sure to keep up-to-date copies of all licenses and credential cards for your MRI personnel, and you should be sure that your staff members keep their required licenses and credentials current. You also should be sure that each MRI team member has an up-to-date training record that shows they have taken the required amount of continuing medical education credits.
Although this information likely is included in each team member’s personnel file, it is a good idea to make a second copy and keep it in a “MRI audit file” for easier access. Your MRI accreditation consultant / coordinator can help your facility to organize this information and develop a credentialing and continuing education policy that meets all accreditation requirements.
If you’ve taken the right steps to prepare, you and your staff will be able to avoid panic and participate in your facility’s onsite MRI accreditation audit with confidence. If you have questions about onsite MRI accreditation audits or need help creating an audit readiness program, our MRI accreditation specialists are here for you. For more information or to speak with a Resonant expert, contact us.
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