Middle East Federation of Middle East Federation of
Middle East Federation of Organization of Medical Physics
Middle East Federation of Organizations of Medical Physics

The role of medical physicist in the ACR accreditation for KFSHRC, Riyadh, KSA

MEFOMP is encouraging all hospitals and Medical Centres in our region to seek accreditation for their practices (in all the fields of medical physics such as Diagnostic Radiology, Nuclear Medicine and Radiotherapy). MEFOMP has started its own accreditation program for services providing quality control in Diagnostic Radiology.

Recently, the nuclear medicine section of King Faisal Specialist Hospital and Research Centre, Riyadh has applied for the American College of Radiology (ACR) accreditation and passed it. Based on our experience, the role of medical physicist (MP) in this accreditation process will be shown in this article.
ACR accreditation is recognized as the gold standard evaluation method in medical imaging. It is a self-assessment and peer review process focused on diagnostic image quality, staff qualifications, policies, protocols, equipment, and therapeutic treatment. This accreditation will allow facilities to improve the quality of patient care and to perform with high standards which will be reflected on the satisfaction of the referring physicians, patients and regulatory agencies. Imaging centres seek ACR accreditations to validate their work with peer review process and have their image quality assisted by experts. Also, this process will show their need for new equipment, continuing education or qualified personnel.
This article will show ACR requirements of reports, data to be acquired and data to be uploaded by the nuclear medicine Medical Physicist (MP) for the Gamma Camera only. 

Medical physicists to be authorized to conduct the survey, must meet one of these qualifications;

A- Board certified in nuclear medicine.
B- If not board certified, should meet all the following:
1- Hold a graduate degree (M.Sc. or Ph.D.) in relevant science or engineering discipline.
2- Had formal coursework in biological sciences.
3- Three years of documented experience in clinical nuclear medicine environment even if he/she board certified in another speciality.
C- Grandfathered; conducted surveys of at least 3 NM units between 2007 and 2010.
ACR requires acquiring the following images on annual bases:
1- Intrinsic (Tc-99m point source) or extrinsic (flood sheet) flood field uniformity test.
2- System spatial resolution test using the ACR SPECT phantom and Tc-99m activity if applying for SPECT, otherwise, use the 4 quadrant Bar phantom.
3- If applying for SPECT, SPECT study should be acquired using the ACR SPECT phantom injected with Tc-99m activity.
If the center is applying to accredit Ga-67/In-111 and/or Tl-201 clinical images, they should acquire the following:
4- For Ga-67 or In-111; acquire intrinsic flood field uniformity and intrinsic spatial resolution tests using point source at a distance as it is practical and more convenient.
5- Perform similar tests as in step 4, but using Tl-201 point source.
Details of these tests can be found in the "Phantom Testing: Nuclear Medicine" Article on ACR web site.
ACR requires that acceptance tests must be performed on systems when they are installed and should be completed before clinical use. To submit and finalize the application, the following should be uploaded in the ACR web site:

1- All the ACR required images, as listed and acquired in the previous points. Also filling the "phantom site scanning data" form on the website.
2- Most recent medical physicist annual survey report for each unit and filling it’s check list on the website.
3- Most recent dose calibrator report.

Also, the following should be filled in the website:
A. The gamma camera system information.
B. The most recent camera calibration files.
C. Checklist of the Technologist evaluation QC Program.
These are the most important points the medical physicists should be aware off.
Mr. Refaat AlMazrou, M.Sc., FIPEM
Chairman, Training and Education Committee, MEFOMP
Deputy Chairman, Biomedical Physics Department
King Faisal Specialist Hospital and Research Centre, Riyadh

September 13th 2020
mefomp reporter


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