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The Importance of Medical Physicists in ACR Accreditation

Charles (Chuck) Lazarre, MS, MBA, DABR

Accreditation by the American College of Radiology (ACR) is a voluntary and nationally recognized standard denoting a facility’s high level of image quality and patient safety. ACR Accreditation covers a range of medical imaging modalities, including CT, MRI, PET and Ultrasound. It is a rigorous process that involves the efforts of the entire imaging team. The medical physicist plays a major role throughout.

There are four main areas where the input of a qualified medical physicist is needed to ensure a successful outcome to the accreditation process and compliance throughout the three-year accreditation cycle.

Quality control direction. The ACR requires that all ACR accredited facilities and those applying for accreditation implement a documented quality control program with minimum frequencies established. The medical physicist assists with the implementation and evaluation of a continuous quality control program and should provide any necessary direction for corrective action for improving the quality control activities.

Preventive maintenance. While the equipment service team performs preventive maintenance, the medical physicist acts as another check to ensure that a repair or change to an imaging system component is completed and retested, when required.

Annual testing parameters. Medical physicists identify the individual testing parameters for imaging equipment by modality that must be performed to ensure that ACR accreditation standards are met. They also work with the facility to schedule a time for testing the specific ACR imaging equipment. Depending upon the modality testing parameters and availability of the imaging equipment, normal performance evaluations may require up to four hours.

LANDAUER has a qualified medical physics team capable of testing all modalities for ACR Accreditation

Imaging equipment safety and image quality. Medical physicists ensure that imaging equipment is safe for use by staff and for patients. They are responsible for the dosimetry part of the ACR’s required phantom submission for CT exams and assess image quality to ensure that it allows for the best image interpretation by the clinician.

Exporting phantom and patient images from PACS to the ACR accreditation software can be a daunting task. A LANDAUER medical physicist will help you work through the process and even discuss you exporting issues directly with the ACR, when necessary.


Most of the accreditation process takes place by mail and applicants have 45 days to complete requirements in the testing packet and submit. The ACR also conducts site visits without prior notification within the three-year accreditation period to ensure that accreditation criteria are maintained.

For ACR survey readiness, accredited facilities should have all the listed documentation required in the accreditation manual. This includes:

  • The staff, physicist and the interpreting physicians credentials 
  • Annual equipment performance evaluations
  • Quality control and any patient dose logs that must be maintained according to ACR standards 

The ACR has taken steps t ensure that the application process is as simple as possible, and they have staff available to answer all of an applicant's accreditation questions. Note that LANDAUER medical physicist consultants will work with a facility seeking accreditation for the firs time r renewal from the beginning of the accreditation process until all physics-related documentation is submitted to the ACR. 

To ensure that all of our clients are current, the LANDAUER Physics Compliance Team stays on top of all changes to standards, policies and regulations, and updates our Medical Physics team members who share those changes with our clients as they occur.