CE Credits for MQSA Inspection
A Mammography Quality Standard Act (MQSA) inspection is an annual affair where the inspectors who are certified under MQSA evaluate the mammography facility. The assessment is based on the standards set under the act for facilities to provide proper patient care. The inspector informs the facility well in advance about the inspection date for the facility to adjust its schedule accordingly.
The evaluation covers everything present in the facility, such as the equipment, services, patient care, certification, and CE scores of the professionals working there. Every professional working there should have an active license which complies with the latest ARRT guidelines. This article will discuss how credits can help a facility pass the MQSA evaluation.
MQSA evaluation inspectors follow guidelines, which were first implemented in 1999, and have evolved somewhat since then. The main aim of conducting this annual inspection is to maintain mammography quality around America and provide the best quality services to patients. The guidelines mentioned in the Act have an elongated description of the facility and requirements of credits for the personnel working there.
The following are some points you can use to prepare yourself for the inspection. Suppose the facility does not comply with the guidelines and quality standards set by the MQSA. In that case, the license will nullify and the facility will no longer be able to perform mammograms. The inspectors may also ban them from providing any service to the patients.
The facilities to undergo an evaluation need to have the following:
- Every person should meet the quality standard set by the MQSA
- The radiation dose should be under the permissible limit only
- The facility should have an accreditation certificate
- FDA authorizes agencies to certify such facilities.
- You should have a certification from the FDA to perform mammograms
- The facilities should display the certificate to where it is visible to mammography patients
It is necessary for facilities to update the inspection certificate. They should undergo MQSA inspection and evaluations by an authorized physicist to maintain their certification. The facilities should take all the corrective actions when the inspectors point out a mistake.
Preparing for the evaluation
The annual evaluation is not only to assess the mammography units and their quality, but it also evaluates medical records, personnel, customer handling, and medical audits. Below are the mentioned requirements of different departments during the MQSA assessment.
Requirements for personnel:
- Every worker should have a current license
- Should have 15 mammography credits within 36 months from the date of starting their individual practice as a mammography tech
- Interpreting Physicians should have interpreted 960 exams in 24 months
- Radiologic Technologists should have performed 200 exams in the immediate 24 months before the inspection
- Medical Physicists should have surveyed 6 units and 2 facilities in 24 months
- Documentation of all the personnel present in the facility should be available
Mammography continuing education is important for MQSA inspection because the standard set of MQSA suggests that all professional workers should have the latest knowledge and updated skillset to provide quality services to patients. Once a person has satisfied all the requirements to conduct mammography on a patient, he has a timeline of 36 months to complete the continuing education requirements. Of the total 15 continuing education units, 6 must be in each of the mammography modalities used by technologists. Technologists can earn these credits through teaching and attending courses.
Mammography Equipment Check
Likewise, the medical equipment evaluation assesses all the mammography units used in the facility. Each evaluation process takes about 20 minutes to inspect the images and the work of the unit. It also includes checking the major parts of the unit for any replacement. Any new equipment added to the facility should pass a mammography equipment evaluation conducted by a qualified medical physicist. A medical physicist must run the equipment evaluation after disassembling or reassembling it. He should document the problems found and corrective measures taken. The documentation of all the changes made, along with the corrective actions, should be provided to the facility before the equipment is put to use.
The inspector inspects the medical records to assess the language used by the staff to communicate the results to the patients. It is suggested to prepare a document consisting of how the concerned team communicates results to the patients. In addition, the inspector is keen on knowing about workers’ actions to correct poor clinical image quality.
How should a Facility plan the evaluation day?
The facility is informed well in advance about the evaluation day and time. The MQSA has set this to avoid any inconvenience to the mammography patients on that day. The facility should schedule their mammography patients in a way that keeps one unit free at a time for the MQSA inspection to evaluate. Each unit takes around 20 minutes for evaluation. Ensure that one person is available from the facility to answer and attend to the inspector when he has any query or needs any additional information.
If the state you operate in also conducts state-level inspections, you should be informed about them and make your arrangements accordingly. The state inspection may need additional information and requirements.
It is suggested to prepare a documented file well in advance covering each aspect. Keeping the documented copy ready will save time and energy for both the inspector and the facility. This is a great way to showcase that the facility is maintained, has all the records, and operates under set standards. An absence of accurate information will lead to imparting a negative image to the inspector about the facility.
Exit Interview Round in Evaluation
The final round of evaluation is the exit interview, where the inspector questions all the persons present at the facility. The inspector may choose to summarize the results during the exit interview and provide a copy, or send the results via email within two weeks. If the inspector finds any issue during the inspection, the facility will receive a letter addressed to the authorized person mentioning all the deficiencies found and a timeline to take corrective actions.
The workers and equipment of the facility should meet the standards of the MQSA assessment. Workers need to earn continuing education credits per their position, and they have 36 months to earn the continuing education credits after starting their mammography practice individually. If the technologists fail to earn credits within the time period, then it may result in the dismissal of a practicing license. The MQSA evaluation ensures the well-functioning of the facility, which results in improved patient care.