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Massey Cancer Center is accredited by TJC and ACR.

Preparation for accreditation of

any of those bodies could be quite extensive and requires hard work from the hospital
management. The process of TJC accreditation involves fully understanding and complying to
the standards, processes, policies and procedures of the Joint Commission survey. The hospital
must be in compliance with the standards for at least 4 months prior to initial survey, as well as
in compliance with applicable standards during the entire period of accreditation.1 Massey
Cancer Center has been TJC accredited since 7/28/2012 and the last on-site survey was
performed on 9/1/2015.

ACR accreditation is somewhat flexible process with emphasis on image quality in

addition to equipment, quality control procedures, quality assurance programs, and personnel
qualifications.2 Just like the TJC accreditation, ACR accreditation involves a lot of work with a
long checklist. It is a voluntarily done process that evaluates hospitals personnel and assures that
each member is qualified to perform and interpret the medical images and administer the
radiation therapy treatments. In addition, ACR accreditation assures that the equipment is
working properly for the test or treatment patients will be receiving, and the facility meets
quality assurance and safety guidelines. During the ACR survey at Massey Cancer Center, the
surveyors toured the facility, verified the information submitted to them during the facilitys
application, and conducted an interview with the Chief/Medical Director of Radiation Oncology
department, as well as the chief physicist, department administrator, chief therapist, dosimetrist,
and nursing staff. They collected information about the facilitys patient treatment policies and
procedures, safety initiatives and reviewed some of the selected cases. After the radiation
oncologist and medical physicist answered any questions developed by the ACR and completed
all of the other important components of the survey process, the surveyors performed a brief exit

interview to clarify any issues prior to their departure. Post survey our facility received the
certificate of accreditation displayed below.

There are multiple benefits to become ACR and TJC accredited, such as being eligible to
receive reimbursement from Medicare, being able to utilize accreditation as a marketing tool,
provide a competitive edge in the marketplace, and provide education on good practices to
improve business operations, as well as enhance staff recruitment and development.
1. Lenards N. Operational Issues in Radiation Oncology: Accreditation: The Joint Commission.
[SoftChalk]. LaCrosse, WI: UW-L Medical Dosimetry Program; 2011.
2. Lenards N. Operational Issues in Radiation Oncology: Accreditation: ACR. [SoftChalk].

LaCrosse, WI: UW-L Medical Dosimetry Program; 2011.