Our radiology practice consists of several separately certified mammographic facilities. Is it permissible to combine our medical outcomes audit for all our facilities, or must it be broken down for each facility?
The regulations require that each certified facility establish a system to perform a medical outcomes audit analysis for that facility. The mechanics of data collection and analysis do not have to be performed by the individual facility, but may be accomplished by combining the resources of several facilities, pathology registries, or other sources. However, the medical outcomes analysis must be facility specific and must be analyzed (both individually and collectively) for all interpreting physicians at that facility. If physicians read at more than one facility, they may find it beneficial to collectively analyze the data for all the facilities where the physicians interpret. However, this global analysis would not satisfy the requirement that the analysis be facility specific. Note: Under the conditions specified by an approved alternative standard, certain mobile facilities may combine their medical audits and can be exempt from the facility specific requirement. (approved alternative standard)