Section 370.130  Mammography Medical Outcomes Audit

Each facility shall establish and maintain a mammography medical outcomes audit program to follow up positive mammographic assessments and to correlate pathology results with the interpreting physician's findings.  This program shall be designed to ensure the reliability, clarity and accuracy of the interpretation of mammograms.

a)         General requirements.  Each facility shall establish a system to collect and review outcome data for all mammograms performed, including followup on the disposition of all positive mammograms and correlation of pathology results with the interpreting physician's mammography report.  Analysis of these outcome data shall be made individually and collectively for all interpreting physicians at the facility.  In addition, any cases of breast cancer among patients imaged at the facility that subsequently become known to the facility shall prompt the facility to initiate followup on surgical and/or pathology results and review of the mammograms taken prior to the diagnosis of a malignancy.

b)         Frequency of audit analysis.  The facility's first audit analysis shall be initiated no later than 12 months after the date the facility becomes certified.  This audit analysis shall be completed within an additional 12 months to permit completion of diagnostic procedures and data collection.  Subsequent audit analyses will be conducted at least once every 12 months.

c)         Audit interpreting physician.  Each facility shall designate at least one interpreting physician to review the medical outcomes audit data at least once every 12 months.  This individual shall record the dates of the audit periods and shall be responsible for analyzing results based on this audit.  This individual shall also be responsible for documenting the results, notifying other interpreting physicians of their results and the facility aggregate results.  If followup actions are taken, the audit interpreting physician shall also be responsible for documenting the nature of the followup.

(Source:  Amended at 29 Ill. Reg. 20963, effective December 16, 2005)