Presentation on theme: "Accreditation Elements"— Presentation transcript:
1 Accreditation Elements Establishing and Maintaining AccreditationComparing ACR and IAC
2 Objectives Briefly describe ACR and IAC Accreditation processes. List basic requirements of ACR and IAC Accreditation.List key comparisons and contrasts between ACR and IAC Accreditation.
3 The importance of Accreditation Accreditation shows a commitment to quality care to payers, regulatory agencies, physicians, and patients.Accreditation is a sign to patients that the practice has taken steps to provide the highest quality health care available.Accreditation can be a powerful tool in the recruiting of the best and brightest physicians, technologists and sonographers.Accreditation at the present time is a voluntary process, however Medicare and other payers in the United States have enacted reimbursement legislation that adversely effect practices that are not Accredited.Medicare Improvements for Patients and Providers Act of 2008 – Bill requires that by 2012, providers of advanced diagnostic imaging services, inclusive of Nuclear Medicine, MR, CT, and PET, must obtain accreditation as a condition of reimbursement.
4 Medicare Improvements for Patients and Providers Act The portion of the legislation requiring accreditation stipulates that the accreditation programs must evaluate that physicians and staff maintain the proper level of training and education; that laboratories use imaging equipment which adheres to strict standards of performance and operates under proper safety guidelines; and that all laboratories establish and maintain a quality assurance program, thereby upholding the standards of quality care for patients, particularly senior citizens.This powerful legislation (which was just ratified by the house and senate) includes a provision requiring the accreditation of imaging facilities as well as the elimination of a scheduled 10.6% payment cut for physicians.
5 IAC – Intersocietal Accreditation Commission (consisting of four bodies). ICVL – Intersocietal Commission for the Accreditation of Vascular Laboratories.ICANL – Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories.ICAEL - I Intersocietal Commission for the Accreditation of Echocardiography Laboratories.ICACTL - Intersocietal Commission for the Accreditation of Computer Tomography Laboratories.
6 IACFounded in 1990IAC was created by uniting physicians, technologist, and sonographers from the sponsoring organizations (Intersocietal approach).
7 ACR (American College of Radiology) Ultrasound –Includes all modalities (Gen, OB, OB (trimester specific), GYN, and Vascular.Breast UltrasoundMammographyComputer TomographyMagnetic Resonance Imaging (MRI)Stereotactic Breast BiopsyRadiation OncologyNuclear Medicine and PETThe Diagnostic Modality Accreditation Program (DMAP) incorporates all the ACR accreditation programs (except mammography and radiation oncology) under one application process.
8 ACR Ultrasound Program founded in 1995 Membership organization – 34,000 members includes radiologist, radiology oncologist, medical physicists, interventional radiologist, and nuclear medicine physicians.
9 Process Overview IACDownload and review the “Standards” (guidelines and requirements)Make necessary modifications for complianceComplete online application- Accreditation components: Extracranial Cerebrovascular, Intracranial Cerebrovascular, Peripheral Arterial, Peripheral Venous, Visceral, and screening.- Deadlines: Applications Will Now Be Accepted At Any Time Throughout The Year
10 IAC Accreditation Application - IAC Submit Online Accreditation Agreement- Application Fee- Attachments (organizational chart, personnel certifications/licenses, ACLS or BLS cards, NRC license/State registration and inspection reports, specific policies and protocols, case studies)Internal review by IAC application processorApplication review: Medical and Technical Director confirming completeness or requesting more data
11 IAC On site or audit request - Site Visit: Random selection of statistically significant number of labs each quarter- Paper Audit: Notified by “Certified mail”Board review and decision- Grant Accreditation (3 years)- Provisional Grant (1 year)- Delay- DeniedNotified by mail when to reapply
12 IAC Fee Schedule Application Fees - $1500 includes base fees and one testing area- $300 for each additional testing area over one- $750 for each additional site area over one- $200 for each mobile unit
13 Process Overview ACRThe online application contains three separate sections.• Section 1 collects demographic, contact and general modality information for the overall practice site location. It also involves the completion of a legal agreement that may be completed using electronic signatures (if available) or by faxing it to the ACR. Instructions will be provided during the application process. All of section 1 must be completed before section 2 will become available.• Section 2 collects modality-specific contact, unit and exam selection information. All of section 2 must be completed before section 3 will become available.• Section 3 collects personnel and payment information for the application. If multiple practice sites apply under the same user’s account using the online application, they will be able to share their personnel list. For example, facility 1 applied for accreditation using the online application and entered all of their personnel. If facility 2 is entered under the same user’s account, facility 2 will have the option to select their personnel from the list that is already on file and/or to enter additional personnel. This eliminates the need to enter the same personnel more than one time. Once personnel and payment information are entered, the application is ready to submit to the ACR for processing.
14 ACR ACR review of initial application Laboratory receives testing materialsSites have 45 days to complete testing materials phase.– Lab submits: Clinical Images and Protocols/Test Image Data sheets; Phantom images/Site scanning data form; Physicist Report (for each unit); Quality assurance questionnaire; Quality Control Form; NRC and/or State inspectionClinical and Phantom Images reviewed and scoredPass/Fail determined
15 Application Fees ACR $1200 OB antepartum ultrasound, only $1200 Trimester Specific Obstetrical, only$1200 Gynecological ultrasound, only$1200 General ultrasound, only$1200 Vascular only$1400 Combination accreditation (two types)$1500 Combination accreditation (three types)
16 Personnel Qualifications IAC Medical DirectorThe Medical Director is responsible for all clinical services providedand for the determination of the quality and appropriateness of careprovided.The Medical Director supervises the entire operation of the laboratory or may delegate specific operations to appropriate laboratory or administrative staff.The Medical Director is responsible for the approval of medical staffand the supervision of their work.The Medical Director is responsible for maintaining and assuringcompliance of the medical and technical staff to the “standards”.
17 Medical Director IACThe medical director must be a licensed physician and qualified to interpret studies.The medical director must demonstrate an appropriate level of training and experience by meeting one or more of the following:Formal Training Program – Completion of a residency or fellowship that includes appropriate didactic and clinical vascular laboratory experience as an integral part of the program.Informal training - Appropriate training and experience for proper qualifications to interpret noninvasive vascular laboratory studies can be achieved through formal accredited post-graduate education. A minimum of 40 hours of relevant Category I CME credit must be acquired within the three-year period prior to the initial application.Established practice – Training and experience will be consideredappropriate for a physician who has worked in a vascular laboratory for at least three years and has interpreted more than 300 diagnostic studies in the specific areas.Registered Physician In Vascular Interpretation – A physician has successfully obtained the ARDMS RPVI credential or ASN neurosonology certificate for extracranial and/or intracranial test interpretation.
18 Medical Staff IACThe medical staff interprets and/or performs clinical studies in accord with privileges approved by the Medical Director and in compliance with the standards outlined in the “standards”.Qualification: Same as Medical Director
19 Technical Director IAC A qualified Technical Director must be designated for the facility.The Technical Director reports directly to the Medical Director.Responsibilities include, but are not limited to, and may be delegated to other staff:All laboratory duties delegated by the Medical DirectorSupervision of the technical and ancillary staffDaily technical operation of the laboratory (e.g., staff scheduling,patient scheduling, laboratory record keeping, etc.)Operation and maintenance of laboratory equipmentThe compliance of the technical and ancillary staff to theStandards.Quality patient careTechnical training
20 Technical Director IAC The Technical Director must have an appropriate credential in vascular testing. Appropriate credentials include: Registered Vascular Technologist (RVT); Registered Vascular Specialist (RVS); Registered Technologist Vascular Sonography [RT(VS)]; for physician Technical Directors performing only Extracranial and/or Intracranial testing, the American Society of Neuroimaging’s certificate in Neurosonology.
21 Technical StaffThe technical staff must demonstrate an appropriate level of training and experience by meeting one or more criteria.- Credential in vascular testing Appropriate credentials include: Registered Vascular Technologist (RVT); Registered Vascular Specialist (RVS); Registered Technologist Vascular Sonography [RT(VS)]; if applying for visceral vascular only Registered Diagnostic Medical Sonographer in Abdomen [RDMS (AB)].- Formal Ultrasound training: Successful completion of an ultrasound, vascular technology or cardiovascular technology program that includes verified didactic and supervised clinical experience in vascular testing. The program should be accredited by either the Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS), the Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT), or the Canadian Medical Association (CMA).- Post secondary education plus experience: 12 months full time (at least 35 hours/week) clinical vascular testing experience plus one of the following:1) Completion of a formal two-year program or equivalent inanother allied health profession2) Completion of a bachelor’s degree unrelated to vasculartechnology3) A MD or DO degree- Experience only: A minimum of 12 months of vascular testing experience with the performance of at least 600 noninvasive vascular examinations under the supervision of medical or technical staff who meet the above criteria. The noninvasive vascular examinations performed by these technical staff membersmust be appropriately distributed among the testing areas performed within the laboratory.
22 Physician Qualifications ACR Radiologist/Physicians must initially meet one of four qualifications.A. Completion of an approved residency program including three months of training supervised by qualified individuals, and involvement with 500 ultrasound examinations, including a broad spectrum of uses. The physician should have passed written and oral board certification examinations, including sections related to diagnostic ultrasoundB. If residency did not include ultrasound, the physician must have had appropriate fellowship or post graduate training supervised by a qualified physician.C. Physicians trained prior to 1982 must have performed and interpreted ultrasound examinations for at least 10 years.D. Physicians without formal fellowship or postgraduate training must have two years of ultrasound experience in which 500 exams must have been performed or supervised and interpreted. They must show documentation and show a history of a quality assurance program.
23 Ultrasound Technologist ACR Certified or eligible for certification by:American Registry of Diagnostic Medical Sonographers (ARDMS), or American Registry of Radiologic Technologists, Sonography (ARRT) (S).• All sonographers must be certified and currently registered as RDMS (OB or AB), RT(S), RT (VS), RVT, or RVS at the time of application for renewal of accreditation. (All sonographers should obtain certification within twenty-four months of eligibility or cross training.)**Sites applying for Vascular Ultrasound Accreditation must have at least one technologist who has an RVT (Registered Vascular Technologist) by the ARDMS, a Vascular Sonographer (VS) by the ARRT, or as a Registered Vascular Specialist (RVS) (also known as RCVT) by Cardiovascular Credentialing International (CCI) credential working on-site during the performance of vascular examinations.
24 Policies and Protocols IAC Protocols should meet that “standards”They should be written, detailed, lab-specific policies and protocols- Clinical Procedures- Equipment Quality Control- Required Documentation of Examination- Diagnostic Criteria and interpretation- The indication for testing must be documented- Correlation and Confirmation of ResultsRequired policies and protocols will be reviewed for compliance with Standards.Missing protocols and detail (reporting) – common problem areas
25 Policies and Protocols ACR All sites initially applying for ACR accreditation and all sites renewing their accreditation must actively participate in a physician peer review program that performs the following functions:• Includes a double reading (2 MDs interpreting the same study) assessment.• Allows for random selection of studies to be reviewed on a regularly scheduled basis.• Exams and procedures representative of the actual clinical practice of each physician.• Reviewer assessment of the agreement of the original report with subsequent review (or with surgical or pathological findings).• A classification of peer review findings with regard to level of quality concerns (One example is a 4 point scoring scale).• Policies and procedures for action to be taken on significant discrepant peer review findings for the purpose of achieving quality outcomes improvement.• Summary statistics and comparisons generated for each physician by imaging modality.• Summary data for each facility/practice by modality.There are several options available to meet this requirement. Sites may develop their own peer review program, use a vendor product or RADPEER, a peer review process developed by the ACR.Clinical ImagesVascular Exam Diagnostic CriteriaReporting of ResultsVery limited number of case studies
26 Equipment Quality Control IAC Instrumentation used for diagnostic testing must be maintained in good operating condition.The accuracy of the data collected by ultrasound instruments is paramount in the interpretation and diagnostic utilization of the information collected.Required CharacteristicsGuidelines for equipment maintenance include, but are not limited to, thefollowing:Recording of the method and frequency of maintenance of ultrasoundinstrumentation and non-imaging equipment.Establishment of and adherence to a policy regarding routine safety inspections and testing of all laboratory electrical equipment.You are required to document proper maintenance including calibration of equipment semi-annually, however the facility does not have to submit reports with application.The reports can be audited as part of the review process.
27 Equipment Quality Control ACR Continuous Quality ControlRoutine quality control testing must occur regularly; a minimum requirement is semiannually. The same tests must be performed during each testing period so that changes can be monitored over time and effective corrective action can be taken. Testing results, corrective action, and the effects of corrective action must be documented and the documentation maintained on site. In the event of a site survey, reviewers will expect to see such documentation.The QC program must evaluate at least the following items in gray-scale imaging mode:System sensitivity and/or penetration capability.Image uniformity.Assurance of electrical and mechanical safety and cleanlinessPhotography and other hard-copy recording.QC Data to be Submitted for AccreditationFor each unit, submit a copy of your most recent physicist’s or service engineer’s report. The QC report should document results of the QC testing.
28 Quality Assurance IACThere must be a written policy regarding quality assurance for all procedures performed in the laboratory.Regular Ongoing quality assurance must be performed for all areas ofvascular testing performed by the laboratory as outlined in the standardsspecific to that area.A minimum of two vascular laboratory quality assurance conferences peryear must be held to review the results of comparative studies, addressdiscrepancies and to discuss difficult cases and laboratory issues and minutesmaintained.Quality controls for studies is done by correlation according to the standards for each area of testing. A minimum of 30 correlations must be done for each modality.
29 Quality Assurance ACRAll sites initially applying for ACR accreditation and all sites renewing their accreditation must actively participate in a physician peer review program that performs the following functions:• Includes a double reading (2 MDs interpreting the same study) assessment.• Allows for random selection of studies to be reviewed on a regularly scheduled basis.• Exams and procedures representative of the actual clinical practice of each physician.• Reviewer assessment of the agreement of the original report with subsequent review (or with surgical or pathological findings).• A classification of peer review findings with regard to level of quality concerns (One example is a 4-point scoring scale).• Policies and procedures for action to be taken on significant discrepant peer review findings for the purpose of achieving quality outcomes improvement.• Summary statistics and comparisons generated for each physician by imaging modality.• Summary data for each facility/practice by modality.
30 Case Studies IACExtensive case studies with contemporary staff to include multiple abnormal and one normal exam for each modality. Example:Extracranial Cerebrovascular: Normal, 1-20%, 21-49%, 50-69%, 70-99%, and one showing Occlusion.Case studies must adhere to the “Standards”.It is preferred to submit case studies with matching correlation data.
31 Case Studies ACRFor Vascular one exam (normal and abnormal) from each category performed at the site: Peripheral, Cerebrovascular, Abdominal, and/or deep abdominal.OB - there should be 1 first trimester, 2 second trimester and 1 third trimester.Trimester specific OB - as many as four case studies must be submitted with two of these being transvaginal.GYN – three endovaginal and one transabdominal even if female pelvis is selected on the GEN application.GEN – One complete upper abdominal exam. Three different exams from either: Female pelvis, Renal/Urinary, Transrectal/prostate, Pediatric neurosonology, or small parts.In regards to the ultrasound case studies outside of vascular normal and abnormal are not required. These studies are supposed to be the facilities best studies.Does not require representative staff and the vascular criteria is far less stringent.
32 Comparisons Qualified Personnel (similar qualifications) Interpreting physicians are encouraged to be authorized usersRegular schedule of Quality Control proceduresRandom site visitsOpportunity to correct deficienciesThree year Accreditation
33 Contrasts IAC ACR No application deadline Organizational structure (IAC Medical and Technical Director)Policy and protocol format and review: site specific, guidelines that adhere to the “StandardsIntersocietal approach (representative of many organizations including technologist, physician, surgeons, radiologist, and sonographers), allowing for a comprehensive evaluation of testing in each modality.Case studies – Comprehensive case studies that must adhere to the standards and be representative of staff.Final report format (required components and templates for IAC).Quality assurance: Is focused on correlation of exams to gold standards. Not focused on peer review as laboratories have to have exams read under laboratory specific criteria.Accreditation for Vascular Lab only.Recognized as the highest level of accreditation for Vascular Laboratories.Clinical data is due within 45 days of submission of online applicationPhysician lead, no organizational structureOrganizational approach: Member driven: radiologist, radiology oncologist, medical physicists, interventional radiologist, and nuclear medicine physicians.Quality assurance: Is more focused on interpretation not correlation.Accreditation for General, OB, GYN, Vascular, and Small parts.DMAP – The ability to have accreditation of all modalities except mammography and radiation Oncology under one application.
34 Which Path?There are many similarities and differences between IAC and ACR accreditation. IAC accreditation is the higher of the two standards; is held in a much higher regard; and will increase the ability of your organization. ACR is a minimum standard accreditation in regard to modalities outside of conventional radiology modalities (Vascular, Cardiac, CT and Nuclear Medicine). In these areas ACR accreditation is viewed as less than the standard. Whichever path you choose to take will impact the clinical quality of an organization and the quality of patient care.