WHAT IS DELAYED ACCREDITATION?
After the review of a laboratory's accreditation
application, the Board of Directors renders an accreditation
decision. One of four decisions will be made: granted,
provisional grant, delayed, or denied.
A delayed decision means that there are significant issues,
deficiencies or lack of adherence to the ICANL Standards
that must be addressed by the laboratory before it can be granted
ICANL accreditation. A provisional grant bestows a one-year
accreditation in order to allow time to correct minor deficiencies,
such as less significant items missing from protocols, policies,
or reports, and/or deficient CME (first-time applicants only).
WHAT DELAY MEANS TO THE LAB SEEKING REACCREDITATION
All accredited laboratories receive a notification
letter twelve to fourteen months prior to the expiration of
their accreditation. Board meetings are generally scheduled
within two weeks of the expiration dates on the laboratory's
current accreditation certificates. It is crucial that laboratories
apply by the deadline specified in this letter and submit a
complete application without significant deficiencies.
The laboratory will be notified in writing of
the Board's accreditation decisions within two to three weeks
after the Board meeting. This letter will outline the reasons
for the delayed decision and include the documentation that
must be submitted in order to correct the lack of adherence
to the ICANL Standards. To better accommodate laboratories
in the reaccreditation stage, the Board of Directors instituted
a 60-day grace period to maintain accreditation status.
The grace period gives a laboratory that has been delayed reaccreditation
60 days to resolve the delay issues and provide the required
or corrected documentation to the ICANL, upon which the final
decision will be made by the Board of Directors. During the
60 days, the laboratory will be granted a continued presence
on the ICANL website as an accredited laboratory and allowed
continued use of the ICANL Accredited Laboratory logo. The 60-day
extended timeframe is intended to minimize the inconvenience
of needing to redesign reports and letterhead acknowledging
their accreditation status and concerns about meeting reimbursement
guidelines, if applicable. However, laboratories are still required
to submit their reaccreditation applications for the recommended
application deadlines.
Laboratories that do not correct delay issues
during the 60-day grace period will no longer be considered
accredited. Those laboratories are automatically deleted from
the list posted on the ICANL website if the delay materials
has not been received in the ICANL office by the end of the
60-day grace period. Because Medicare, third party payers, referring
physicians and patients refer to this list, a lapse in status
can affect billing or community relations. In addition, the
ICANL logo affirming the laboratory's status as an "Accredited
Nuclear Laboratory" must be removed from any materials,
along with any other references to accreditation by the ICANL,
by any laboratory that does not maintain its accreditation.
STEPS YOU CAN TAKE TO AVOID DELAY
There are several steps that laboratories can take
to increase the likelihood that accreditation is attained without
any delay.
- Review the Application Review Findings (ARF)
letter and/or CD sent to your laboratory when accreditation
was last achieved.
- Verify that your laboratory is adhering
to the current edition of the ICANL Standards. Dates
of revision are listed in the footer of every page. Verify
that the date on your materials corresponds to those on the
web, or contact our office to make sure you are using the
correct edition.
- Review the ICANL reference bibliography to
update procedures with current recommended guidelines from
ASNC, SNM, NRC (or state), and other published sources.
- Be certain that all case studies document
your laboratory's adherence to The Standards and the
application requirements for submission. For example, approximately
20% of nuclear cardiology cases do not include an appropriate
log sheet documenting the random selection, work sheets, ECG
tracings, or hard copy images. General nuclear medicine and
PET studies are often missing patient diagnosis, clinical
indication for study, and documented correlation with other
imaging modalities.
COMMON REASONS FOR DELAY
- The most common reason for delay in Nuclear
Cardiology, Nuclear Medicine and PET is reporting issues;
i.e., reports being inconsistent among readers, missing required
components as listed in the ICANL Standards, not using
standard nomenclature, or failure to render a concise conclusion.
Other frequent causes for delay are incorrect acquisition
parameters and missing protocols. The ICANL Standards
clearly outline the required components for all areas of imaging
and offer references, samples, and links to the appropriate
guidelines.
- A number of laboratories are also delayed
for insufficient documentation of quality control and radiation
safety. The ICANL Standards outline the requirements
for routine QC of cameras and non-imaging equipment. The content
for radiation materials policy and procedure manual requirements
with documentation is specified in the Standards.
- Insufficient CME credits are submitted for
the medical or technical staff members. You are advised to
review the ICANL Standards, which define the CME area and
the requirement for 15 continuing education credit hours,
at the time of application submission for both medical and
technical staff. First-time accreditation applicants may receive
a provisional grant (allowing up to one year to complete this
requirement if no other significant issues are present to
cause delay). However, a laboratory applying for reaccreditation
is expected to stay current with accreditation requirements
and will be delayed accreditation (though they may be afforded
the 60-day grace period to complete the requirement).
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