Reaccreditation: Raising The Bar (continued)
from
the October 2005 issue
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General
Application Requirements
Often
at the time of reaccreditation, the application completers assume
that information previously submitted to the ICAVL need not
be sent again. However, due to the volume of paperwork received
by the ICAVL, previously submitted applications are stored offsite
in a secured location and not available to the application reviewers.
- Submission
of two printed copies of the application documents, the
required attachments and the case studies are required.
- Organize
the application information into two sets. Do not place
the information into binders or page protectors.
- Review
the case study requirements. The most current requirements
can be found on the ICAVL website at www.intersocietal.org/icavl/news/articles/figure2.htm.
- Submit
all protocols, diagnostic criteria, quality assurance statistics
and quality assurance logs with the testing applications
at the time of every reaccreditation application submission.
Organization
Application
At
approximately 12%, the fewest number of reaccreditation delays
are a result of problems in the Organization Application.
- All
staff data must be updated at the time of reaccreditation.
- The
Continuing Medical Education (CME) requirements must be
documented for all staff members. A minimum of 15 CME hours
relevant to noninvasive vascular testing must be obtained
by all staff members within three years of the application
submission. For medical staff members, a minimum of 10 of
the 15 hours must be AMA Category I credits. The CME requirements
can be reviewed in the Organization Standards or on the
website at www.intersocietal.org/icavl/community/cmerequirements.htm.
To assist laboratory staff members with meeting this requirement,
a CME Opportunities section of the website includes an up-to-date
listing of upcoming courses and conferences, as well as
self-study and recurring courses, and can be found at www.intersocietal.org/icavl/community/cme.htm.
Testing
Applications And Case Studies
Though
the procedures specific to each area of testing differ, the
most common reasons for delay in each particular testing application
are generally very similar.
- TESTING
PROTOCOLS - Testing protocols submitted with the application
must reflect the most current requirements of the Standards
as well as define the contemporary practice of the laboratory.
Protocols included with applications are often vague or
outdated and do not clearly define the procedures being
carried out in the laboratory. This often becomes evident
to the application reviewers when they are evaluating the
submitted case studies.
- QUALITY
ASSURANCE - At the time of reaccreditation, it is mandatory
that the application include documentation of the quality
assurance correlation performed in the laboratory for the
previous three-year accreditation cycle. The minimum number
(located in section 6 of each testing area) of quality assurance
correlations must be clearly identified by submitting a
log or similar documentation that includes dates, patient
identification, non-invasive exam results and correlation
outcome. In most instances, a matrix must be completed to
reflect those patients included in the log and to provide
an overall accuracy of the comparisons. If the laboratory
finds that meeting the ICAVL quality assurance standards
is difficult to achieve through use of the recommended comparison
modalities (i.e.: angiography, surgical pathology, MRA),
alternative methods will be considered and may assist in
avoiding a delayed
accreditation decision for a particular testing area due
to limited quality assurance information.
- FINAL
REPORTS - Final reports submitted with the case studies
must include the content and meet the standards for reporting,
as written in Section 4 of the Organization Standards.
- DIAGNOSTIC
CRITERIA - Lack of adherence to the laboratory's diagnostic
criteria is often a reason for delay in a reaccreditation
application. It is required that all medical staff members
interpreting examinations in the laboratory adhere to one
standardized criteria. The final report must document adherence
to the specific categories of disease, as written in the
criteria; sub-setting, generalization and estimations should
be avoided. Again, compliance to this standard becomes evident
to the application reviewers when they are evaluating the
submitted case studies.
- CASE
STUDIES - A primary factor resulting in the delay of reaccreditation
applications is incomplete documentation and overall poor
quality of submitted case studies. The cases must include
all of the hardcopy documentation required by the Standards,
while demonstrating good testing techniques. Over a year
ago, the ICAVL Board of Directors voted to decrease the
number of case studies required for submission by reaccreditation
applicants. The decrease in the number of case studies is
intended to assist in making the reaccreditation process
less laborious, however; adherence to the standards remains
imperative. Again, a thorough and regular review of the
ICAVL Standards, the laboratory's protocols, diagnostic
criteria and quality assurance will assist in assuring that
testing procedures are being performed and documented in
a standardized method, in compliance with the requirements
of the ICAVL process.
Laboratories
that receive notification that their reaccreditation application
has been delayed are often surprised and frustrated with the
results of the application review. Previous granting of accreditation
does not ensure that the laboratory will automatically be granted
accreditation at the time of reaccreditation. It is the philosophy
of the ICAVL that with each reaccreditation cycle, the applicant
laboratory should be coming ever closer to being in compliance
with every one of the ICAVL Standards, thus offering the best
possible quality of noninvasive vascular testing available to
its patients. While this expectation of the laboratories seeking
ICAVL reaccreditation is high, it has enabled the ICAVL process
to gain recognition as the gold standard in the field and for
ICAVL accredited laboratories to be highly regarded.
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