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Improving health care through accreditation

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Presented by: Marge Hutchisson, RVT, RDCS Director of Accreditation – Vascular Testing/Vein Center

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Today’s Objectives

1. IAC History 2. The Portal 3. The Application 4. New Standards 5. AVOID THE DELAY 6. Mid-cycle audits

Marge Hutchisson, RVT, RDCS Director of Accreditation – Vascular Testing/Vein Center

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IAC History

1990 1996 1997 2000 2007 2008 2009 2010 2011 2012 Future

ICAVL 8 sponsors Incorporated 1990

IAC 2 Members Incorporated 1996

ICAMRL 5 Sponsors (now 8) Incorporated2000

CMS recognizes IAC as one of 3 AOs for ADI

Vein Center 10 Sponsors (now 11) 2013

ICAEL 4 Sponsors Incorporated 1996

ICANL 6 Sponsors Incorporated 1997

ICACTL 10 Sponsors (now 12) 2007

ICACSF 10 Sponsors 2009

ICACTL Dental CT IAC rebranding initiative

IAC launches rebranding Renames all divisions, Streamlines processes

IAC Merger All divisions unincorporated and merged into IAC 2008

• Academy of Molecular Imaging • American Academy of Dermatology • American Academy of Neurology • American Academy of Orthopaedic Surgeons • American Academy of Otolaryngology • American Association of Neurological

Surgeons • American Association of Physicists in Medicine • American College of Cardiology • American College of Nuclear Medicine • American College of Phlebology • American College of Surgeons • American Institute of Ultrasound in Medicine • American Society of Echocardiography • American Society of Neuroimaging • American Society of Neuroradiology • American Society of Nuclear Cardiology • American Society of Radiologic Technologists • American Venous Forum

• Neurocritical Care Society • Society for Cardiovascular Angiography and

Interventions • Society for Cardiovascular Magnetic

Resonance • Society for Clinical Vascular Surgery • Society for Vascular Medicine • Society for Vascular Surgery • Society for Vascular Ultrasound • Society of Cardiovascular

Computed Tomography • Society of Diagnostic Medical Sonography • Society of Interventional Radiology • Society of NeuroInterventional Surgery • Society of Pediatric Echocardiography • Society of Radiologists in Ultrasound • Society of Nuclear Medicine • Society of Nuclear Medicine Technologists • Society of Vascular and Interventional

Neurology

116 Board Members 34 Sponsoring Organizations

•American Academy of Dermatology (AAD) –Robert Weiss, MD, FAAD, FACPh

•American College of Phlebology (ACP) –Stephen Daugherty, MD, FACS, RVT, RPhS –Steven E. Zimmet, MD, RVT, FACPh

•American College of Surgeons (ACS) –John Blebea, MD, FACS

•American Society for Dermatologic Surgery Association (ASDSA) –Mitchel P. Goldman, MD

•American Venous Forum (AVF) –Mark Meissner, MD –Lowell Kabnick, MD, RPhS, FACS, FACPh, President

•Society for Clinical Vascular Surgery (SCVS) –Alan Dietzek, MD, FACS, RPVI, RVT, President-Elect –Ellen D. Dillavou, MD, RPVI, FACS, Vice President

•Society for Vascular Medicine (SVM) –Thom Rooke, MD, RVT

•Society for Vascular Nursing (SVN)

•Society for Vascular Surgery (SVS) –Marc Passman, MD –Deepak Nair, MD, FACS, MS, MHA, RVT

•Society for Vascular Ultrasound (SVU) –Diana L. Neuhardt, RVT, RPhS

•Society of Interventional Radiology (SIR) –Mark Garcia, MD, FSIR –Neil Khilnani, MD, Secretary

Vein Center Board of Directors and Sponsoring Organizations

TWO CRUCIAL STEPS

• A detailed self-evaluation: • Using the IAC Standards and Guidelines for Vascular Testing

Accreditation - These accreditation Standards and Guidelines are the minimum Standards for accreditation of vascular testing facilities. Standards are the minimum requirements to which an accredited facility is held accountable.

• Submission of actual patient case studies for peer review: • The case studies are crucial in determining the facility's compliance

with the Standards, and are the basis for judgment of the quality of work that facilities perform.

Designed to Serve as an Educational Tool

• Demonstrates accountability and a commitment to quality patient care

• Demonstrates a willingness to surpass current expectations

Goals of Accreditation

• Awareness of your processes

• The process reviews all

aspects of the facility

Raising the Bar

The Portal

Mail Call

READ !

Application

Organization Personnel and Supervision

Medical Director Technical Director Medical Staff Technical Staff Support Services

Facility Examination Areas Interpretation Areas Storage

Examination Reports and Records Records Examination Interpretation and Reports Interpretation Diagnostic Criteria

Facility Safety Patient and Facility Safety

Administrative Patient Confidentiality Patient or Other Customer Complaints Primary Source Verification

Multiple Sites

Testing Area(s) Extracranial Cerebrovascular Testing

Indications Equipment Protocols Techniques Documentation Procedure Volumes

Intracranial Cerebrovascular Testing

Indications Equipment Protocols Techniques Documentation Procedure Volumes

Lab Assessment

Accreditation 3 Years

Audit or Site Visit

Online Application

IAC Internal Review

IAC Peer

Review

Board Review And Decision

Accreditation Process

Organization

Attestation

I promise to

tell the truth

I promise to

tell the truth

I promise to

tell the truth

I promise to

tell the truth

I promise to

tell the truth

Experience Only

I promise to

supervise

I promise we have them on

CMS Required Policies

Testing Sections

Primary Site:

• Submit a total of three representative patient examinations; all must be abnormal of varying degrees of pathology.

Multiple Site:

• Submit one abnormal primary case from each site

Case Study Submission

The Medical and Technical

Directors MUST be

represented

I’ll do the

carotid

I got the

Ugh – stuck with DVT

I’ll do the

WHEW !

All Technical

Staff MUST be

represented

All Doctors MUST be

represented

All Cases MUST come

from the previous

12 months

Staff representation and cases are the

Number One missing item issues.

Only ABNORMAL

ALL cases must be abnormal

Each case scored for: • Data quality and technique (image, Doppler, sites) • Adherence to stated protocol and the IAC Standards • Appropriate indications • Adherence to stated diagnostic criteria • Report components included (Pt. ID, date, indication,

body, summary, signature and signature date) • Accurate interpretation • Performed by staff listed in the application

Case Study Review Criteria

You tell us what your primary cases are

Cases 1 and 2

“User Choice” Case 3 Type

may only be submitted as the

‘User Choice' examination in one testing area

Abdominal Aorta Duplex

If Case 3 is not your primary…

Submit Only Your BEST Work

Case Studies

Latest Version is Dated 6/15/2013

The Standards

New In 2013

A current abnormal case study final report interpreted by each physician

applying under the established practice pathway must be submitted in the

application.

Established Practice

• 40 hours of relevant Category 1 CME credits

• 8 hours supervised practical experience for each testing area to be interpreted; observing or participating in testing procedures in a facility accredited for vascular testing

• Comment: Experience must be documented with a letter from the Medical Director of the facility where the experience was obtained.

• The physician must acquire experience in the interpretation of exams while under the supervision of a physician who has already met the IAC Vascular Testing Standard.

• Comment: Interpretive experience must be documented with a letter from the supervising physician of the facility where the experience was obtained indicating the dates of participation and the number of cases in each testing area.

Informal Training

• Registered Vascular Technologist (RVT); • Registered Vascular Specialist (RVS); • Registered Technologist Vascular Sonography [RT(VS)]; • Registered Diagnostic Medical Sonographer in Abdomen

[RDMS (AB)] (visceral vascular testing only); • Neurosonology credential from the American Society of

Neuroimaging (ASN) (extracranial and intracranial testing only);

• Registered Phlebology Sonographer (RPhS) (peripheral venous testing only).

Vascular Credential

Now user choice for either Arterial or Venous Testing areas

Arteriovenous Fistula or Dialysis Access Grafts

• Repeat examination performed within three days of the initial examination;

• Clinical outcome

• Case peer review by a second interpreting physician that includes comments regarding: technical adequacy, interpretation accuracy and final report completeness

• Comparison with venography or surgical pathology.

Venous QA

Decisions

Dude, listen to me! Do you want be

GRANTED?

2012 Application Delay Issues

Ask yourself these questions…

Before you submit your application

• Is it accurate? • Do you have images or data to

support the interpretation?

Interpretation

• Did you submit the log and the policy? • Do you have the required numbers? • Is it performed by approved methods? • Is your accuracy 70% or greater?

Quality Assurance

• Did you submit it? • Is it published data? • Do your Doctors use it? … properly?

Diagnostic Criteria

• Did you submit it? • Does everyone have 15? • Are they vascular testing related? • Do the medical staff have at least 10

that are Category 1?

Protocols

• Did you submit it? • Is it updated to current Standards and

current lab practices? • Is everyone following it?

Continued Compliance

Mid-Cycle Audits

800.838.2110

If you are unsure what to submit –

call us!

Contact IAC Vascular Testing / Vein Center

Liz Hardesty Senior Application Specialist ehardesty@intersocietal.org

Shelly McManamon Senior Clinical Specialist mcmanamon@intersocietal.org

Polly Khoury Application Processor pkhoury@intersocietal.org

Laura Henson Clinical Specialist lhenson@intersocietal.org 6021 University Boulevard

Suite 500 Ellicott City, MD 21043

800.838.2110 fax 800.581.7889

NOTE: To receive SVU CME credit for this webinar,

you must complete the survey.

Question & Answer Session

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