REVIEW of TRAINER ACCREDITATION & REACCREDITATION Dr Mohan Kumar.
Reaccreditation Easy As 1-2-3 · •The phone lines will be muted during the presentation •...
Transcript of Reaccreditation Easy As 1-2-3 · •The phone lines will be muted during the presentation •...
Improving health care through accreditation
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877-796-1325
Improving health care through accreditation
Presented by: Marge Hutchisson, RVT, RDCS Director of Accreditation – Vascular Testing/Vein Center
Improving health care through accreditation
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Improving health care through accreditation
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
Improving health care through accreditation
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IAC History
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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
2013
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• 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
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•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
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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
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• Demonstrates accountability and a commitment to quality patient care
• Demonstrates a willingness to surpass current expectations
Goals of Accreditation
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• Awareness of your processes
• The process reviews all
aspects of the facility
Raising the Bar
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The Portal
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Mail Call
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READ !
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Application
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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
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Lab Assessment
Accreditation 3 Years
Audit or Site Visit
Online Application
IAC Internal Review
IAC Peer
Review
Board Review And Decision
Accreditation Process
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Organization
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Attestation
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I promise to
tell the truth
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I promise to
tell the truth
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I promise to
tell the truth
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I promise to
tell the truth
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I promise to
tell the truth
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Experience Only
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I promise to
supervise
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I promise we have them on
file
CMS Required Policies
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Testing Sections
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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
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The Medical and Technical
Directors MUST be
represented
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I’ll do the
carotid
I got the
renal
Ugh – stuck with DVT
I’ll do the
PVR
WHEW !
All Technical
Staff MUST be
represented
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All Doctors MUST be
represented
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All Cases MUST come
from the previous
12 months
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Staff representation and cases are the
Number One missing item issues.
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Only ABNORMAL
cases
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ALL cases must be abnormal
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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
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You tell us what your primary cases are
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Cases 1 and 2
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“User Choice” Case 3 Type
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may only be submitted as the
‘User Choice' examination in one testing area
Abdominal Aorta Duplex
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If Case 3 is not your primary…
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Submit Only Your BEST Work
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Case Studies
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Latest Version is Dated 6/15/2013
The Standards
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New In 2013
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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
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• 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
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• 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
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Now user choice for either Arterial or Venous Testing areas
Arteriovenous Fistula or Dialysis Access Grafts
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• 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
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Decisions
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Dude, listen to me! Do you want be
GRANTED?
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2012 Application Delay Issues
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Ask yourself these questions…
Before you submit your application
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• Is it accurate? • Do you have images or data to
support the interpretation?
Interpretation
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• 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
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• Did you submit it? • Is it published data? • Do your Doctors use it? … properly?
Diagnostic Criteria
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CME
• 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?
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Protocols
• Did you submit it? • Is it updated to current Standards and
current lab practices? • Is everyone following it?
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Musts
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Continued Compliance
Mid-Cycle Audits
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800.838.2110
If you are unsure what to submit –
call us!
Improving health care through accreditation
Contact IAC Vascular Testing / Vein Center
Liz Hardesty Senior Application Specialist [email protected]
Shelly McManamon Senior Clinical Specialist [email protected]
Polly Khoury Application Processor [email protected]
Laura Henson Clinical Specialist [email protected] 6021 University Boulevard
Suite 500 Ellicott City, MD 21043
800.838.2110 fax 800.581.7889
Improving health care through accreditation
NOTE: To receive SVU CME credit for this webinar,
you must complete the survey.
Improving health care through accreditation
Question & Answer Session