Achieving Accreditation in Echo, Nuclear and Vascular Robert Skotnicki, D'O', F'A'C'C'

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Achieving AccreditationinEcho, Nuclear and
VascularRobert Skotnicki, D.O., F.A.C.C.

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• Outline
• What is the Intersocietal Accreditation
  Commission?
• Why do we need Accreditation?
• AC history
• Where do we start?
• Where do we find help?
• How much does Accreditation cost?
• What are the Application essentials?
• Any Tips or Quips from AC experience?

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• Accreditation achieved through
• Intersocietal Commission for the Accreditation of
  Echocardiography Laboratories in Echo (ICAEL)
• Intersocietal Commission for the Accreditation of
  Nuclear Medicine Laboratories in Nuclear Imaging
  (ICANL)
• Intersocietal Commission for the Accreditation of
  Vascular Laboratories (ICAVL)
• Under the auspices of the Intersocietal
  Accreditation Commission

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• What is an Intersocietal Commission on
• Accreditation (IAC)?
• IAC founded on April 5, 1997
• Seven years after the Intersocietal Commission
  for the Accreditation of Vascular Laboratories
• Prompted by the incorporation of the
• Intersocietal Commission for the Accreditation of
  Echocardiographic Laboratories
• Followed later in the same year by Intersocietal
  Commission for the Accreditation of Nuclear
  Medicine Laboratories

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• The Intersocietal Accreditation Commission
• Is composed of
• The past president of all Commissions
• The current president of all Commissions

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• The Intersocietal Accreditation Commission (IAC)
• provides oversight to
• Intersocietal Commission for the Accreditation of
  Echocardiography Laboratories
• Intersocietal Commission for the Accreditation of
  Nuclear Medicine Laboratories
• Intersocietal Commission for the Accreditation of
  Vascular Laboratories
• Intersocietal Commission for the Accreditation of
  Computed Tomography Laboratories
• Intersocietal Commission for the Accreditation of
  Magnetic Resonance Laboratories

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• Intersocietal Commission for the
• Accreditation of Echocardiography Labs
• American College of Cardiology
• American Society of Echocardiography
• Society of Diagnostic Medical Sonographers
• Society of Pediatric Echocardiography
• Consultant
• Technical Manager
• CEO

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• Intersocietal Commission for the Accreditation of
  Nuclear Laboratories
• Academy of Molecular Imaging
• American College of Cardiology
• American College of Nuclear Physicians
• American Society of Nuclear Cardiology
• Society of Nuclear Medicine
• Society of Nuclear Medicine
• - Technologist Section
• CEO
• Physicist

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• Intersocietal Commission for the
• Accreditation of Vascular Laboratories
• American Academy of Neurology American Society
  of Neuroimaging
• American College of Cardiology
• American Institute of Ultrasound in Medicine
• American Society of Echocardiography
• Joint Section on Cerebrovascular Surgery/American
  Association of Neurologic Surgeons/Congress of
  Neurologic Surgeons
• Society of Clinical Vascular Surgery
• Society for Vascular Medicine
• Society for Vascular Surgery
• Society for Vascular Ultrasound
• Society for Diagnostic Medical Sonography
• Society of Interventional Radiologists
• Society of Radiologists in Ultrasound
• CEO
• Technical Manager

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• Why should my practice/hospital become
  accredited?
• Improve standard or quality of care by our
• facility
• protocol review and organization
• enhanced quality assurance and correlation
• Confidential peer review
• Recruiting gem for technologists and physicians
• Marketing tool
• patient confidence
• referral physicians
• Qualification for re-imbursement
• Strongly recommended by ASNC and ACC
• Litigation
• Pros
• Cons
• Every one is doing it!

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• ICANL
• How many at present-607 labs
• Private offices 77
• Freestanding Imaging Ctrs 4
• Hospitals
  10
• Mobile labs 3
• Other
  6
• Type of imaging
• MPI
  598
• RNA
  210
• General Nuclear Med 45
• PET
  19

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• Associated Cardiologists has been accredited
  since
• 2000 in Adult Echocardiography
• 2001 in Nuclear Cardiology
• 2001 in Vascular Ultrasound
• Accreditation re-cycles every 3 years
• Nine times!

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• First time around
• 6-8 months in Nuclear by Chief Technologist
• while supervising 2 sites, 5,000 case/yr
• volume.
• 4-6 months in Echocardiography by Chief
• Technologist while supervising 2 sites,
• 6,000/yr volume.
• 8-10 months in Vascular Ultrasound by Chief
• Technologist while supervising 2,000
  exams/yr
• Prior to present resources
• www.Intersocietal.org
• consultants

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• Where/How to Start
• Review the Standards
• www.Intersocietal.org
• www.ICAVL.org
• www.ICANL.org
• www.ICAEL.org
• www.ICAMRL.org
• www.ICACTL.org
• Each discipline has their own unique set with
  ultimately the same content albeit different
  order
• List of specific requirements and regs
• Document that is 50-80 pages

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• Standards
• General Summary
• Definition
• Personnel
• Type of studies
• Minimal Volume
• Overall
• Per physician
• Per Technologist
• Instrumentation
• Protocols
• Exam
• Report
• Safety
• Imaging Energy Exposure
• Emergency procedures/resuscitation equipment
• QA
• Multiple Site Requirements

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• Definitions
• Vascular A Vascular laboratory is a unit
  performing noninvasive vascular diagnostic
  testing under the overall direction of a Medical
  Director. A Technical Director is appointed who
  is responsible for direct supervision of the
  technical staff and the daily operations of the
  laboratory.
• Nuclear A Nuclear Cardiology, Nuclear Medicine
  and/or Pet facility consists of at least one
  nuclear imaging camera, a qualified physician and
  a nuclear medicine technologist. Each facility
  must have a Medical Director and a Technical
  Director. It may be a single site or a
  conglomerate of sites, a mobile facility or a
  combination of the above, meeting the
  organizational structures defined in this
  document. There may be additional physicians,
  nuclear medicine technologists, and other
  professional and/or technical personnel. When
  more than one technical member is employed, a
  Technical Director (e.g. chief technologist) is
  responsible for supervision of the technical
  staff.
• Echo An Echocardiographic laboratory is defined
  as an entity located at one postal address,
  composed of at least one ultrasound instrument
  and a Medical Director and a Technical Director
  performing and/or interpreting transthoracic
  echocardiography. There may be additional
  physicians and sonographers. The laboratory may
  also perform transesophageal, stress or fetal
  echocardiography.

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• Personnel
• Medical Director
• Training
• Experience
• Technical Director qualifications
• Qualifications
• Medical Staff
• Additional Technical staff
• Patient care Personnel
• CME requirements
• Physicians
• Technologists
• Responsibilities and duties
• Physicians
• Technologists
• Ancillary personnel
• Clerical, administrative
• Physicist
• IT support

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• Medical Director
• Echocardiography

The Medical Director must be a licensed
physician. The Medical Director must meet one of
the following criteria1 A) Level III training in
echocardiography. B) Completion of a twelve-month
formal training program in echocardiography. C)
Level II training in echocardiography plus one
year of experience that includes interpretation
of at least 600 echo/Doppler examinations. D)
Completion of a six-month formal training program
in echocardiography plus one year of experience
that includes interpretation of at least 600
Echo/Doppler examinations. E) Three years of
echocardiography practice experience and at least
1800 echo/Doppler examination interpretations,
preferably with Testamur status by the National
Board of Echocardiography (NBE) in
Echocardiography by 2010.
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Medical Director
Nuclear A. Certification in nuclear cardiology
by the Certification Board of Nuclear Cardiology
(CBNC). B. Board certified (or Board eligible but
within two years of finishing training) in
cardiology and completion of a minimum of a 4
month formal training program in nuclear
cardiology Level 2 as outlined in the ACC/ASNC
COCATS Training Guidelines (2006 revision).
This requirement applies only to cardiologists
who began their cardiology training in July 1995
or later C. Board certified in cardiology and
training equivalent to Level 2 training, or at
least one year (full time equivalent) of nuclear
cardiology practice experience with independent
interpretation of at least 600 nuclear cardiology
studies. This requirement applies only to
cardiologists who began their cardiology training
before July 1995. D. Board certified (or Board
eligible but within two years of
finishing training) in nuclear medicine. E. Board
certified (or Board eligible but within two years
of finishing training) in radiology with at least
4 months of nuclear cardiology training. F. Board
certified (or Board eligible but within two years
of finishing training) in radiology and at least
one year (full time equivalent) of
nuclear cardiology practice experience with
independent interpretation of at least 600
nuclear cardiology studies.
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• Medical Director
  
• Vascular
• A.) 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. For those
  testing areas in which training is
• provided, the physician should have experience in
  interpreting the following
• minimum number of studies while under
  supervision
• Vascular Laboratory Examination Minimum Number
  of Cases
• carotid duplex ultrasound 100 cases
• transcranial Doppler 100 cases
• peripheral arterial physiologic tests (e.g.
  extremity pressures, Doppler waveforms, exercise
  testing, reactive hyperemia) 100 cases
• peripheral arterial duplex 100 cases
  ultrasound
• venous duplex ultrasound 100 cases
• visceral vascular duplex 75 cases ultrasound
• The formal training experience must be documented
  by a letter from the
• director of the training program verifying the
  areas of testing and the extent
• of the training and experience

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• Choices
• Nuclear
• Myocardial perfusion imaging
• Equilibrium radionuclide Angiography
• General Nuclear Medicine
• PET
• Echocardiography
• Adult Transthoracic
• Adult Transesophageal
• Adult Stress Echo
• Pediatric Transthoracic
• Pediatric Transesophageal
• Fetal Echo
• Vascular
• Carotid Duplex Ultrasound
• Transcranial Doppler
• Peripheral Arterial
• Peripheral Venous
• Visceral Vascular

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• Volume
• 600 cases
• Training minimum in Echo and Nuclear
• Overall laboratory volume/year in Echo and
  Nuclear
• 300 cases
• Minimum/year for Medical Staff in Echo
• Minimum/year for Sonographers
• Minimum Vascular studies (of each 5 types)
  performed in established practice for training
• 100 cases
• Overall laboratory volume/year Stress Echo
• Minimum/year for Medical Staff in Stress Echo
• Minimum/year for Sonographers in Stress Echo
• Minimum Vascular (5) studies in formal training
  program
• Minimum/year (5) for Vascular Sonographers
• Minimum/year (5) for Medical Staff in Vascular

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• Lower Volumes than those recommended here,
  however, should not dissuade a laboratory that is
  otherwise compliant with the ICAEL/ICANL/ICAVL
  Standards from applying for Accreditation.

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• Standards
• General Summary
• Definition
• Personnel
• Type of studies
• Minimal Volume
• Overall
• Per physician
• Per Technologist
• Instrumentation
• Protocols
• Exam
• Report
• Safety
• Imaging Energy Exposure
• Emergency procedures/resuscitation equipment
• QA
• Multiple Site Requirements

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• Decision
• Proceed without any changes necessary
• Proceed with minor changes necessary
• Re-writing protocols
• Patient confidentiality concerns
• Archiving issues
• Delay for 6 months to a year with major changes
• Bldg additions
• Staff certification
• HELP!

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• Where to get HELP
• Web sites of each Commission with hyperlink to
  Accreditation OnDemand
• Free webcasts of 15-20 minute duration each on
  5-7 topics
• Preparing your staff and facility for
  accreditation
• Do your protocols meet the minimum requirements?
• Documenting your laboratories accuracy
• Are all of your final reports complete and
  accurate?
• Case studies documenting your accuracy
• What to expect at the site visit

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• Where to get HELP
• Web sites of each Commission with hyperlink to
  Accreditation OnDemand
• Software assistance available for all 5
  disciplines from private vendors at a cost!
• JR associates offers protocol support for Echo
  and Vascular
• at a cost of 900 for 33 protocols
• Echo ToolBox from the ASE is offered at a very
  reasonable price.
• The American Society of Echocardiography
  developed Echo ToolBox as a web-based,
  interactive program that facilitates the
  accreditation process and promotes excellence in
  cardiovascular ultrasound laboratories.
• Not only is Echo ToolBox a user-friendly and
  comprehensive tool that walks participants step
  by step, screen by screen, through the
  application process itself, but it is also an
  affordable and time-saving option forlabs of all
  sizes.
• Prices start at 75/yr for ASE members and
  150/yr non ASE members, with reduction for high
  numbers of staff members. This is a yearly
  subscription.

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• Where to get HELP
• Web sites of each Commission with hyperlink to
  Accreditation OnDemand
• Software assistance available for all 5
  disciplines from private vendors at a cost!
• Consultants
• Vascular has about /- 30
• Echo has about /- 34
• Nuclear has about /- 40
• Cost 4,000- 10,000
• Location may add thousands of dollars
• Extent of services
• Fill in the blanks-software integration with
  DiCOM networking
• ACCREDITATION IMAGING ASSOCIATES NORTH AMERICA,
  INC. Nuclear consulting. Contact April A.
  Adams, RN, CNMT, RT(N). 11111-70 San Jose Blvd,
  310, Jacksonville, FL 32223. Phone
  904-524-2892, Fax [phone]. Email
  aiana_at_bellsouth.net
• ACCREDITATION CONSULTING GROUP Vascular,
  Echocardiography, and Nuclear consulting.
  Contact Ken Suhr, 71 Heritage Drive, Shrewsbury,
  NJ 07702. Phone [phone], Fax [phone].
  Email acgconsult_at_comcast.net

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• Cost of Accreditation
• Technologist hours
• Outside assistance
• Software only 400 e.g.Echo Toolbox
• 900 software
  protocol
• In House Consultants 4,000-15,000
• consider location
• consider networking
• consider support
• phone
• onsite (extra
  cost?)
• All start with The Standards at 200

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• Individual Disciplines
• ICAVL Base Fee 1,000
• 300 for
  each area
• 750 each
  site
• ICAEL Base Fee 1,500 Adult TT
• 250 Adult
  TE
• 250 Adult
  Stress
• 1,500
  Pediatric TT
• 250
  Pediatric TE
• 250 Fetal
• 200 per
  staff (7-25)
• 50 per
  staff over 25
• 750 per
  site
• 500 mobile
• ICANL Base Fee 3,800 Comprehensive
• 
  Nuclear Stress
• 
  PET
• 
  Nuclear Medicine
• 3,300 any
  one of the three

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• Application Essentials
• Use online application
• Must purchase a copy of the Standards
• Include Random Audit Consent
• Include Accreditation Agreement
• Two sets of case studies
• Complete mobile or multiple site supplemental
  application
• Review web site often for changes and updates in
  all of the above before submission

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• Tips and Quips

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• Case Studies
• Prepare case studies based on lab volumes and
  staff (both Technologists and Medical)
• Submit two copies
• Do not delete names
• Do not send originals
• Send best quality images
• Send entire examination
• Representative cases from as many staff members
  as possible
• Actual typed reports must be unified

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• Miscellaneous
• Insufficient CMEs will hold up acceptance
• Incomplete QA policies
• QA documentation
• Cases must be done to current Guidelines
• Appropriateness
• ASE Report Standards
• ASNC
• Report must be standardized
• No typographical errors
• Rapidity of report production
• Prepare for site visit
• Ready access to all documents and facilities
• Including CME certificates
• Nuclear will want to watch physician interpret
  nuclear studies!
• Not reading from hard copy
• Review of all data systematic order
• They like colors

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• Conclusion
• The Intersocietal Accreditation Commission is the
  governing body providing oversight to
  Accreditation Commissions.
• Yes, we need Accreditation.
• AC history was provided as example.
• We have direction regarding initiation of the
  credentialing process.
• Help is available through multiple resources.
• A list of the Accreditation cost was provided.
• The Application essentials were presented.
• Brief list of Tips and Quips from AC experience.