IAC Accreditation Checklistfor Vascular Testing

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The IAC Accreditation Checklist for Vascular Testing

Use the following checklist as a guide when preparing your application for vascular testing accreditation.

Step 1: Before You BeginPRead and Review the IAC Standards and Guidelines for Vascular Testing Accreditation

The Standards are the basis for the accreditation program; defining the minimum requirements for all vascular testing facilities to provide high quality care. It is imperative to read and understand the Standards. Always follow the most current version of the Standards, which are posted on the vascular testing website at: intersocietal.org/vascular/seeking/vascular_standards.htm

Explore the Website

• Sample Documents (intersocietal.org/vascular/seeking/sample_documents.htm)

• On Demand Webcasts (intersocietal.org/vascular/main/on_demand.htm)

• Frequently Asked Questions (intersocietal.org/vascular/main/faq.htm)

• Links & References (intersocietal.org/vascular/main/links_references.htm)

• CME Resources (intersocietal.org/vascular/main/cme_resources.htm)

Perform a Thorough Facility Self-Assessment

Prior to completing the application, facilities must identify and correct potential problems; when necessary revising protocols and Quality Improvement (QI) programs to be in compliance with the Standards.

IAC Accreditation Agreement

It is important to have the appropriate personnel at your facility review

the IAC Agreement and decide if changes need to be made prior to application submission.

- If making modifications to the IAC Agreement: Be sure to have the agreement filled out completely and signed in all areas (by an authorized representative). Applications submitted to the IAC must be accompanied by a completed IAC Accreditation Agreement (current published version) in order to receive an accreditation decision. - If no modifications are required: The facility can electronically complete and sign the unmodified Agreement provided at the end of the IAC Online Accreditation application. Read and follow all prompts in the ‘Accreditation Agreement’ portion of the online application when utilizing this option.

For the complete instructions, please review “Legal, IAC Agreement” at intersocietal.org/iac/legal/agreement.htm.

Create or Access Existing Online Accreditation Account

To apply for IAC accreditation, applicant facilities need to access their existing or create a new IAC Online Accreditation account. To learn more, please visit iaconlineaccreditation.org/webdriver/AcctAssistance.aspx. For facilities applying for reaccreditation, the IAC QuickFill Reaccreditation feature retains previous application data (answers and attachments) and copies the information into your reaccreditation application, making reaccreditation easier than ever.

Step 2: Gather InformationPAll facilities are required to submit the items listed below as part of the Online Accreditation application.

Equipment Information (manufacturer, model and year)

Procedure Volumes (estimated annual facility procedure volume information)

Training/Experience Qualification Pathways for Physicians, Sonographers and Technologists

Credential Information (i.e., RVT, RVS, RT(VS) for technical staff, RPVI for medical staff [including dates and certificate/registry numbers]). Additional credentials may be accepted for specific areas of testing, see Standards for complete details.

CME Information for All Staff (must be kept on file and available for review) All staff members are required to have 15 CME relevant to noninvasive vascular testing every three years. Physicians must document 15 CME with 10 listed as AMA Category I.

Policies and Protocols The following policies and protocols must be in place prior to application submission. Sample versions of these policies and protocols can be found at

intersocietal.org/vascular/seeking/sample_documents.htm.

Primary Source Verification Policy A policy for verifying all medical and technical staff member credentials through the applicable issuing agencies.

Patient Complaint Policy A policy that outlines the process for patients to issue a complaint/grievance in reference to the care/services they received at your facility.

Personnel Safety Policy (Ergonomics) A policy must be in place to address technical staff safety, comfort and avoidance of work-related musculoskeletal disorders (MSD).

Patient Safety Policy A policy to ensure patient safety.

Patient Confidentiality Policy A policy that all facility personnel must ascribe to professional principles of patient confidentiality as legally required by federal, HIPPA, state, local or institutional policy or regulation.

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Quality Improvement (QI) Policy A written policy regarding QI that reflects the current Standard requirements.

QI Meeting Minutes Prepare minutes from a minimum of two QI meetings per year.

Facility-Specific, Step-by-Step Technical Protocols For all modalities the facility is applying for accreditation.

For details on what should be included in these policies and protocols, review the IAC Standards and Guidelines for Vascular Testing Accreditation at: intersocietal.org/vascular/seeking/vascular_standards.htm.

Case Study Requirements

Following are the accreditation case study requirements for each area of testing:

1. All cases must be selected from within the past 12 months from the date of application filing.

2. All medical and technical staff must be represented including the Medical and Technical Director. EXTRACRANIAL CEROBROVASCULAR:

• Primary Examination | Submit a total of three representative patient examinations; all must be bilateral testing and demonstrate >50% ICA stenosis.

INTRACRANIAL CEROBROVASCULAR:

• Primary Examination | Submit two representative case studies for the primary testing performed. The case studies must be bilateral and abnormal with varying degrees of pathology. The third representative case study must be chosen from the options below. If no additional testing is performed, a third abnormal primary case study must be submitted.

○ Emboli detection ○ Vasomotor reactivity ○ Right-to-left shunt ○ Assessment of cerebral circulatory arrest ○ Peri-procedural or intra-operative monitoring ○ Monitoring of reperfusion therapies in acute stroke ○ Monitoring in the neuro-intensive care setting

PERIPHERAL ARTERIAL:

• Primary Examination | Submit two representative case studies for the primary testing performed. The case studies must be bilateral and abnormal with varying degrees of pathology. If arterial duplex testing is submitted, the case studies must demonstrate >50% stenosis. The primary case study requirements will be automatically calculated based on the information entered in the online application. Dependent on testing performed, the facility may be given the option to submit a third abnormal case study chosen from the list below. If no additional testing is performed, a third abnormal primary case study must be submitted.

○ Upper extremity arterial duplex (bilateral) ○ Abdominal aorta duplex (Comment: This examination is only an

option in one testing area and cannot be submitted if already submitted in visceral vascular.)

○ Bypass graft duplex

○ Dialysis access graft/AVF duplex (Comment: This examination is only an option in one testing area and cannot be submitted if already submitted in peripheral venous.)

PERIPHERAL VENOUS:

• Primary Examination | Submit two representative abnormal case studies for the primary testing performed. The primary case study requirements will be automatically calculated based on the information entered in the online application. Dependent on testing performed, the facility may be given the option to submit a third abnormal case study chosen from the list below. If no additional testing is performed, a third abnormal primary case study must be submitted.

○ Upper extremity venous duplex for patency

○ Dialysis access graft/AVF duplex (Comment: This examination is only an option in one testing area and cannot be submitted if already submitted in peripheral arterial.)

○ If no additional testing is performed, submit a third primary case study.

VISCERAL VASCULAR:

• Primary Examination | Submit two representative abnormal case studies for the primary testing performed. If renal artery duplex case studies are submitted; they must be bilateral and document greater than 60% stenosis. The third representative case study must be chosen from the options below. If no additional testing is performed, a third abnormal primary case study must be submitted.

○ Mesenteric duplex

○ Hepatoportal duplex

○ Renal artery duplex

○ Renal transplant duplex

○ Liver transplant duplex

○ Abdominal aorta duplex (Comment: This examination is only an option in one testing area and cannot be submitted if already submitted in peripheral arterial.)

SCREENING:

• Submit a total of three representative case studies per type of screening for which the facility is applying. The case studies do not need to be abnormal.

MULTIPLE SITES:

• Primary Examination (for each testing section the facility is applying in) | 1 Abnormal

Complete case study requirements and instructions can be found on the website at intersocietal.org/vascular/seeking/case_studies.htm.

Step 2: Gather Information (continued ...)P

Have a question? Contact the Vascular Testing division of IAC at 800-838-2110 or via e-mail at vascular@intersocietal.org.

The pre-submission case study requirements check is initiated by the facility after the application questionnaire is completed but prior to the final application submission. The check MUST be initiated about two weeks prior to the expected final submission.

� Facilities complete the application questionnaire and enter the case study information in its entirety.

� Facilities then initiate the pre-submission case check which allows IAC staff to check the application to ensure proper case study, document

and staff representation. The check is performed by IAC staff within two business days, in an effort to provide a more efficient application submission and review process for the applicant facility.

� Facilities then receive an e-mail from the IAC to update their case studies, as requested.

� Once any updates to the cases have been made, facilities are notified to submit their final application and send corresponding materials (case study images, Agreement [if modified], etc.).

Step 4: Pre-submission Case Requirements CheckP

� Once the pre-submission case requirements check has been completed and any errors rectified, facilities will submit via the conclusion screen.

� During the final submission you will select the payment method and be instructed to send the case study materials within 5 business days* to the IAC office.

� The application is locked and the data becomes your final application submission. A read-only copy of the submitted application questionnaire is accessible by using the Applications link.

� The case studies, IAC Accreditation Agreement (if modified and not submitted in the application) and fee (if paid by check) are sent to the IAC office via a traceable carrier (i.e., UPS, FedEx) and will not be

accepted via e-mail or fax.

� Application submissions with the corresponding application materials that arrive late or are incomplete will be processed with the subsequent submission group.

� It is highly advised that all information be collected and sent in a single shipment. Send your materials to IAC Vascular Testing, 6021 University Blvd., Suite 500, Ellicott City, MD 21043.

*Expedited submissions per the terms and conditions (Page 5 of the IAC Policies and Procedures) must be received in the IAC office no later than the first business day of the submission month.

Step 5: Submitting the ApplicationP

Once your facility has submitted the online application and mailed the corresponding materials, the IAC will begin the process of reviewing the completed application and rendering a decision.

� The in-house review, peer review and board decision are conducted prior to sending the official notification letter.

� The application review process generally takes approximately 8 to 12 weeks to complete, at which time the decision is provided to the facility

� During the three-year accreditation cycle, the facility will be notified regarding a site visit.

� It is important to periodically monitor your Online Accreditation account profile and update any changes to Medical or Technical Directors, medical or technical staff, administrators or contact information for any online users.

For more details on application review and decisions, refer to the IAC Accreditation Program Policies & Procedures on the IAC website at intersocietal.org/iac/legal/policies.htm.

Have a question? Contact the Vascular division of IAC at 800-838-2110 or via e-mail at vascular@intersocietal.org.

Step 6: After You SubmitP

IAC Online Accreditation is used by facilities when applying for accreditation for the first time or for reaccreditation:

� Applicant facilities that do not already have an existing IAC Online Accreditation account, can create one at iaconlineaccreditation.org/webdriver/AcctAssistance.aspx.

� IAC Online Accreditation has two major aspects: an account profile and an application questionnaire. After completing required fields and sections (Manage Staff, Manage Sites and Manage Equipment) of the profile, proceed to the questionnaire by clicking the Applications tab.

� It is within the questionnaire that applicant facilities will provide detailed information about the facility and upload the supporting

documentation as attachments.

� When the questionnaire is completed, the [Begin Presubmission Check] button is presented on the Conclusion screen. Once the pre-submission case requirements check is initiated, changes to the application are not permitted unless the IAC staff find errors in the case selection.

To learn more about Online Accreditation, visit intersocietal.org/iac/helpfulresources/online_accreditation.htm.

Step 3: Complete Online ApplicationP

NOTES

The IAC and its divisions are fully staffed with customer service-oriented clinical and administrative personnel trained to guide you through the application process. For assistance, please contact the Vascular Testing division of

IAC at 800-838-2110, by e-mail at vascular@intersocietal.org or via the website at intersocietal.org/vascular.

Remember, the IAC is here to help.