CT Accreditation
History & Useful Tips
to Ensure Optimal
Outcomes with
Accreditation Process
Improving health care through accreditation
IAC
Vascular Testing|ICAVL - 1990
Echocardiography|ICAEL- 1996
Nuclear/PET|ICANL - 1997
MRI|ICAMRL - 2000
CT|ICACTL – 2007
Dental CT|ICACTL - 2011
Carotid Stenting|ICACSF - 2009
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Red=MIPPA definition of advanced
diagnostic imaging (ADI)
Factors Affecting the Growth of Accreditation
1. Reimbursement – Federal Mandate
– MIPPA 2008
– Affects “advanced imaging” (Nuclear, PET, MRI, CT)
in outpatient setting (not hospitals)
– Accreditation required by 1/1/2012
– 120 day CMS grace period for adding new sites or
additional imaging modality
2. Reimbursement – Private Insurers
– United Healthcare (Affects “advanced imaging” – MRI,
CT, PET, nuclear medicine plus echocardiography)
– Various other private insurers and RBMs
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IAC Application Receipt by Division
UHc Req
1800
MIPPA
1600
1400
ICAVL
ICAEL
ICANL
ICAMRL
ICACTL
1200
1000
800
600
400
200
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
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Additional Payment Policies
• California
– California Senate Bill 1237 Requires CT Facilities Be Accredited
by July 1, 2013
– Commencing July 1, 2012, a person that uses a computed
tomography (CT) X-ray system for human use shall record the
dose of radiation on every CT study produced during a CT
examination
• Minnesota
– MN Bill HF 2276 :Any facility that performs advanced diagnostic
imaging services (MR, CT, Nuclear/PET) must obtain
accreditation by August 1, 2013.
– Thereafter, all facilities that provide advanced diagnostic imaging
services in the state must obtain accreditation prior to
commencing operations and must, at all times, maintain
accreditation with an accrediting organization
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IAC CT Standards
• Organization
• Examinations and Procedures
• Quality Improvement
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Areas of CT Accreditation
•
•
•
•
•
coronary calcium scoring CT
coronary CTA
neurological CT [brain, spine, CTA]
sinus and temporal bone CT
body CT [chest (non-coronary), abdomen,
pelvis, extremity]
• vascular/other CTA [chest (non-coronary),
abdomen, pelvis, peripheral/extremity]
Improving health care through accreditation
Improving health care through accreditation
IAC CT|ICACTL Statistics
Accredited CT labs: 469
Accredited CT sites: 574
Testing Areas Currently Granted Accreditation
CCS
73 (15.57%)
CCTA
71 (12.37%)
NCT
120 (25.59%)
STB
351 (61.15%)
WBCT
173 (36.89%)
Other CTA 95 (16.55%)
Improving health care through accreditation
Application Decisions
• Grant
– Valid for three years from date of decision
• Delay
– Issues related to quality identified
– Notification letter outlines deficiencies and
additionally required information
– Accreditation will be granted once issues are
corrected
– Lab will have one year to correct deficiencies
• Site visit
– Unable to make decision based on written
application
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Lessons Learned – Tips for Success
• Create a culture of quality
• Start early (6-12 months)
• Be familiar with the accreditation
guidelines
• Design policies that meet IAC Standards
• Buy-in from all staff and physicians before
starting
• Involve key staff and physicians
Improving health care through accreditation
Lessons Learned – Tips for Success
Physicians
• Help understand rationale
• Select a physician champion
• Review policies
• Start early-provide feedback
• Understand compliance is mandatory
• Consider tying accreditation to privileging
• CME’s – Category 1 AMA or equivalent specific
to the CT
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Lessons Learned – Tips for Success
• One staff champion, but involve staff in acquiring
the data
• Have policies and procedures in place before
acquiring studies
• Keep a running collection of perfect studies
• Clinical correlation or peer review QA required
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Common Pitfalls
•
•
•
•
Not giving yourself enough time
Not pre identifying abnormal studies
Not sending in your best cases
Not having physician/staff modality
specific CME’s
• Not addressing previous deficiencies
• Not having QA documentation
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Reporting
• Reporting requirements are detailed
• Compliance with IAC CT reporting
requirements
• Reports need to be near PERFECT
– Compliant with the Standards
– Complete
– Interpretation reflects study findings
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How to Contact IAC CT|ICACTL:
6021 University
Boulevard, Suite 500
Ellicott City, MD 21043
Phone: 800.838.2110
Fax: 800.581.7889
Mary Lally, MS, RT(R)(MR)
Director CT Accreditation
lally@intersocietal.org
Nancy Merrill, RT(R)(M)(CT)
nmerrill@intersocietal.org
Brandy Mertz
Accreditation Coordinator
mertz@intersocietal.org
Improving health care through accreditation