IAC Echocardiography Pediatric TEE
Add-on Supplement
An additional testing area (or areas) may be added to a facility’s current accreditation at any time during the threeyear accreditation cycle. Accreditation is granted only for the specific testing areas for which a facility has applied
and submitted an application. Though facilities may be performing other testing in the facility, those areas are not
covered under the accreditation until an application for the specific testing type is submitted and granted
accreditation. The following form is to be used for supplemental testing only. If your facility is not currently
accredited in Echocardiography please contact the IAC.
Please answer all questions, required attachments will be indicated by the  symbol. Case studies requirements are
listed on page two.
Name of institution (as listed in the IAC Accreditation Agreement):
(This institution name will be tracked in the IAC database and will receive all IAC correspondence)
Department:
Street Address 1:
Street Address 2:
City:
State:
Zip code:
Location of Echocardiography facility:
Hospital (number of beds:
Private Office
Freestanding imaging center
Independent facility
Other (specify):
)
1) Enter the total number of procedures performed in the facility(s) annually by type of examination. This includes
all sites and mobile locations.
Transesophageal Echocardiography:
2) Does the Medical Director interpret TEE echocardiography exams in this facility?
Yes
No
3) Enter the average annual volume of studies interpreted by the Medical Director in this facility:
(Applicable Standard: Part 2.3B):
IAC Echocardiography PTEE Add-On Supplemental Form
Reviewed 11/2014
1
4) Please list the medical staff that interprets TEE studies and their annual TEE volumes:
Interpreting Physician
Annual TEE Volumes
Enter how many minutes are allotted for each of the following echocardiogram procedures from patient
encounter to patient departure in the facility (Applicable Standard: 2.5.2B):
Initial complete TEE echocardiogram:
 Submit a copy of the facility-specific, step-by-step TEE Echocardiography protocol.
PEDIATRIC TEE ECHOCARDIOGRAPHY CASE STUDIES:



1 case per physician that includes a complete examination (not limited) including all of the views listed in
the Standards.
Cases submitted with the application must not be independently performed by physician trainees.
All cases must be selected from within the past 12 months from the date of application filing.
Note: Although “limited” or shorter pathology-directed TEE exams may be appropriate in some circumstances,
these are not the types of cases that should be submitted for the purpose of facility accreditation review.
Intraoperative TEE may be submitted if the facility physician performed the entire study including:




Passing the probe
Image acquisition and documentation
Reporting
Imaging archiving on echocardiography laboratory archiving system
IAC Echocardiography PTEE Add-On Supplemental Form
Reviewed 11/2014
2