Providers are pursuing accreditation with heretofore unsurpassed enthusiasm, and not just accreditation under the umbrella of a generalized program, but accreditation involving new and sometimes specialized offerings.
“The reason accreditation has become so much more important to so many more providers is that it affords outward evidence that an organization has undergone external peer review and been found to meet a certain high standard of quality,” says Marie Zinninger, associate executive director of the American College of Radiology (ACR) in Reston, Va. “In today’s health care environment, this kind of evidence means a great deal.”
Guy D’Andrea, vice president of policy for the Utilization Review Accreditation Commission (URAC) in Washington, DC, concurs. “As medicine becomes more organized,” he says, “more control is exercised at the organizational level as opposed to the individual provider level; consequently, there is a duty on the part of those organizations to attend to quality. Accreditation is a symbol that represents a commitment to quality.”
The ultimate, albeit unspoken, message of accreditation is that it removes doubt about the competence of the clinicians performing the procedures. Observers note that public anxiety over competency usually escalates in the wake of news coverage that focuses on isolated cases of botched diagnoses or on very rapid proliferation of a specific type of service or equipment. Last year, for example, the competence of ultrasound providers was questioned on a nationally televised news show.
Lynn Burnett, director of accreditation for the American Institute of Ultrasound in Medicine (AIUM), Laurel, Md, reported an upsurge in the number of accreditation applicants last year, noting that more than 1,000 practices were completing the paperwork required for AIUM accreditation by the end of 1998, a substantial increase over that of the previous year.
The push to become accredited, however, touches on every specialty in radiology. “As third-party payors become more involved in patient care, they have become aware that not all facilities provide the same level of service and, ultimately, the same quality of patient care,” Burnett says.
Adds Zinninger, “Third-party organizations are looking more and more at accreditation as a way of ensuring that the providers they are paying are delivering a quality product.”
Zinninger points to the example of Aetna US Healthcare. Late last year, Aetna announced its intent to begin requiring ACR accreditation from all of its MRI providers, Zinninger reports. Burnett notes that CIGNA Healthcare in Connecticut, TUFTS Health Plan in Massachusetts, Physician Health Services in New York and Pennsylvania, United Health Care in Florida, and Xact Medicare, Medicare Part B carrier for the state of Pennsylvania, are now similarly requiring accreditation as a condition of reimbursement.
“If the number of payors requiring some form of accreditation increases, accreditation will continue to grow,” Burnett says.
CONFLICTING STANDARDS
A problem for providers seeking accreditation from multiple accrediting bodies is the potential that one organization’s standards may require the implementation of specific quality assurance procedures that contradict the requirements of a second accrediting organization.
For the ACR, the solution to that conundrum entailed entering into a joint agreement with its leading accreditation counterpart, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Under this agreement, the Joint Commission will accept ACR accreditation decisions for radiation oncology programs that are part of health plans or integrated delivery networks seeking accreditation under the JCAHO’s Network Accreditation Program.
What prompted this accord was a 1986 query from the ACR to the JCAHO in which the former asked whether the Joint Commission would consider recognizing the ACR’s accreditation so radiology departments accredited by the ACR would not have to undergo a separate JCAHO accreditation process.
“Under our proposal that year, the Joint Commission would simply see that a radiology department was ACR accredited and accept that as proof of the department’s ability to satisfy JCAHO standards,” Zinninger says.
Joint Commission officials politely declined to embrace this plan, but left the door open to being asked again at some point in the future. In 1993, the ACR again raised the subject with the JCAHO. This time, the Joint Commission was receptive, being on the verge of launching an initiative of its own to reduce redundancy in the accreditation of health care organizations.
“The new willingness of the Joint Commission to discuss this issue had a lot to do with the changes that were occurring in health care,” Zinninger says. “In particular, there was growing interest throughout health care in finding ways to avoid duplication. The timing was right.”
The ACR selected its radiation oncology accreditation program to serve as a model. Zinninger says, “The radiation oncology program most closely parallels that of the Joint Commission program, including on-site surveyors sent every 3 years.”
JCAHO recognition of the ACR radiation oncology accreditation program took effect this past August. “We also asked the Joint Commission if it would be willing to consider a different model as well,” Zinninger continues. “We were thinking specifically of our accreditation programs for modalities in diagnostic radiology, which lack the on-site visit component. The Joint Commission agreed to consider it, and we are developing this with the JCAHO now and anticipate recognition later this year.”
Currently, Joint Commission recognition of ACR-accredited radiation oncology programs is being extended only to providers that belong to either a health plan or an integrated delivery network and are applying for accreditation under the JCAHO’s Network Accreditation Program. It is anticipated that JCAHO recognition will expand later this year to cover the gamut of providers of ACR-accredited oncology programs applying under all other JCAHO network accreditation programs.
Meanwhile, the AIUM has followed a similar route: its vascular ultrasound accreditation program is now administered through a joint agreement with the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL), Burnett indicates. However, joint agreements these days are extending beyond accreditation programs to create entire accrediting bodies. In 1997, the Society of Nuclear Medicine and its technologist section joined with the American College of Nuclear Physicians, the AmericanSociety of Nuclear Cardiology, the American College of Cardiology, and the Institute for Clinical PET to establish the Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL). Late last year, the ICANL granted accreditation to its first five pilot applicants. The ICANL currently is developing a general nuclear medicine accreditation program.
In the main, the growth in the numbers of radiology providers (and the specialties they represent) has prompted accrediting bodies to develop a broader slate of accreditation programs. The ACR, to cite one example, is developing an accreditation program that will actually be a package of specialty-specific programs.”It will be a good overall measure of a department’s ability to produce quality imaging in a number of different areas,” Zinninger divulges.
In development at the ACR are accreditation programs covering breast ultrasound, nuclear medicine, chest radiography/fluoroscopy/plain radiography, interventional radiology, and CT. These will be introduced in the order in which they become ready for rollout, with the last of them coming online no later than the beginning of 2001, Zinninger says.
(Already, the ACR offers programs in radiation oncology, stereotactic breast biopsy, ultrasound-guided breast biopsy, general ultrasound, and MRI. Its mammography program is a nationally recognized model under the federal Mammography Quality Standards Act for approximately 10,000 participating facilities.)
Zinninger says development of accreditation programs within the ACR is often driven by the organization’s membership rather than by a few key leaders. “Our stereotactic breast biopsy accreditation program is an example of a program that was developed in response to the demands of the membership,” she says. “One of the state chapters submitted a resolution requesting this program. It made the request because it needed a way to address the changing demands of its marketplace.”
Currently, the AIUM offers ultrasound accreditation in six areas: abdomen/general, obstetrics, focused obstetrics, gynecology, breast, and vascular, according to Burnett. “Each of our programs evaluates six aspects of a provider’s practice,” she explains. “First is the personal education, training, and experience of the ultrasound operators. Second is the physical facilities. Third, document storage and record-keeping methodologies. Fourth, policies and procedures currently in place designed to safeguard patients, ultrasound personnel, and equipment. Fifth, instrumentation quality assurance. Sixth, case studies and supporting documents.”
URAC requires that applicants for accreditation demonstrate that they have in place a process by which they can ensure that appropriate medical expertise is brought to bear whenever medical-necessity determinations are rendered. “For instance, our standards assert that no denial of services can be issued without first being reviewed by a physician,” D’Andrea says.
D’Andrea argues that accreditation program developers need to strike a balance between stringency and accommodation. “To attract voluntary applicants,” he says, “we must take great pains to ensure that our accreditation process is attractive. At the same time, the accreditation standards must be rigorous enough that they mean something to consumers,” he concludes.
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Rich Smith is a contributing writer for Decisions in Axis Imaging News.
