Accreditation: Countdown to 2012

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imageMichael Kulczycki

You know the year 2012 will be here in a blink, but as of today, no one knows which accrediting bodies will be accrediting all outpatient facilities performing high tech imaging as mandated by Medicare Improvement for Patients and Providers Act of 2008, deadline January 1, 2012. Currently, the ACR, ICANL, and The Joint Commission are the primary accrediting bodies in the outpatient imaging environment, though they each take very different approaches. Michael Kulczycki, The Joint Commission’s executive director, ambulatory care accreditation, plans for The Joint Commission to be among the accrediting bodies approved by CMS. The final criteria will be published in the final rule by November 2009, and accrediting bodies will be designated by January 1, 2010. The exquisitely short application period—just two months—underscores the tight timetable for would-be accreditation bodies.

In a presentation on Monday, Key Concepts to Use When Seeking Accreditation—How to Beat the Odds in Meeting the CMS Mandate for Accreditation, Kulczycki outlined his argument for including The Joint Commission as an accreditor, even though its systems-based and on-site approach to accreditation is far different than the remote, technology-based program currently offered by the ACR. In fact, Kulczycki anticipates that both organizations will have to make adjustments to their current accreditation programs in order to qualify as accrediting bodies.

The Joint Commission currently accredits 16,000 organizations including fixed diagnostic imaging centers, mobile imaging, interventional sites, and about 30 teleradiology providers. Ambulatory alone accredits more than 1,700 organizations representing 5,910 sites, including 10% of the freestanding imaging center market.

The process involves an onsite survey done every three years and an annual self-assessment that the provider does once a year to help them maintain compliance until the next survey date. The focus is on patient safety and staff safety, and the process is patient-centered, involving the shadowing of a percentage of representative patients.

Kulczycki says that The Joint Commission’s systems-oriented process supports the prevention of adverse events in the outpatient setting through the training of staff to deal with such events. Philosophically, this approach is in line with the government’s interest in quality and safety, as well as a risk management tool for imaging providers in what is likely to be an area of growing scrutiny. He cited an article in the March 11, 2009 issue of JAMA: Diagnostic errors: the next frontier for patient safety.

Key facts:

• MIPPA mandates accreditation by 2012 for all IDTFs and physician offices billing for the technical component for MRI, CT, PET, and nuclear medicine.
• The program will b administered by the CMS Office of Financial Management, which primarily deals with fraud and abuse.
• CMS will designate mutiple accrediting organization that qualify by January 2010.
• The proposed rule (CMS-1413-P) was published in Federal Register in early July, with comments due later this month.
• The final rule will be published by November 1, 2009.
• The proposed rule covered accreditation criteria, qualifications of non-physician staff, qualifications of medical directors, procedures to ensure quality of images, and staff safety
• For durable medical equipment providers, CMS designated 10 accrediting bodies. Kulczycki estimated that market to be twice as big as medical imaging.

To be continued!