Accreditation and Radiology
Accreditation is important to radiology providers not only in ensuring reimbursement eligibility and protecting turf, but in creating the opportunity to make needed operational changes, according to David M. Yousem, MD, MBA. Yousem, who is professor of radiology and director of neuroradiology at Johns Hopkins Medical Institutions, Baltimore, Maryland, is the co-editor of Radiology Business Practice: How to Succeed.¹ At the Economics of Diagnostic Imaging conference in Arlington, Virginia, he drew on that text to present “Credentialing, Accreditation, and Certification” on October 24, 2008.
David M. Yousem, MD, MBA
In the accreditation portion of his presentation, he covered the need for site accreditation by the ACR for all radiology providers, and by the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) for hospitals. Good standing with both state and federal regulatory agencies is one of that organization’s requirements, which have focused on the quality and safety of health care since the organization was founded in 1951. Joint Commission Accreditation Certification of programs and services within the health care organization is also a function of the Joint Commission; examples of certified services include cardiac care and kidney-disease care. Certification in radiology, however, is usually considered part of the physician’s training process (for example, board certification), not as part of the facility’s service/program validation. The Joint Commission’s on-site surveys are a major part of the accreditation process. These were once scheduled events that were preceded by a flurry of preparatory activity intended to ensure that the facility met accreditation standards and could show the site reviewers the records needed to prove this. Today, however, reviewers’ site visits are unscheduled (random and unannounced); because the on-site survey can take place at any time, health care organizations must stay prepared for review at all times by making survey readiness an ongoing process. Yousem notes that his facility uses this opportunity to make changes, calling it an excellent motivator for putting things in order. Under the new system of unannounced site reviews, there is a far larger chance that any changes that are made in order to bring the facility into better compliance with accreditation standards will then become permanent alterations. The older system, he says, promoted pulses of improvement with periods of deterioration between Joint Commission reviews. In radiology, accreditation is based less on the quality of physicians’ work than on that of administrators, technologists, and staff. It does, however, consider the facility’s activities in physician credentialing [see part 2 of this article in the July 2009 edition] and the physicians’ certification and recertification status. Another part of the accreditation process involves self-review, with plans being developed by the facility itself and then submitted to the Joint Commission for review and approval. These plans can cover areas that may not be part of on-site surveys. During the on-site reviews, the Joint Commission now uses what it calls tracer methodology, following the course of a real patient through the entire hospital experience. This begins with admission and includes transport to the nursing floor, care while there, diagnostic/therapeutic procedures and other interventions, discharge planning, social work, and discharge itself. This method replaces what Yousem describes as the broad strokes that were previously the norm with a detailed review of individual patients’ records. The surveyors focus intently on the quality of care, as reflected in these records, and try to identify the weakest points in the system. Among the most common flaws pointed out by the Joint Commission and other accrediting bodies is poor documentation of programs’ safety standards, Yousem notes, in addition to poor oversight and supervision of patient care, failure to verify that the facility meets basic requirements, and inadequate review of problems pointed out by the site surveyors. Being ready for Joint Commission inspections, Yousem says, is an important activity because those inspections act to give the entire facility a tune-up, with preparation and response involving nearly all staff. Internal assessment of the facility’s performance is a side benefit, and this creates an opportunity to establish new standards wherever they are needed. When the Joint Commission gives its Gold Seal of Approval™ to a facility, Yousem says that this should be both recognized by employees and advertised to the public as a statement of quality. ACR Accreditation Site accreditation is also conducted by the ACR, using a process that differs from that of the Joint Commission. ACR accreditation is a demonstration of quality required by some insurers, and Yousem says that it is a distinction that every radiology facility should acquire. This accreditation is a means of distinguishing between the high quality of imaging and patient care provided at a radiology facility and the lower levels likely to be found where imaging is provided by nonradiologists. About 95% of radiologists meet the criteria of the ACR accreditation process if they undergo it; the pass rate is similar for cardiologists, but is much lower for orthopedists, obstetrician/gynecologists, internists, podiatrists, and chiropractors. When the radiology community asks CMS and other payors for differential reimbursement for imaging, ACR accreditation is one of the indicators of high quality that the field can use to make its case, Yousem says, because it shows that an important high standard of patient care is being upheld. When accreditation failure occurs under ACR criteria among nonradiologists, it tends to be due to deficits in the quality of images produced and/or to the unavailability of written reports. In addition, Levin and Rao2 found, 20% of nonradiologists’ facilities had not undergone any equipment inspections during the previous year. Nearly four-fifths of nonradiologists’ imaging facilities can exhibit deficiencies in one or more of five key areas. In addition to poor image quality and lack of reports, these are errors in marking right and left on images, in film storage and handling, and in patient identification. It is these kinds of findings that clarify the importance of accreditation as tool to reduce self-referral, Yousem notes. Where self-referral is prevalent, the quantity of imaging increases and its quality decreases,2 creating not only reductions in the quality of patient care, but an escalating cost burden for the United States as a whole.1 ACR accreditation is particularly valuable in ensuring the provision of safe, high-quality imaging services, Yousem adds, because it serves to weed out providers unwilling to upgrade their operations. In Massachusetts, for example, when Blue Shield began to require ACR accreditation for imaging reimbursement, nearly 18% of providers dropped out before attempting to gain accreditation, and about 38% of podiatrists, chiropractors, and internists failed to achieve it (as did 17% to 25% of obstetricians and orthopedic surgeons). Only about 5% of radiologists and cardiologists failed to gain ACR accreditation.2 The effort involved in pursuing accreditation yields rewards that go far beyond turf protection and reimbursement eligibility, Yousem concludes, because the process of preparing for accreditation helps the practice perfect its operations. While it attempts to prove its quality of care to the accrediting body, it is simultaneously acting on several fronts to ensure and improve that level of quality, becoming the best imaging provider that it can be.