Accreditation and Radiology

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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.

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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