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The added value of accreditation

Radiology Administrator's Compliance and Reimbursement Insider, June 1, 2006

Obtaining Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) approval can be harrowing enough for a healthcare facility.

But many radiology administrators and big-time insurers believe that the JCAHO’s seal of approval may not be stringent or specific enough to meet radiology’s quality needs.

Enter the American College of Radiology (ACR).

The nonprofit group offers accreditation in nearly every radiological modality, from mammography to ultrasound and magnetic resonance imagery (MRI) to PET. Although each modality comes with its own set of criteria, ACR judges quality on basic overarching themes from staff qualifications to machine optimization and patient records to image quality.

“We would never think of not having ACR accreditation,” says Shannon Gutierrez, RT, director of radiology at North Texas Hospital in Denton. “It’s just an automatic part of running things.”

Although ACR’s accreditation process has been around since 1963, Gutierrez says only three major hospitals in her geographical area have received accreditation, meaning that most others—including outpatient and independent imaging facilities—haven’t.

Although North Texas Hospital maintains accreditation from the JCAHO, it also received ACR accreditation for MRI services in February. It sought accreditation partly because a major area payer requires it and partly because of what accreditation means for overall business and quality imaging, she says.

Payment for quality

Several insurers require some type of accreditation, generally in MRI, CT, or PET for radiology reimbursement, says Leonard Lucey, legal counsel and senior director of nonbreast imaging accreditation for ACR.

Insurers requiring ACR accreditation for MRI services include Aetna U.S. Healthcare, Blue Cross of California, and New York Medical Imaging, among others, according to a recent article by Auntminnie.com.

“Two to three years ago, there was a major push from third-party payers for radiology programs to have accreditation to qualify for reimbursement, but that has slowed down a bit since then,” says Lucey.

A few state legislatures, including those of Connecticut and Rhode Island, require ACR accreditation of any physician who performs MRI imaging to ensure the quality of in-office MRI exams.

Accreditation choices

Although some radiology facility directors see ACR accreditation as a no-brainer, others slough off the association’s process, citing the JCAHO as the premiere accreditation body. Still others, such as Barbara Ana Perez, MSM, RT, (R)(M)(QM), RDMS, director of imaging and therapeutic services at Jackson Memorial Hospital in Miami, participate in both JCAHO and ACR accreditation and with other accrediting bodies as well.

Discerning which guidelines applied to which accreditation body used to be like playing pin-the-tail-on-the-donkey, says Perez. But now the various standards essentially complement one another.

For example, the JCAHO concerns itself with credentialing, patient flow and processing, patient safety, medication errors, etc.

ACR “takes it one step further,” Gutierrez says. It examines film quality and resolution and requires phantom testing and case-analysis to ensure the accuracy and quality of each reading and therefore the quality of patient care, she says. And ACR checks that technologists are certified and specifically trained on the machine that they operate, says Gutierrez.

“ACR examines the radiology department and has great expertise in that field,” says Kurt Patton, MS, RPh, former executive director of the JCAHO’s hospital accreditation program.

The JCAHO looks outside of the radiology department to see how it interfaces with the rest of the hospital. ACR looks more in-depth within the department, says Patton.

The JCAHO does not claim to have expertise in clinical radiology, but it does have expertise regarding how radiology interfaces with other clinicians who rely on radiological services, he says.

The bottom line is that most hospital-based radiology departments will be JCAHO-accredited, but not all will be ACR-accredited, Lucey says. And although many freestanding facilities boast ACR accreditation approval, many more maintain only the minimum quality requirements specified by third-party payers or state and federal regulators.

But if Gutierrez had her druthers, both the JCAHO and ACR sets of inspections would be standard. “They each offer different things. For me, a combination [would] represent the best of both worlds.”

Paperwork and other problems

The most difficult part of handling any accreditation process—whether by the JCAHO, ACR, or another accreditor—is the sheer volume of an operation.

At least that’s the case for Perez and her counterpart Joan Maddix, RN, BSM, Radiology Quality Assurance Manager at Jackson Memorial.

With more than 300 full-time employees, making sure that everyone follows proper protocol takes organization and communication skills.

So on every pay day, employees receive a JCAHO newsletter. In the newsletter, Maddix places JCAHO facts and patient safety tips along with other relevant information.

At Jackson, a special committee examines best practices for administering medications. Radiology administrators complete monthly dashboards about incident reports, patient safety, and the like.

“With a department this size, sharing information is vital,” says Maddix.

To make matters more difficult, Jackson isn’t yet a digital entity, although it plans to be 100% electronic with a complete radiology information system update later this year.

“It’s a slower process not being digital,” says Perez. “But I have to give this department credit; the amount of follow-through is wonderful. Everything here has a paper trail. We’re in line with all the qualifications. But being digital will make it that much easier.”

The cost, time, and organization associated with accreditation processes worry Gutierrez. “The process takes a long time, and we have to wait to gather all the appropriate scans [that] ACR requires.”

For example, North Texas Hospital completes many neurology scans, but not many knee exams. ACR wants to see competencies for every variable on a given machine—in this case, an MRI, Gutierrez says.

The process has to be completed within two weeks unless the facility applies for an extension. North Texas Hospital obtained an additional two weeks for its knee exams.

Fortunately, Gutierrez and her staff were able to complete all of the ACR paperwork during normal working hours thanks to their combined experience and built-in quality training and assurance programs, she says. “Some facilities have a difficult time getting through the process, especially their first time. But we are fortunate to be adamant about quality control here. It makes the process a lot easier.”

Insider sources

Shannon Gutierrez, RT, director of radiology, North Texas Hospital; 2801 South Mayhill Road, Denton, TX, 76208; sgutierrez@allianceimaging.com.

Leonard Lucey, American College of Radiology, legal counsel and senior director of nonbreast imaging accreditation, 1891 Preston White Dr, Reston, VA 20191, 703/648-8900; llucey@acr.com.

Joan Maddix, RN, BSM, Jackson Memorial Hospital, 1611 NW 12 Avenue, Central 253 E, Miami, FL 33136-1096; 305/585-5381; jmaddix@um-jmh.org.

Kurt Patton, MS, RPh, former executive director of the JCAHO’s hospital accreditation program.

Barbara Ana Perez, MSM, RT, (R)(M)(QM), RDMS, director of imaging and therapeutic services, Jackson Memorial Hospital, 1611 NW 12 Avenue, Central 253 E, Miami, FL 33136-1096, 305/585-5381; Bperez@um-jmh.org.

Follow these five steps to ACR accreditation

Getting that big manila envelope in the mail from the American College of Radiology (ACR) represents the first step in the seemingly monumental paperwork and review process necessary to earn accreditation from the agency. But don’t despair. The following tips will help you survive and conquer your ACR accreditation:

1. Know your quality-control standards. ACR committees developed quality-assurance standards for nearly every modality of radiology to help hospitals and freestanding facilities establish and maintain their own quality programs. Understand which scans ACR deems acceptable and which reviewers may mark with red flags. Document your procedures and administer them throughout the entire year. This helps make the accreditation process run smoothly.

2. Keep accurate records and make duplicates of them, especially if you have off-site locations. Sometimes files get lost, so make a copy of everything that you send to ACR and keep the copies on file at your facility as back-up. That way, if ACR reviewers ask questions, the paperwork and potential answers remain at hand.

3. Perform every patient’s image as though you need to send that film to the ACR for approval. Always send your best-quality work after it has been reviewed and approved by your radiologist. Use all of the resources available. The ACR manual is a great resource, but also ask the physicist and the radiologist for assistance. Do not try to do it alone.

4. Meet the application deadline. Submit your renewal application six months prior to the accreditation expiration date and return test materials to the ACR within 45 days. If you don’t, you may not complete your review before the expiration date.

5. Use the following tips when submitting phantom images:

-Make a test shot without a dosimeter

Verify that the four largest fibers are present

-Make sure that you can see the three largest speck groups

-Ensure that the image has an adequate optical density

-Give all clinical images to a supervising radiologist to review and approve before submission to ACR

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