Getting The Most Out Of Your
Application Review Findings

from the October 2004 issue

Historically, after completing the accreditation process, laboratories received a critique letter outlining the areas in which the laboratory was found to be deficient or non-compliant with The ICAVL Standards. Approximately two years ago, the ICAVL made the decision to modify the feedback sent to the applicant laboratories.

With the advent of new forms used by the Application Reviewers, it was decided that in lieu of the previously sent critique letter, the laboratory would receive a copy of the actual review forms completed by the Reviewers. Due to the potential length of this document, it is currently being sent to the laboratory medical director on a CD, as a component within the final accreditation portfolio. The remainder of this article is meant to clarify the content and use of the Application Review Findings (ARF) documents. Portions of the ARF documents are located on pages 6 and 7 for reference. (See Examples 1 and 2.) The CD you receive will look similar to the graphic shown at the right. >>

After inserting the CD into your computer, open the disk and locate the file. Upon opening the file you will view a document that looks similar to the example shown below. Currently the file is a Word document; however, in the near future, the format of these documents will be changed to an HTML document. Though the format will differ, the information will be organized in the same fashion and the tips below will still apply.

EXAMPLE 1 [ View Example 1 ]

Each area of the application submitted by the laboratory will be included in the ARF. At the beginning of each section, the header will indicate the specific application section (Example 1A).

Though at first the document might appear confusing, it is actually organized so that each area of questions is numbered in accordance with the ICAVL standard that applies to the section (Example 1B).

The questions under each numbered section coincide with The ICAVL Standards. To the right of each question are boxes labeled Yes, No, NA, Performed, and/or Incomplete. Some of these boxes will be marked with an X to indicate the Application Reviewers' finding when completing the review of your laboratory's application (Example 1C).

There are areas in which the Application Reviewers may perhaps add additional comments (Example 1D). The goal of the application review is to make it as objective as possible by utilizing questions that pertain directly to The ICAVL Standards. Consequently, there are not always additional comments included. If a question is answered No, the laboratory can refer to the standard in question for additional information that will clarify the ICAVL requirements and provide an explanation as to why the Reviewer chose No.

EXAMPLE 2 [ View Example 2 ]

The forms completed for the case study reviews are slightly different from the application documents review (Example 2). The initials of the patient names are included so that the laboratory can refer to the examination under review (Example 2A). Also of note is the scoring legend located at the bottom of the page (Example 2B). Space is once again provided for the Application Reviewers to make comments if applicable (Example 2C).

The Application Reviewers mark the boxes for each component of the case study, in accordance with the requirements of The ICAVL Standards. When reviewing your laboratory's case review findings, keep in mind that, as stated earlier, the goal is to have the application review remain as objective as possible. There will always be a margin of personal subjectivity when scrutinizing the case studies.

Frequently, laboratory staff will contact the ICAVL office to defend or refute the "grading" of the case studies or the content of the application review. The ICAVL encourages all laboratories to look at the results of this peer review as constructive and realize that, occasionally, slight inaccuracies occur. It is always difficult to accept criticism; however, it can be used as a valuable tool in assessing and refining the work performed in your laboratory.

As always, if you find that there are remaining questions concerning the Application Review Findings and would like further explanation, please contact the ICAVL at 410-872-0100, or toll-free at 800-838-2110.