The Long And Not-So-Lonely Path To Accreditation

by Cindy Weiland, RRT, RVT
ICAVL Technical Manager

from the Summer 2002 issue

The ICAVL office often receives inquiries and comments regarding the lag time between a laboratory's submission of their application for accreditation and their subsequent receipt of notification of the accreditation decision. This article will outline the multiple steps an application undergoes during the ICAVL review process.

Upon an application's arrival at the ICAVL office, it is unpacked and organized in color-coded folders. The application floppy disk is removed from the material, and an ICAVL staff member imports the information on disk into the ICAVL database. It is at this point that the application is assigned an identification number and filed in a holding area.

Once the application is placed in the holding file, it is ready to undergo an in-house review of the organization application and a general review of the remaining application sections to assess the completeness and appropriateness of the materials submitted. This is not a review of the technical components of the application. If obvious information has not been included in the application (e.g., CME information is incomplete or an inappropriate number of case studies is submitted), the ICAVL staff contacts the laboratory to request needed information. It is advantageous to the laboratory to send this information as soon as possible, so that it can be included with the application before it is sent to the Application Reviewers. This in-house review of information does not ensure that the Board Of Directors will not request more information, but it does assist in avoiding some unnecessary delays to a laboratory's accreditation.

The ICAVL application process functions on a quarterly schedule: application deadlines are the first of March, June, September and December (or the first working day of the month if the first day falls on a weekend or a federal holiday). Following the deadline, the ICAVL staff tabulates the number of applications to be reviewed. A staff member contacts the ICAVL Application Reviewers and applications are assigned according to each reviewer's availability and expertise. All Application Reviewers are employed in accredited laboratories, are credentialed and have attended an invitational training workshop with the ICAVL. Reviewers include physicians, sonographers and technologists.

The number of applications per quarter varies, but generally exceeds 100, resulting in over 200 reviews per quarter. During this time, two laboratories are randomly selected for site visits using a computer program created for this purpose.

Once the in-house reviews are complete and applications are assigned to Application Reviewers, the completed applications are boxed and shipped to reviewers who are located throughout the United States and Canada. Over the next four to six weeks, the applications undergo a detailed review of clinical components, including the case studies, for adherence to the ICAVL Essentials and Standards.

Upon completion of each application's review, the comments and recommendations are returned to the ICAVL office, and the ICAVL Technical Manager enters the information from both reviewers into the database. The data is then compiled and reviewed by the IAC Executive Director and Technical Manager in preparation for discussion and a final review by the ICAVL Board Of Directors.

After the Board Of Directors meets and makes the accreditation decisions, the Technical Manager notifies the laboratory in writing of the Board decisions and any additional information required to grant accreditation. These notification letters are given priority and are sent in the timeliest manner possible. Two copies of the correspondence are sent, an original to the Medical Director and a copy to the Technical Director. When accreditation is granted, the certificates accompany the letter to the Medical Director and are sent UPS ground in order to provide a tracking mechanism of the documents.

As illustrated above, there are a number of avenues through which an accreditation application must travel in order to complete the cycle. The Board Of Director's meetings are held within the same months each quarter, but the dates vary based on the availability of these volunteers.

It should be reassuring to laboratories that the process of reviewing applications and determining accreditation decisions is thorough and lengthy - a fitting complement to the time and efforts put into their initial preparation by staff members seeking accreditation.

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