Delayed Decisions And Their Effect On Reaccreditation

from the Fall 2001 issue

Seeking reaccreditation? The impact of a delayed decision on laboratories seeking reaccreditation can be significant. All accredited laboratories receive a notification letter twelve months prior to the expiration of their accreditation. It is crucial that laboratories apply by the deadline specified in this letter and submit a complete application without significant deficiencies.

Board meetings are generally scheduled within two weeks of the expiration dates on certificates. Following the date of that Board meeting, laboratories will no longer be considered accredited if the Board decides to delay laboratory accreditation for specific deficiencies. Laboratories are automatically deleted from the list posted on the ICAVL website once their accreditation has expired. Because Medicare, third party payers, referring physicians and patients refer to the list, a lapse in status can affect billing or community relations. In addition, the ICAVL logo affirming the laboratory's status as an "Accredited Vascular Laboratory" must be removed from any materials, along with any other references to accreditation by the ICAVL, by any laboratory that does not maintain its accreditation.

There are several steps that laboratories can take to increase the likelihood that accreditation is attained without any delay.

• The first step in preparing for accreditation is to review the critique letter sent to your laboratory when accreditation was last achieved. Be certain to correct any deficiencies or inconsistencies that are addressed in the letter.

• Verify that your laboratory is adhering to the current edition of the Essentials and Standards. Dates of revision are listed in the footer of every page. Verify that the date on your materials corresponds to those on the web or contact our office to make sure you are using the correct edition.

• Be certain that all case studies document your laboratory's adherence to the Standards. For example, approximately 50% of venous applications are delayed because laboratories fail to document Doppler insonation of the contralateral common femoral vein in unilateral cases and/or because they have not revised protocols to reflect its documentation.

The most common reasons for delay in Extracranial Cerebrovascular, Peripheral Arterial and Visceral Vascular testing are insufficient documentation of complete examinations or erroneous Doppler angle correction techniques. The Standards clearly outline the minimum number of images and Doppler samples required for each vascular examination.

A number of laboratories are also delayed for insufficient numbers of quality assurance correlation. With the exception of Peripheral Venous testing, the Standards specify minimum numbers of correlations required for reaccreditation in each area of testing. For example, laboratories are now required to submit a minimum of 30 internal carotid artery correlations with radiographic and/or surgical results over the past three years. A more detailed article regarding quality assurance will appear in the next issue of the newsletter.

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