From Application To Accreditation

from the Spring 1999 issue

The staff of the ICAVL knows our UPS and Federal Express deliverymen well. Every three months, on the first day of the month, they wheel box loads into our office that they say rival delivery loads during the holiday season. Anyone who has completed an application for accreditation is aware of the quantity of documents necessary to thoroughly demonstrate the quality of examinations performed in a laboratory. To calculate the amount of paperwork received by the ICAVL on each quarterly application deadline, multiply the size of your application by 210 (a quarterly average of 105 applications, 2 copies of each application), and you'll understand why the delivery people know each of our staff members by name.

Once applications are received, we initiate a four-phase process of review, during which every application receives several individual reviews, each by a trained staff member, reviewer or Board member and each review with a very important objective. Ensuring that every laboratory receives the same comprehensive review requires 10 to 12 months; however, we recently improved our timeline so that accredited laboratories receive their Accreditation Portfolio, containing certificates, a press release, and the camera-ready logo, only 19 weeks after submitting their application (within 2 to 3 weeks of the decision date).

Phase One: In-House Review -- 10 to 12 Weeks

The goal of phase one is to ensure that every application is as prepared as possible for the ICAVL reviewers. Upon arriving at the ICAVL office, each application is assigned a number and laboratory information is logged into our database. Applications are then checked for completeness to ensure that all questions have been answered, attachments included and case studies adequately documented. Often, mistakes made by laboratory personnel are due to their unfamiliarity with our process. While time and labor-intensive, the first phase of the review process allows every laboratory an equal opportunity to achieve accreditation. If additional information is required, the laboratory is notified in writing and by telephone. Once the requested information arrives, it is added to the appropriate section of the application and filed by application number, fully prepared for the reviewers.

As applications are checked for completeness, two laboratories are randomly selected to receive site visits. Completed prior to the application review, random site visits are a means to internally validate the accreditation's process by assessing the accuracy of the ICAVL's paper document review. The names of new applicant laboratories for that quarter are entered into a computer database designed to select two laboratories on the basis of a pure random number generation program. As such, every laboratory has an equal opportunity to be selected for a random site visit. Unlike traditional site visits, which are necessary to validate and clarify the information provided in the application, random site visit costs are paid entirely by the ICAVL. Laboratories selected for random site visits are notified within two weeks of the application deadline, and the visit is conducted during the 10 to 12 week time frame for in-house review.

During the first phase, the ICAVL Technical Manager assigns each application to two reviewers. Presently, the ICAVL has more than 100 trained application reviewers, all members of accredited vascular laboratories throughout the United States and Canada. To avoid possible conflicts of interest, no reviewer receives the application of a laboratory of which they may have personal knowledge. In addition, to maintain the confidentiality of the application process for all laboratories, the identity of the reviewers is never disclosed to any laboratory.

Phase Two: External Review And Board Of Directors' Meeting -- 3 to 4 Weeks

The second phase, in which the application reviewers and Board of Directors evaluate the applications, occurs outside of the ICAVL office. All documents are carefully examined. In addition to providing a decision recommendation to the Board, reviewers meticulously record their observations, both positive and negative, of each application. They have no contact with applicant laboratories or with other reviewers. While the technical manager is available to answer questions for the reviewers, their recommendations rest solely on the merits of the presented application.

The technical manager and Sandra Katanick, Executive Director of the ICAVL, consolidate the recommendations of the reviewers for presentation to the Board. Comparing the documentation of the two reviewers allows the Board to discuss any areas of concern before reaching a conclusion. The following decisions are available to the Board: accreditation granted; accreditation deferred due to missing information; accreditation delayed until compliance to the Essentials and Standards can be demonstrated; site visit to determine compliance with the Essentials and Standards; or accreditation denied.

Phase Three: Laboratory Notification -- 2 to 3 Weeks

Following the Board Meeting, the technical manager collates all final decisions and enters them into the database. Laboratories are always notified of their decision in writing, and the technical manager immediately writes the letters of notification to the laboratories. Along with the letter, accredited laboratories receive an Accreditation Portfolio containing certificates, a press release, and the camera-ready logo. Laboratories that attain accreditation in one or more testing areas but are delayed or deferred in one or more of the other areas receive the certificates and recognition materials for the appropriate areas immediately. For these laboratories, the technical manager composes a letter explaining the current status and specific instructions for successfully correcting cited deficiencies in the other testing area(s). Similarly, laboratories that are deferred, delayed, denied or determined to require a site visit receive a letter stating their current status and instructions to proceed.

Phase Four: Laboratory Critique -- 4 to 6 Months

Mailed within four to six months following the Board Meeting or a laboratory's correction of cited deficiencies, the critique letter is a detailed evaluation written to outline the strengths and weaknesses of each laboratory. The Essentials and Standards are minimal requirements for accreditation, meaning that even those laboratories that attain accreditation should use the experience as a tool for continued improvement of the care provided. The critique letter should be used as the foundation for continued learning by laboratory staff. When applying for reaccreditation every three years, laboratories will need to demonstrate that they have addressed the issues raised in the critique letter as part of their commitment to patient care.

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