Reaccreditation: Raising The Bar

THE ICAVL CHALLENGES LABORATORIES TO KEEP IMPROVING AND EVOLVING

from the October 2005 issue

While the ICAVL Board of Directors has taken steps in recent years to streamline the application process for laboratories that have been previously granted accreditation (i.e.: fewer case studies required), the expectations for laboratories seeking reaccreditation are high. As outlined in detail below, when it comes to areas such as compliance with CME standards, the use of current testing protocols, documentation of quality assurance measures, consistency among final reports, adherence to diagnostic criteria and hardcopy documentation for case studies, laboratories that have already been through the accreditation process at least once are expected to demonstrate continual improvement, particularly in these crucial areas.

Currently there are approximately 1,100 vascular laboratories in the United States, Canada and Puerto Rico accredited by the ICAVL. Some of these laboratories have been granted accreditation as many as six times by the ICAVL. Each quarter there are between 100 and 120 laboratories that submit applications for accreditation. Of these applicants, just over 80% are applying for reaccreditation of their laboratory. Each quarter nearly 65% of the laboratories applying for reaccreditation receive a delayed accreditation decision, due to lack of adherence to one or more of the ICAVL Standards.

The Standards are reviewed and revised by the Board of Directors every two years. All laboratories that have purchased the accreditation material are notified of the standard revisions and encouraged to read the revisions and make any necessary changes to the laboratory policies and procedures at that time.

Below is a summary of some of the most common errors or exclusions noted in applications submitted for reaccreditation, and ways to potentially avoid a delay or lapse in your laboratory's accreditation status.

Application Deadlines

The ICAVL application deadlines do not change and are as follows: December 1, March 1, June 1, and September 1.

• The ICAVL attempts to assist labs in avoiding a lapse in their accreditation status through reminding applicants of the application deadline they must meet through two pieces of correspondence. The reaccreditation reminder letter is sent twelve to fourteen months prior to the application deadline, followed by a reminder postcard approximately six months before the required submission date. Keep in mind that the review process takes four months to complete. Therefore, the reaccreditation application must be submitted at the deadline that falls on the first of the month, four months prior to the expiration date listed on the laboratory's current accreditation certificates. The accreditation will not be extended under any circumstance and failure to meet the required deadline will result in expiration of the accreditation.

Accreditation Agreement

A substantial number of applicant laboratories experience a delay in receipt of their accreditation decisions rendered by the Board of Directors due to problems with the Accreditation Agreement. The Accreditation Agreement is a legal contract between the applicant laboratory and the ICAVL and a new Agreement must be completed and sent at the time of every application submission.

• The most current Accreditation Agreement and Business Associate Agreement can be completed and printed from the ICAVL website at: www.intersocietal.org/icavl/apply/agreements.htm. When completing these documents, be certain to answer all questions as they pertain to your laboratory and to obtain the appropriate signatures. The original document must be sent to the ICAVL and after final review of the text, the ICAVL will return a copy to the laboratory. As well, be aware that any changes to the content of the Agreement must have prior approval by the ICAVL.

Application Data Disk

As part of the complete application that is prepared for submission to the ICAVL, an application information disk must be included in order for the ICAVL to upload the laboratory information into our database. The application data disk is required in order to proceed with the application process.

• As the last step for the laboratory staff members preparing an application for submission, a disk containing the most current data must be created. Instructions for creating the disk can be located by clicking the icon located on the main menu of the application.

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