Most people dread accreditation. The paperwork and the time is a drag. "How do you enjoy this?" is a question I hear often. But I will let you in on a secret. Accreditation is a lot easier than people know!
Judith Buckland, president of CardioServ.In addition, the entire team at the Intersocietal Accreditation Commission (IAC) is phenomenal to work with. The IAC group consists of friendly, smart, and extremely helpful people. We interviewed Sue Jensen, a senior clinical specialist at the IAC, to discuss the culture at the commission and to gain some insight on the accreditation process. We addressed common accreditation process misconceptions, including delayed status, and discussed noncompliant staff and many other pearls of wisdom.
CardioServ: Does the Intersocietal Accreditation Commission expect perfection?
Sue Jensen: It does not. Sonographers and physicians are human beings taking care of other human beings, and, that being said, we understand the challenges that occur daily in the healthcare environment. The IAC process is designed to enable facilities to self-evaluate, learn from the feedback provided by the peer review, and make continuous improvements to provide the best care for their patients. Accreditation applications are reviewed, and related feedback is provided to enable facilities to improve and excel with each consecutive application.
What is the one greatest recommendation you would like to give every lab hesitating to submit their accreditation application?
Just jump in and test the water. You will be surprised how easy the process is and how supportive our staff will be.
What makes you passionate about accreditation as a tool for improving quality?
I have always believed in putting the patient first and doing the best that I could to provide the cardiologist with all the information necessary for excellent patient care. I see accreditation as focusing on enabling the facilities (sonographers and physicians) to be the best that they can be by holding them accountable for meeting high standards and, thus, providing the best for their patients. I also find that accreditation improves communication between technical and medical staff members, which then improves the overall quality of care.
What is your clinical background, and how did you end up at the Intersocietal Accreditation Commission?
I have been a cardiac sonographer for 36 years and credentialed through the American Registry for Diagnostic Medical Sonography (ARDMS) for 33 years. I have worked in various settings performing echocardiograms (private office, hospitals, and mobile imaging service). I joined the IAC staff in 2014 as I felt it was a great fit and a wonderful next step in my echo career.
What do you love most about working at IAC?
The dedication of the staff in assisting facilities in being the best that they can be. And I really enjoy talking to sonographers and cardiologists from all over the country on the phone and being able to help them achieve accreditation.
If you were to describe the culture of the Intersocietal Accreditation Commission in one word what would it be?
Invested.
Which team approach is used that benefits applicants?
Everyone on the team strives to become an expert on all aspects of accreditation, and then together the whole team better assists labs through the accreditation process, without having to transfer callers, etc.
Is a "delayed status" notification bad?
No. Each application is carefully reviewed, and when there are areas of noncompliance with the standards, we ask for further documentation. Once these delay issues have been reviewed and remedied, accreditation is granted.
As I mentioned earlier, oftentimes, we see that a delayed accreditation status can actually help give a facility leverage to alleviate issues that were otherwise ongoing. It can actually be very positive. From a staff perspective, we make it a priority to react quickly to submitted delay materials to enable facilities to attain accreditation as efficiently as possible.
How should a facility handle a physician who is noncompliant in an area (continuing medical education, report turnaround time)?
Go ahead and submit, and then let the IAC provide the feedback that the physician is noncompliant with the IAC standards and, thus, holding up accreditation for the lab. Oftentimes, we see that a delayed accreditation status can actually help alleviate issues related to a few members of the facility who are noncompliant. It is a powerful statement when the national accrediting body points out why a facility is not meeting the standard of care illustrated by accreditation, and most individuals are willing to react positively to see their facilities' come into compliance.
What are some of the most common mistakes or areas for improvement that you see on applications?
Ironically, it's not solely clinical issues that cause facilities to have delayed accreditation. Many noncompliance issues are related to the applicant facility's staff not reading the questions completely and then not submitting the required documentation. We offer resources to help facilities avoid this, such as the sample documents on our webpage and utilization of the new quality improvement self-assessment tool. Also, labs often jump in to work on the application first rather than taking the time to fully read and share the standards to make sure they are in compliance (e.g., protocols missing required views).
What is the intention of audits?
As accreditation is granted for a three-year cycle, it is critical to ensure that ongoing compliance is occurring and is not simply a one-time "snapshot" of the facility's functions and quality. Audits are a mechanism for ensuring that the accredited facility is maintaining compliance with the standards.
How does IAC help applicants?
Our No. 1 priority is being a resource to applicant facilities. We encourage sonographers, physicians, or anyone else working on their echo facility's application to contact us anytime. We are easily accessible by phone, email, and live chat to answer all questions they may have about accreditation. For facilities that are working on their reaccreditation applications, we present two live webinars yearly in which changes are pointed out. But again, we're always happy to have those conversations one-on-one with a more casual phone call.
What resources do you feel are underused and maybe not even known about?
While we strive to offer our live webinars at times that will meet the scheduling needs of most, we understand that they sometimes interfere with patient testing times, etc. Links to the recorded versions can be found on the IAC website to view whenever convenient. Also, the live chat feature is really convenient and can be a great resource for a busy sonographer wanting to ask us a quick question in between patients.
5 things you now know about accreditation
We enjoyed interviewing Sue Jensen, a clinical specialist at IAC. As consultants, we thoroughly enjoy working with IAC. They are an accrediting organization that has consistent values followed by all. We hope you gained some insightful tips.
Here are five things I hope you take away from our interview:
- Your application does not have to be perfect.
- You may never feel ready to submit -- submit anyway!
- Let the reviewers render a decision.
- A delayed status is not the end of the world and is often a helpful way to keep moving!
- The staff at IAC are awesome!
Thank you, Sue and all the hard working team members at IAC. As we celebrate Medical Ultrasound Awareness Month, we are happy to spotlight an organization dedicated to improving the field of ultrasound. IAC may be short for Intersocietal Accreditation Commission, but to me IAC is short for Insightful Awesome Champions!
Judith Buckland is president of CardioServ, a consulting firm focused on inspiring excellence in diagnostic imaging. Judith can be reached by email at [email protected] or via CardioServ's website.
The comments and observations expressed herein do not necessarily reflect the opinions of AuntMinnie.com, nor should they be construed as an endorsement or admonishment of any particular vendor, analyst, industry consultant, or consulting group.
