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5) WRITE A POLICY FOR EACH QA
PROCEDURE.
State the purpose, establish the criteria, outline
the means of assessment and describe the action taken.
- which area/monitor will be assessed
- how often or for how long
- what is the threshold for acceptance
- determine cause if results are below accepted
limits in order to improve
- define how the laboratory will resolve poor
performance and make corrections
- document the review and dissemination of
information
- discuss at QA meetings
In summary, create your own organization plan
for developing a QA program, or follow one of the sample guidelines
from the ICANL website, under Sample Documents (www.icanl.org/icanl/apply/sampledocs.htm).
Determine the scope of quality assessment for the facility.
Identify the goals of a QA program that best fit the type of
service and volume provided by your laboratory. Organize the
procedures to be followed for each area to be assessed. Design
a plan to measure, assess and improve your nuclear medicine
laboratory by using the resources available through the ICANL
and its supporting organizations: the American College of Cardiology
(ACC), the Academy of Molecular Imaging (AMI), the American
Society of Nuclear Cardiology (ASNC), and the Society of Nuclear
Medicine (SNM).
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SOME OF THE QUESTIONS
MOST OFTEN ASKED...
Q. How many kinds of QA must I perform
in each designated area?
A.
The ICANL recommends several types of QA in each area.
You should perform at least one form of technical, adminstrative
and interpretive QA each year.
Q. How often should QA be performed?
A.
Each nuclear medicine facility should decide what would
work best for them and whether monthly, quarterly or yearly
studies are feasible depending on the size of the department.
Q. What are acceptable limits and how
does one decide?
A.
The office or department QA committee, medical director
and technical director should decide what is appropriate
for their laboratory based on scope of practice, number
of studies performed and number of staff. 100% is not
necessarily a realistic goal. Anything below 80% should
be marked for action to improve or correct.
Q. How many patient studies must be
evaluated for technical and interpretive QA?
A.
The size of the laboratory, and the number of studies
performed should help determine for each facility the
appropriate volume to assess. Generally a minimum of 10
- 25% of the annual volume should be included in a quality
assurance survey.
Q. Why does the ICANL recommend that
applicants submit patient and physician satisfaction surveys?
A.
Patient satisfaction and physician satisfaction surveys
are considered reasonable administrative areas to be assessed
for quality performance. Many third party payers require
their accepted health care providers to document physician
and patient satisfaction of the services provided.
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Frequently asked questions
regarding the quality assurance program requirements for ICANL
accreditation can be found on the ICANL website FAQ section
(www.icanl.org/icanl/apply/faq.htm).
Select 'ICANL' at the top of the FAQ menu, then use the search
engine to type in your specific question and find similar inquiries
that may help you.
These suggestions are designed to assist laboratories
taking the first necessary steps in establishing an effective
QA program. Still have specific questions? The staff of ICANL
is here to help. Please contact the ICANL via email at maier@intersocietal.org
or call the office at (800) 838-2110.
The
ICANL thanks Alice Pichan, CNMT, RT(N)
of Northpointe Heart Center in Berkley, Michigan,
an ICANL reviewer,
for her contributions to this article.
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