WHAT
IS DELAYED ACCREDITATION?
After
the review of a laboratory's accreditation application, the
Board of Directors renders an accreditation decision. One of
four decisions will be made: granted, delayed,
site-visit or denied. A delayed decision means
that there are significant issues, deficiencies or lack of adherence
to the ICAVL Standards that must be addressed by the
laboratory before it can be granted ICAVL accreditation.
CHANGE IN POLICY FOR DELAYED LABORATORIES
[Applies to all applications received after 9/1/2008]
Upon receiving a delayed accreditation decision, the laboratory will:
- have one year to provide the additionally requested documentation demonstrating adherence to the Standards as outlined in the accreditation notification letter
- be permitted to submit one set of delay material to be reviewed by the applicable IAC division, free of charge
- be assessed a $200 review fee if, after providing the additional material, the laboratory still has not demonstrated compliance and further information is required
- have a maximum of only three delay material submissions to demonstrate compliance; if continued non-compliance is documented after review of the three resubmissions, the laboratory will be required to fully reapply for accreditation and undergo a complete application review. (Note: Each testing area in which a lab applies is considered independent and allowed a total of three submissions each.)
- All accreditation fees are non-refundable and will be due at the time of subsequent application submissions.
To learn more, please see Change In Policy: Delay Status, appearing in the Autumn 2008 issue of the IAC newsletter. >>
WHAT DELAY MEANS TO THE LAB SEEKING
REACCREDITATION
All
accredited laboratories receive a notification letter twelve
to fourteen months prior to the expiration of their accreditation.
Board meetings are generally scheduled within two weeks of the
expiration dates on the laboratory's current accreditation certificates.
It is crucial that laboratories apply by the deadline specified
in this letter and submit a complete application without significant
deficiencies.
The
laboratory will be notified in writing of the Board's accreditation
decisions within two to three weeks after the Board meeting.
This letter will outline the reasons for the delayed decision
and include the documentation that must be submitted in order
to correct the lack of adherence to the ICAVL Standards.
To better accommodate laboratories in the reaccreditation stage,
the Board of Directors instituted a 60-day grace period
to maintain accreditation status.
The grace period gives a laboratory that has been delayed
reaccreditation 60 days to resolve delay issues and provide
the required or corrected documentation to the ICAVL, upon which
the final decision will be made by the Board of Directors. During
the 60 days, the laboratory will be granted a continued presence
on the ICAVL website as an accredited laboratory and allowed continued
use of the ICAVL Accredited Laboratory logo. The 60-day extended
timeframe is intended to minimize the inconvenience of needing
to redesign reports and letterhead acknowledging their accreditation
status and concerns about meeting reimbursement guidelines, if applicable.
However, laboratories are still required to submit their reaccreditation
applications for the recommended application deadlines.
Laboratories
that do not correct delay issues during the 60-day grace
period will no longer be considered accredited. Those laboratories
are automatically deleted from the list posted on the ICAVL
website if the delay materials have not been received in the ICAVL office by the end of the 60-day grace period. Because Medicare,
third party payers, referring physicians and patients refer
to this 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.
STEPS YOU CAN TAKE TO AVOID DELAY
There
are several steps that laboratories can take to increase the likelihood
that accreditation is attained without any delay.
- Application Review Findings (ARF) letter. Review the Application Review Findings (ARF) letter sent to
your laboratory when accreditation was last achieved.
-
Version of The ICAVL Standards. Verify that your laboratory is adhering to the current edition
of the ICAVL Standards. Dates of revision are listed
in the footer of every page. Make sure the Standards you reference are current by checking the dates of revision against the Standards posted to the ICAVL website, or simply download a current copy. Visit Standards section>>
-
Case Studies. 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.
- Documentation requirements. The
most common reasons for delay in Extracranial Cerebrovascular,
Peripheral Arterial and Visceral Vascular testing are insufficient
documentation of complete examinations. The Standards
clearly outline the minimum number of images and Doppler samples
required for each vascular examination.
- QA correlation. A
number of laboratories are also delayed for insufficient documentation
of quality assurance correlation. The Standards specify
the minimum numbers of correlations required for reaccreditation
in each area of testing. For example, laboratories are required
to submit a minimum of 30 internal carotid artery correlations
with radiographic and/or surgical results over the past three
years.
- CME. Be sure that sufficient
CME credits are submitted for the medical or technical staff
members. You can review the ICAVL requirements for continuing
medical education credits here.
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