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QUALITY ASSURANCE / QUALITY CONTROL DELAYS

29% of the applications received in 2008 were delayed for issues related to quality assurance/quality control.

An integral component of the ICAMRL process is the laboratory’s responsibility to develop and implement an ongoing comprehensive quality assurance (QA) program. The program should be a continuous process of education, evaluation, corrective action, development and implementation with the ultimate goal of providing quality patient care. A Quality Assurance Committee should be assigned to oversee and monitor the assessment of the quality assurance program. Applicant laboratories are required to perform daily and periodic quality control (QC) testing that meets manufacturers’ specifications, industry guidelines, or as outlined by a medical physicist. Two months of quality assurance testing performed by the operators must be submitted as well as the current preventive maintenance and acceptance test. The quality control tests performed and the results of the tests must be specified in the submitted documents. One of the main reasons for delay in this area is incomplete documentation of the quality assurance/quality control tests requested. The ICAMRL Standards related to quality assurance/quality control tests can be found in Part I, Organization, Section 7, Quality Assurance.

FINAL REPORT COMPLETION TIME DELAYS

20% of the applications received in 2008 were delayed for issues related to timeliness of final reports.

The ICAMRL Standards require that the physician’s final interpretation be available within two working days of the examination date and the final, verified, signed report sent to the referring physician within four working days, unless awaiting additional clinical information. An interpretation can be in the form of paper, digital storage or voice system.

STEPS TO AVOID DELAY

There are several steps that laboratories can take to increase the likelihood that accreditation is granted outright, without any delay.

• Contact the ICAMRL staff with any questions about the process.
• Allow adequate time to prepare the application materials for submission.
• Laboratory staff should verify that they are adhering to the current version of The ICAMRL Standards. The ICAMRL website contains the current version and the links within the Online Accreditation application interact with this version.
• Carefully review all the material, prior to submission, for accuracy and completeness.
• Submit all documentation that is required in the application.
• The policies and procedures must be laboratory-specific and reflect current practices.
• Each of the case studies submitted must include all of the images, including eformats used in the interpretation, and the applicable final report.
• The case studies should be representative of “best work” and stored on CDs with the DICOM viewer installed.
• Those laboratories applying for reaccreditation are strongly encouraged to review the Application Review Findings (ARF) CD sent to the laboratory with the initial decision letter for improvement guidance.

WHAT DELAY MEANS TO THE LAB SEEKING REACCREDITATION

To facilitate timely preparation of their reaccreditation applications, accredited laboratories receive a notification letter twelve to fourteen months prior to the expiration of their accreditation. ICAMRL 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 the notification letter and submit a complete application without significant deficiencies.

The laboratory is notified in writing of the Board’s accreditation decision within two to three weeks after the Board meeting. Laboratories receiving a delay decision are sent a letter outlining the reasons for the delayed decision, inclusive of the documentation that must be submitted in order to correct the lack of adherence to The ICAMRL Standards. To better accommodate laboratories in the reaccreditation stage, the Board of Directors instituted a 60-day grace period. This timeframe gives a laboratory that has been delayed reaccreditation 60 days to resolve delay issues and provide the required or corrected documentation to the ICAMRL, upon which the final decision will be made by the Board of Directors. During the 60 days, the laboratory is granted a continued presence on the ICAMRL website as an accredited laboratory and continued use of the ICAMRL Accredited Laboratory logo. The 60-day time period is intended to minimize the inconvenience of needing to redesign reports and letterhead acknowledging their accreditation status and concerns about meeting reimbursement guidelines. 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 are no longer considered accredited. Those laboratories are automatically deleted from the list published on the ICAMRL website once their grace period has expired. 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 ICAMRL logo affirming the laboratory’s status as an ‘Accredited Magnetic Resonance Laboratory” must be removed from any materials, along with any other references to accreditation by the ICAMRL, by any laboratory that does not maintain its accreditation.

IN CONCLUSION

In summary, laboratories that receive notification that their accreditation application has been delayed are often surprised and frustrated with the results of the application review. This is a particular sentiment amongst laboratories applying for reaccreditation. Previous granting of accreditation does not ensure that the laboratory will automatically be granted accreditation at the time of reaccreditation. It is the philosophy of the ICAMRL that with each reaccreditation cycle, the applicant laboratory should be coming ever closer to being in compliance with every one of The ICAMRL Standards, thus offering the best possible quality of magnetic resonance testing available to its patients. While laboratories seeking ICAMRL accreditation and reaccreditation are held to extremely high standards, these expectations have enabled the ICAMRL process to gain recognition and be highly regarded amongst referring physicians, payers and patients.

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