Abstract
Objective
Accreditation for noninvasive vascular testing facilities has been available since 1990, but is not mandatory. We sought to determine the perceived value of accreditation among the staff of vascular laboratories accredited by the Intersocietal Accreditation Commission (IAC).
Methods
A multi-item electronic survey was sent to medical and technical staff and administrative contacts within the IAC database. Respondents were asked to rate statements about the impact of accreditation on their facility. Data for vascular testing facilities are presented.
Results
Of the 7,289 surveys sent, there were 882 (12.1%) respondents. Respondents were primarily responsible for the facility's accreditation application (75.0%), with the majority being technologists (82.0%), followed by physicians (11.3%). Most respondents were from hospital-based facilities (51.1%) and from facilities accredited for >3 years (79.6%). The majority, 94.3% of respondents, felt that maintaining accreditation of their facility was important (3.5% neutral, 2.2% not important). The greatest perceived benefits were in standardization of study acquisition and reporting, adherence to guidelines, and report completeness.
Conclusions
The majority of respondents from IAC-accredited vascular testing facilities viewed accreditation favorably. The favorable perception of accreditation by its users supports the value of accreditation for vascular testing facilities.
Introduction
Vascular laboratory facility accreditation first became available in 1990 through the Intersocietal Accreditation Commission (or IAC), previously known as the Intersocietal Commission for the Accreditation of Vascular Laboratories. 1 The goal of vascular laboratory accreditation is to optimize the quality of patient care delivered in vascular testing facilities.1,2 The process of accreditation includes evaluation of the laboratory organizational structure, assurance of appropriate training and certification of medical and technical personnel, assessment of the performance and the interpretation of studies according to accreditation standards, and the development of a rigorous, ongoing quality improvement program. Accredited facilities must adhere to a set of standards in order to minimize variance of testing performance and interpretation in and between facilities, with the ultimate objective of improving diagnostic quality and patient care. Initially, IAC offered only vascular laboratory accreditation but has grown to offer accreditation for echocardiography, nuclear medicine, magnetic resonance (MR) imaging, and computed tomography (CT) facilities. In addition to IAC, accreditation for noninvasive diagnostic testing facilities is also offered by the American College of Radiology (ACR), The Joint Commission, and RadSite.3–5 Of these, only IAC and ACR offer specific accreditation pathways for vascular testing facilities.
As the accreditation process does incur cost, personnel time, and training, we sought to determine the perceived value of accreditation from individuals who were involved with the process of vascular laboratory accreditation.
Materials and Methods
On September 27, 2012, an electronic questionnaire (SurveyMonkey LLC., Palo Alto, CA) was sent to contacts for medical and technical staff and administrators at all current or previously accredited IAC vascular testing facilities, including those that did not maintain current accreditation (n = 7,289). This study population was selected due to their prior knowledge of the accreditation process and, therefore, ability to provide educated assessments of the quality metrics and importance of IAC accreditation. The vascular testing data were a part of a multidisciplinary assessment survey sent to personnel from all IAC-accredited facilities, including vascular testing, echocardiography, and nuclear medicine/positron emission tomography (PET), as well as MR and CT imaging.6,7 A follow-up e-mail was sent 1 week later to those contacts that did not open the initial e-mail (n = 5,689).
IAC senior staff, board member representatives of the IAC testing divisions, and a consultant developed the survey to assess the impact of accreditation on key determinants of testing facility quality. The survey questions were organized into five domains: (1) familiarity/involvement in IAC accreditation process, (2) respondent and laboratory demographics, (3) quality metrics, (4) perceived importance of accreditation to the facility, and (5) suggestions for improvement. The complete survey is shown in Table 1.
Electronic Survey Elements
The first two survey questions gathered information about respondents' familiarity with and involvement in the accreditation process. Participants were asked to rank their familiarity with the IAC accreditation process (not at all familiar, not very familiar, neutral, somewhat familiar, or very familiar) and how involved they were in this process (primarily responsible, involved but did not have primary responsibility, or not involved).
Data were collected regarding respondents' employment positions, facility type and geographical region, and number of years for which the facility has been IAC accredited. Respondents included physicians, technologists, administrators, and other personnel from an array of different types of vascular facilities (hospital based, private practice, multispecialty clinic, freestanding imaging centers, or mobile services only). Surveys were sent to facilities in Canada, Puerto Rico, and the United States, with further categorization based on their U.S. Census–defined regions—Northeast, Midwest, South, or West. 8 The length of facility accreditation was grouped into four categories: >3 years, 1–3 years, <1 year, and not currently accredited. The facility was not identified otherwise, so multiple responses by members of the same facility were possible.
The survey also consisted of 15 statements about the perceived impact of accreditation on image quality, reporting, safety and performance, and facility marketing metrics. Participants were asked to rank the degree to which they agreed with these statements (strongly agree, agree, neutral, disagree, strongly disagree, or not applicable).
Respondents were then asked to rate the importance of maintaining accreditation of their testing facilities (very important, somewhat important, neutral, not very important, or not important at all). Finally, respondents were also given the opportunity to provide suggestions for improvement through a free-text field.
Statistical Analyses
Descriptive statistics were generated based on survey results. To simplify presentation of data, individual ordinal responses were placed into the following categories: agree (strongly agree and agree responses), neutral (neutral response), disagree (disagree and strongly disagree responses), or not applicable (N/A responses); or important (very important and somewhat important responses), neutral (neutral response), or not important (not very important, not important at all). Percentages are presented with denominators representing the number of respondents who completed each survey element. Fisher's exact tests were used to investigate associations among perceived importance of maintaining facility accreditation and various respondent demographic features, with a p value <0.05 considered significant. Statistical analyses were performed using SAS (v.9.3; SAS, Cary, NC).
Results
Familiarity with and Involvement in the Accreditation Process
Of the 7,289 surveys initially sent, there were 882 (12.1%) respondents. Most respondents were very familiar (78.2%) with the accreditation process, while 19.1% were somewhat familiar with the process. Only 14 respondents (1.6%) reported being not at all familiar or not very familiar regarding the statement. The majority reported being primarily responsible for the accreditation process of their facility (74.9%), and an additional 22.5% were involved in the accreditation process but did not have primary responsibility at their facility.
Demographics
The majority of respondents were technologists (82.0%), followed by physicians (11.3%), administrators (5.7%), and others (1.0%). The most common type of respondent facility was hospital based (51.1%), followed by private practice based (36.1%), multispecialty clinic (9.1%), freestanding imaging center (3.3%), and mobile service only (0.5%). Respondents' facilities were primarily located in the south (32.7%), midwest (28.6%), and northeast (24.9%) regions, with fewer respondents from the west region (11.5%), Canada (1.9%), and Puerto Rico (0.5%). Most respondents were from facilities accredited for over 3 years (79.6%), although there were respondents from facilities accredited 1–3 years (15.1%), less than a year (3.8%), and some from facilities that were not currently accredited (1.5%). The 1.5% of respondents from facilities that were not currently accredited in vascular testing may reflect facilities that were previously accredited in this modality, or responses of personnel that serve as directors for multimodality facilities that do not have vascular laboratory accreditation.
Quality Metrics
Respondents rated 15 statements regarding the impact of accreditation on quality metrics and marketing categorized into four groups: image quality (n = 7), reporting quality (n = 3), study performance (n = 3), and facility marketing (n = 2). Responses from the quality metrics evaluation portion of the survey showed that the majority of personnel agree that accreditation has a positive impact on image quality, result reporting, test performance, and facility marketing (Table 2). In terms of image quality, most respondents felt accreditation improved standardization of study acquisition (85.3%), increased adherence to published guidelines (84.5%), helped identify facility imaging deficiencies (75.6%), increased staff knowledge of imaging procedures (75.2%), improved image quality (69.6%), and aided in correction of facility imaging deficiencies (68.9%). Most vascular laboratory staff were also in agreement that accreditation improved standardization of study reporting (86.2%), report completeness (81.2%), and report timeliness (71.9%). Approximately half of respondents agreed that accreditation improved patient safety (54.4%), facility efficiency (49.0%), and respondent perception of decreased percentage of suboptimal (47.0%) or inappropriate studies (42.0%). A majority of respondents (69.0%) agreed that accreditation distinguished their facility as a quality provider in the region and/or helped with marketing of imaging services. There was no consensus as to whether accreditation enhanced patient satisfaction (39.4% agree, 36.6% neutral, and 22.7% disagree).
Perceived Impact of Accreditation on Vascular Testing Facility Quality Metrics
n = number of respondents per survey item; values in parentheses are percentages.
Responses strongly agree and agree are combined.
Responses strongly disagree and disagree are combined.
Importance of Accreditation
Among 882 respondents, 94.3% reported that maintaining accreditation at their testing facility was either very important or somewhat important (Figure 1). The perceived importance of maintaining accreditation did not vary based on type of respondent, type of facility, or number of years of facility accreditation (Table 3). Vascular laboratory accreditation was valued even by lab personnel not directly engaged in the accreditation process.
Perceived Importance of Maintaining Facility Accreditation, According to Respondent Demographics
n = number of respondents per survey item; values in parentheses are percentages.
Responses very important and somewhat important are combined.
Responses not very important and not important at all are combined.
Mobile service only respondents (n = 4) excluded.
Perceived importance of maintaining vascular facility accreditation (n = 882 respondents).
Discussion
The IAC aims to optimize patient care within vascular testing facilities by providing a structured organization with quality improvement programs that emphasize standardization of testing facility procedures and reporting, as well as adequate personnel training and certification.1,2 IAC mandates training, experience, and continuing education of personnel, and ensures that facilities adhere to performance and interpretive standards before receiving accreditation. 2 The process of accreditation can be time consuming and costly, and maintaining accreditation is an ongoing expense, as vascular laboratories are required to renew every 3 years. 1 Results from both the multidisciplinary assessment of accreditation across all IAC-accredited noninvasive facilities and those specific to nuclear/PET testing demonstrated general support of IAC accreditation among personnel of these facilities.6,7 Of note, this study, a substudy of a broader survey of IAC-accredited facilities, focused specifically on vascular testing facilities and is the first study to assess the perspective of IAC accreditation in vascular facilities exclusively.
This study found that the majority of respondents who have worked within IAC-accredited vascular testing laboratories value accreditation offered by the IAC, despite the requisite time and expense of the accreditation process. Survey results indicate that the study cohort was largely supportive of IAC accreditation regardless of employee type, type of facility, or number of years of accreditation. Most respondents were familiar or involved in the accreditation process, which validates the use of this study population to provide meaningful feedback. Accreditation was perceived to have the greatest benefit on standardization of study acquisition, adherence to published guidelines, standardization of study reporting, and report completeness. There was less agreement regarding the perceived benefit of accreditation on patient safety, facility efficiency, decreased percentage of suboptimal studies, and decreased in appropriate studies. The majority of respondents felt that maintaining accreditation in their facility was important.
An area of greatest perceived value of accreditation was in regard to standardization of reporting and study acquisition. Discrepancies that exist among vascular laboratory reports can be problematic for cross-study comparisons, incurring additional testing or unnecessary procedures that may ultimately lead to suboptimal patient care and increased medical costs. 9 Failure of a facility to achieve standardization of study acquisition and/or reporting is a common reason for delay in laboratory accreditation. In a study evaluating the reliability of extracranial carotid artery duplex ultrasound for assessment of internal carotid artery (ICA) stenosis, Brown et al. reported the value of IAC accreditation in generating more accurate ultrasound reports when compared with reports of nonaccredited vascular laboratories. 10 In their series of ultrasound studies in 174 asymptomatic patients, clinically significant discordant findings in studies performed between IAC-accredited and nonaccredited labs were noted in 35% of arteries evaluated, and changed the management of 107 patients (61%), which suggested a discordance in quality between accredited and nonaccredited facilities. 10 The majority of errors were overestimation of ICA stenosis due to technical error in acquisition of Doppler measurements (e.g., inappropriate angle of insonation), reliance on B-mode imaging alone without Doppler velocity criteria, or application of inappropriate velocity criteria. 10 These results are consistent with our findings that a primary perceived benefit of IAC accreditation is standardization of study acquisition and reporting, both of which are important measures of quality and were determined to be deficient in the nonaccredited carotid duplex studies reviewed by Brown et al. 10
Of note, there were some parameters that fewer respondents perceived as being impacted by IAC accreditation. These factors included facility efficiency, the percentage of suboptimal and/or inappropriate studies, enhancement of patient satisfaction, and patient safety. These quality metrics present opportunities for future initiatives to streamline the accreditation process to maximize efficiency. The relatively low perceived impact of accreditation on inappropriate studies may partly reflect the very recent publication of multisocietal appropriate use criteria (AUC) for vascular testing and thus very limited incorporation of AUC into current accreditation standards.11,12 The lower perceived impact of accreditation on patient safety may be attributable to respondents' misunderstanding of how accreditation enhances safety in labs, or may reflect the fact that the majority of respondents were from hospital based facilities which already have significant mandated safety policies and procedures in place. It is possible that less regulated freestanding outpatient facilities (i.e., without pre-existing safety policies) may experience a greater benefit from those safety measures implemented through the accreditation process, though this would require further study.
Accreditation is becoming an increasingly recognized component of quality for noninvasive cardiovascular imaging facilities. While it has yet to be widely mandated or enforced for vascular testing facilities, 13 insurance companies and the Centers for Medicare and Medicaid Services (CMS) now require nonhospital nuclear medicine/PET, MR imaging, and CT facilities to be accredited as a requirement for study reimbursement. Experts in the vascular field have stressed the need to generate complete and accurate study reports and support the accreditation of vascular testing facilities.11,12 Although the role of accreditation across the spectrum of modalities of noninvasive cardiovascular imaging continues to grow, the prevalence of IAC-accredited vascular testing facilities is surprisingly low. 14 In a 5% random sample of outpatient vascular testing facilities receiving CMS reimbursement for vascular studies in Medicare recipients (n = 13,462 facilities), only 13% were IAC accredited in vascular testing. 14 There was significant geographical variation, with 26% of northeastern 12% of southern, 11% of midwestern, and 7% of western facilities having IAC accreditation. 14 While this analysis did not account for laboratories that are accredited by other organizations (i.e., ACR), the findings highlight that there are a large number of active vascular testing facilities that lack accreditation.
Limitations
There were several limitations to this study. Only 12.1% of electronic surveys were completed and returned. Although this percentage is higher than those reported in either personalized email (4.7%) or generic email (2.2%) surveys, a response bias may exist, such that those who positively regard the accreditation process may have been more likely to respond. 15 However, it is also possible that respondents with negative perceptions of accreditation are equally likely to respond. The majority of respondents were technologists, and thus this study may not accurately reflect the views of physicians and other personnel. However, technologists are often centrally involved in preparing the accreditation application and are thus most familiar with and engaged in the process of accreditation. Additionally, a small number of respondents (1.6%) included in this report were not familiar with the accreditation process. The results of this study are specific to IAC accreditation and should not be extrapolated to nonaccredited vascular facilities or other accrediting organizations due to differences in accreditation processes and standards. Finally, it is important to note that we have not assessed the perceived value of accreditation among referring providers to accredited vascular facilities, patients who undergo testing these facilities, or third-party payers. Thus, there is inherent bias in these data as the survey respondents primarily represent staff of accredited testing facilities only.
Conclusion
There is an overall positive view of accreditation among the staff of IAC-accredited vascular testing facilities. Areas of greatest perceived benefit from accreditation are standardization of study acquisition and reporting, adherence to published guidelines, and report completeness. A large majority of respondents agreed that maintaining facility accreditation was important. The favorable perception of accreditation by those involved in the accreditation process supports the value of accreditation for vascular testing facilities, though further research is required to demonstrate the impact of accreditation on quality metrics and patient outcomes.
Footnotes
Acknowledgments
The authors acknowledge other members of the IAC Research Committee, Louis I. Bezold, John Y. Choi, Kevin M. Cockroft, Gary Heller, and Scott Jerome, and Mary Beth Farrell and Sandra Katanick of the IAC for their contributions to the survey design and thoughtful review of the manuscript. The authors would also like to acknowledge Dr. Amy Nowacki for her assistance with statistical analysis. The electronic survey was funded by the IAC. M. L., W. J. M., L. N., and H. L. G. are board members of testing divisions of IAC. E. K. B. and L. J. Z. have nothing to disclose.