Accreditation in Point of Care Ultrasound

Abstract

Accreditation in ultrasound can often be confused with credentialing and privileging and some providers use the terms interchangeably not realizing the implications. Accreditation relates to program, laboratory, departmental or institutional accreditation under a recognized body. Accreditation pathways are available to point-of-care ultrasound programs but there is promise in some developing programs but by various specialties. This chapter provides details on accreditation and discusses possible advantages and disadvantages.

Objectives

• Describe and Define Accreditation in Medicine

• Why Accreditation for Clinical Ultrasound

• The Accreditation process

Introduction

The concept and process of accreditation has seen significant growth in medicine in recent years. Each year it seems additional sites, procedures, and applications of healthcare are seeking accreditation from governing bodies, private companies, and nonprofit organizations.

The concept of accreditation in healthcare began in 1951 with the formation of the Joint Commission on Accreditation of Hospitals (JACH, later known as JACHO) [1]. In 1965 Medicare tied conditions of participation (reimbursement) to JCAH accreditation and changed healthcare forever.

Since 1951 accreditation by external entities has become the accepted norm for validation and scrutiny of the credibility of a healthcare system, process, or group. Hospitals now often seek accreditation to become a Stroke Center, a STEMI receiving center, or a Trauma Center. Many hospital radiology based ultrasound departments, Vascular ultrasound Labs, Echocardiography labs, and Maternal and fetal medicine ultrasound departments are already receiving accreditation from groups such as the American College of Radiology [2], The American Institute of Ultrasound in Medicine [3], and the Intersocietal Accreditation Commission [4]. Yet no external entity had created an appropriate accreditation process for clinical based, point-of-care ultrasound.

In 2007 the American College of Emergency Physicians passed Council Resolution 32:

• RESOLVED, That ACEP, in cooperation with all established College liaisons and relationships with other medical specialty societies, the American Medical Association, the Alliance for Specialty Medicine, the Coalition for Patient-Centric Imaging, and other interested parties actively and fully opposes the imposition upon the specialty of Emergency Medicine of any accreditation programs developed, offered, and/or governed solely by other specialties; and be it further.

• RESOLVED, That the Board of Directors of ACEP submit a comprehensive report to the Council at the 2008 Council Meeting regarding the adoption and execution of a strategic plan to address the long and short-term accreditation issues relating to the performance and interpretation of imaging studies by emergency physicians and, specifically, emergency ultrasound [5].

From 2007 to 2015 the ACEP Accreditation Subcommittee of the Ultrasound Section was tasked in developing what eventually became The Clinical Ultrasound Accreditation Program or CUAP (http://cuap.acep.org). In 2015 CUAP first started accepting application and accrediting hospitals in the performance of clinical ultrasound . This program includes standards such as administration of ultrasound program, education and training of healthcare providers, performing and interpreting ultrasound examinations, equipment management, transducer disinfection, image acquisition and retention, and confidentially and privacy.

What Is Accreditation?

Definition : Accreditation is a process of review that healthcare organizations participate in to demonstrate the ability to meet predetermined criteria and standards of accreditation established by a professional accrediting agency. Accreditation represents agencies as credible and reputable organizations dedicated to ongoing and continuous compliance with the highest standard of quality.

Accreditation, credentialing, and privileging are often confused and used interchangeably within the healthcare setting. Yet each of these is quite different. As it pertains to medicine and specifically physician oversight:

“What CUAP Does……” Accreditation is a self-assessment and external peer assessment process used by a healthcare entity to accurately assess the facility’s level of performance in relation to established standards and to implement ways to continuously improve.

“What the Ultrasound Director Does……” Credentialing is the process of gathering information regarding a physicians qualifications and capacity for appointment to the medical staff and those procedures implied by that appointment.

What the Hospital Medical Board Does……. Privileging is the authority granted to a physician by a hospital governing board to provide patient care in the hospital. Clinical privileges are limited by the individual’s professional license, experience, and competence.

Thus, when we are discussing the process of providing credibility to the process by which an ultrasound division within a hospital entity is directed, we are talking about accreditation. CUAP or any other form of accreditation does not credential or privilege healthcare providers to perform ultrasound, but may approve the process by which the ultrasound director may credential them.

Why Do We Need Accreditation?

There are many reasons why accreditation can benefit your group, hospital, and ultrasound program. These include standardization, quality assurance, and recognition. At its essence, though, accreditation is meant to give you direction and organization in establishing and maintaining an exceptional ultrasound program.

One of the greatest advantages of accreditation is organization. Most accreditation programs such as CUAP outline necessary requirements for a successful, well-run, and standardized ultrasound program. Guidelines such as machine maintenance, credentialing standards, and probe cleaning are often created by the accrediting body and prevent “from-scratch” protocol creation for the ultrasound director. A secondary advantage to this is that in meeting these requirements, directors can often ask for hospital, departmental, or division support.

Take, for example, endocavitary probe cleaning. It can be difficult convincing your chair or hospital administrators to enact a complicated and expensive probe cleaning policy or purchasing the necessary equipment to run such a policy. If, however, that policy is necessary to gain accreditation, the ultrasound director can use those requirements and accreditation itself as leverage to meet the minimum standards created by that accreditation.

Other reasons commonly mentioned to justify accreditation are [6]:

• Exhibit your commitment to clinical excellence.

• Display your commitment to the highest quality patient care.

• Provide credibility to peers and patients.

• Demonstrate that your practice meets the quality assurance requirements of a growing number of insurance companies.

These are all reasonable reasons to seek accreditation. In the case of ACEP and the Clinical Ultrasound Accreditation Program, it was also advantageous to create a non-specialty specific accreditation process for point-of-care ultrasound or clinical ultrasound so that emergency physicians and emergency departments did not have to try to fit into the mold of non-point of care, consultative ultrasound accreditation programs.

What Is the Clinical Ultrasound Accreditation Program?

The Clinical Ultrasound Accreditation Program (CUAP) is an ACEP-governed national accreditation organization with an understanding of clinical bedside ultrasound and a purpose of establishing a system of review for emergency departments performing clinical, point-of-care ultrasound. This accreditation system promotes the goals of quality, patient safety, communication, responsibility, and clarity regarding the use of clinical ultrasound. As the use of ultrasound has become mainstream in clinical medicine, a need has emerged to promulgate and support national standards for clinical ultrasound programs as detailed in the American College of Emergency Physicians’ Ultrasound Guidelines [7].

CUAP has been developed with the express purpose of providing assistance to those looking to implement a point-of-care ultrasound program, so that new programs can take advantage of expert experience to ensure they are meeting best practice standards.

This program includes standards in the areas of administration of ultrasound programs, education and training of healthcare providers, performing and interpreting ultrasound examinations, equipment management, transducer disinfection, image acquisition and retention, and confidentiality and privacy.

What Are the Requirements of CUAP Accreditation?

CUAP, being governed by ACEP, has set the minimum standard for accreditation in an effort to match the ACEP Ultrasound Guidelines [7]. The ACEP 2016 Ultrasound Guidelines are used in multiple specialties as the standard for point-of-care ultrasound. Further validity to these guidelines was gained in 2011 when American institute of Ultrasound In Medicine officially recognized them [8].

CUAP includes standards for administration of an ultrasound program, education and training of healthcare providers, performing and interpreting ultrasound examinations, equipment management, transducer disinfection, image acquisition and retention, and confidentiality and privacy.

Each Institution Will Be Expected to Meet the Following Criteria [9]:

• Every licensed healthcare provider using point-of-care ultrasound either meets ACEP credentialing guidelines or is in the process of meeting these guidelines.

• An emergency ultrasound coordinator/director must oversee the maintenance, education, and monitoring of the ultrasound program.

• The program must also meet minimum standards of continuous quality management (CQM).

• Each healthcare provider must complete a minimum amount of continuing medical education (CME) in each ultrasound credentialing cycle.

• All ultrasound equipment must meet state and federal guidelines and undergo regular maintenance and cleaning.

• A policy must be in place for infection control following the local institution’s standards.

• Periodic review of each healthcare provider must be performed.

• Reports must be generated for ultrasound exams and be included in the medical record, and the images must be archived.

• Each institution should follow storage guidelines, respect patient confidentiality and HIPAA guidelines, and follow the ALARA Principle.

In summary, CUAP is designed to be clinician-relevant, bedside-focused, efficient, and complementary of current hospital processes and accreditation.

Other Ultrasound Imaging Accreditation Organizations

• AIUM  American Institute of Ultrasound in Medicine covering consultative and specific areas including Abdominal/General, Breast, Musculoskeletal (Diagnostic), Musculoskeletal (Ultrasound-Guided Interventional Procedures), Dedicated Thyroid/Parathyroid, Fetal Echocardiography, Gynecologic (with or without 3D), Head and Neck, Obstetric or Trimester-Specific Obstetric, OB with Adjunct Detailed Fetal Anatomic US, Urologic, Ultrasound-Guided Regional Anesthesia

• ACR  American College of Radiology - for radiology based consultative ultrasound

• IAC  Intersocietal Accreditation Commission - for consultative vascular and cardiology imaging

Decision to Seek Accreditation

Accreditation may not be for everyone. Some groups are so small that they may not benefit from the standardization and quality assurances gained through the economies of scale associated with larger ultrasound divisions and accreditation. While we encourage these groups to still strive for excellence in point-of-care ultrasound, accreditation should by no means be set as an absolute requirement for emergency departments practicing well within the standard of care, especially if those groups are adhering to the ACEP Ultrasound Guidelines.

Established ultrasound divisions that are already meeting the accreditation minimum standards, are not receiving reimbursement denials for lack of accreditation, and don’t need the guidance or leverage of applying for accreditation may also choose to continue along their current path without seeking accreditation. However, there is still recognition to be gained through accreditation.

Pitfalls

• 1. New US programs with basic elements of machine or director but without basic elements of accreditation (e.g., scope of practice, clinical or infection control protocols, credentialing, machine maintenance or QA) may not be ready for accreditation processes.

• 2. Not reading or understanding the standards of the accrediting organization.

• 3. Choosing accreditation from an organization that is unfamiliar with the type of your US practice.

• 4. Expecting accreditation to be a one time process. Accreditation is time limited recognition that requires programs to maintain standards.

• 5. Expecting accreditation to resolve all program issues. Accreditation set a bar of quality but other issues may occur.

Key Recommendation

• 1. Ultrasound accreditation should be a desired quality recognition for clinical ultrasound programs.

• 2. Ultrasound accreditation can offer you guidance in developing a top-notch ultrasound program, all without having to start from scratch.

• 3. Develop your US program with awareness of the standards and expectation of accreditation bodies.

• 4. Use accreditation to your program’s advantage including obtaining resources, recognition, and personnel.