Credentialing, Accreditation, and Quality in the Vascular Laboratory

Introduction

Ensuring the quality of studies performed and interpreted in the vascular laboratory is a cornerstone of vascular laboratory management. This chapter will review the processes for credentialing of personnel and accreditation of facilities and the core components of a quality improvement (QI) program. In addition, examples of coordinated efforts to standardize the performance and interpretation of noninvasive vascular studies at the national level will be presented.

Credentialing

In order to produce high-quality studies that can be integrated into the care of patients with vascular disease, it is imperative that individuals who perform and interpret vascular studies have adequate theoretical and hands-on training and experience. Vascular imaging studies, both duplex examinations and physiologic testing studies, are highly dependent on the skill of the sonographer/technologist performing the examination because producing complete studies with adequate quality images is essential for physician interpretation. In addition, the physician must have adequate training and experience in vascular testing in order to accurately interpret the studies. For physicians, some postgraduate training programs include dedicated rotations with training in the interpretation of vascular ultrasound and physiologic testing studies, but the depth and extent of exposure varies widely by subspecialty and environment. Although physicians must be licensed to practice medicine, few US states currently require licensure for vascular sonographers/technologists. Distinct from licensure, credentialing is the process used to certify the qualifications of individuals to either perform or interpret vascular studies.

There are vascular-specific credentials available for both sonographers/technologists and physicians ( Table 32.1 ), with the most common being the Registered Vascular Technologist of the American Registry for Diagnostic Medical Sonography, the Registered Vascular Specialist of Cardiovascular Credentialing International, and the Registered Physician in Vascular Interpretation of the Alliance for Physician Certification and Advancement. These credentials require applicants to meet set prerequisites of training and experience, including documentation of scanning or interpreting a minimum number of studies, followed by a validated credentialing examination and maintenance of the credential, generally through continued medical education. Historically, the Registered Vascular Technologist credential was the only mechanism for formal credentialing of physicians in vascular testing, but the Registered Physician in Vascular Interpretation credential was launched in 2006 as a dedicated process for credentialing physician interpretation (rather than performance) of vascular studies. Though universal credentialing has not been mandated, some Medicare carriers have linked reimbursement to studies being performed by a credentialed sonographer/technologist or within an accredited vascular laboratory, and a limited number of non-Medicare third-party payers have instituted requirements for credentialing of sonographers/technologists. Enforcement of these requirements is variable. As of January 31, 2017, the Intersocietal Accreditation Commission (IAC) has required that all technical personnel within its accredited vascular laboratories have an appropriate vascular credential.

Accreditation

Vascular laboratory accreditation is the process by which a testing facility is certified as having met certain standards of quality as determined by the accrediting organization. There are currently two organizations in the United States that specifically accredit vascular laboratory/vascular ultrasound facilities, the IAC and the American College of Radiology (ACR). Though the two programs have different requirements and emphasis, applications for accreditation through both programs share some common features, including: (1) review of qualifications and/or credentials of medical and technical staff; (2) review of laboratory equipment including a quality control program; (3) requirement for presence of laboratory diagnostic criteria for vascular studies; (4) requirement of a facility QI program; (5) minimum standards for reporting of test results; and (6) submission of selected case studies along with finalized reports for organizational review. As with credentialing, a national requirement for vascular laboratory accreditation has not been achieved. The Medicare Improvements for Patients and Providers Act, which was passed in 2008 and enacted in 2012, required accreditation of facilities performing advanced diagnostic imaging for Medicare bene­ficiaries such as computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine, but excluded ultrasound along with x-ray, fluoroscopy, and mammography from this mandate. As discussed earlier, some Medicare carriers have a credentialing or accreditation requirement, though enforcement of this is limited, and only a few non-Medicare third-party payers have instituted requirements for the accreditation of testing facilities. Based on the Centers for Medicare and Medicaid Services data from 2011, only 13% of outpatient facilities billing Medicare for vascular testing studies were accredited by IAC. Data reporting the percentage of vascular testing facilities accredited by ACR, or facilities accredited by either accrediting organization, have not been published.