SVU Position Papers

Guidelines for Evaluation of Vascular Technology Accreditation Programs

In the interest of patient well-being, the Society for Vascular Ultrasound (SVU) has developed these guidelines. They will allow an objective assessment of an organization's accreditation program to ensure high quality testing andappropriate reporting of results by adequately evaluating all aspects of vascular testing.

The practice of vascular technology requires a broad knowledge of the clinical presentation of vascular disease, anatomy, physiology, and pathology that may vary substantially depending upon the specific type of examination being performed. For example, proficiency in cerebrovascular testing does not ensure proficiency in venous testing. Therefore, a sound accreditation program will differentiate between testing areas and grant accreditation only in those areas that meet designated standards.

The accreditation process will include evaluation of the following elements:

I. PROGRAM ORGANIZATION

A Controlling Board shall be made up of individuals with demonstrated expertise in vascular technology. This board will create bylaws that govern the board and the organization's operations and set standards by which applying laboratories are evaluated. Guidelines for reviewers shall be established to ensure quality evaluation of applicants submission. The program must establish methods that provide for:

A. publication of standards and requirements for accreditation;

B. timely review of applicant documents;

C. comments regarding the evaluation of those documents to the applicant;

D. maintaining confidentiality of status of laboratory application process (until acceptance);

E. communicate to laboratories concerning revisions to the accreditation process, changes in the Standards or other issues that may impact current policy;

F. an appeal process for a second review of laboratories denied initial acccreditation, with a specific time frame for addressing problem areas, implementing policy and documenting results prior to the submission and review of the appeal (and provision that all documents should be reviewed by one initial reviewer and one "new" unbiased reviewer);

G. maintenance of a database of accredited laboratories and a method of confirming accreditation status; and

H. a method for re-accreditation.

II. LABORATORY ORGANIZATION

A. Staff - The accreditation program will review the qualifications of the medical and technical director as well as the medical (interpreting) and technical staff. Evidence of sufficient, relevant training must be documented. The technical director must demonstrate minimum entry level competence by being credentialled in vascular technology. All technical staff should be credentialed prior to re-accreditation. There must be a requirement for continuing education.

B. Support Services - Ancillary personnel (clerical, transport, nursing, etc.) must be consistent with the scope of service to provide for safe and efficient patient care.

C. Physical Facilities - Examination rooms must provide for reasonable patient safety, comfort and privacy, suitable with the scope of service. Space for report preparation, review and interpretation must be provided. Records, reports, and supplies must be appropriately stored. It is strongly suggested that some type of computerized data base be in place for documentation of patient data and ongoing statistical analysis of results.

D. Patient Safety - A policy or provisions to provide adequate patient safety and comfort must exist. Additionally, protocols for response to life-threatening emergencies must be established.

E. Reports and Record Keeping - Provisions for the generation, disemination, and retention of reports must be evaluated. Studies should be interpreted and reports distributed or otherwise made available to the referring physician within a specified length of time. Records of all examinations performed and resultant data must be retained and be made accessible according to state statute or regulations. In the absence of state regulations, records shall be maintained for a minimum of five years.

III. TESTING

A. Types of testing - All areas of vascular testing performed by the laboratory must be listed and included in the evaluation. Minimum standards must be outlined for each area.

B. Instrumentation - Minimum standards for various procedures must be established. In addition, instruments must be properly maintained and configured with software and hardware sufficient for the performance of each specific type of examination.

C. Indication / Volumes - the indications for each exam shall be documented and consistent with patient presentation. The volume of studies must be suffiecient to demonstrate and maintain proficiency in each area of testing provided by the laboratory. Numbers of procedures performed and indications shall be documented.

D. Protocols / Technique - Complete protocols, procedure and technique shall be thoroughly documented for each area and specific examination type.

E. Diagnostic Criteria - shall be documented, referenced and supported.

F. Sample examinations - shall be provided. These shall be actual examinations ( with protection of patient confidentiality) representing the range of exams performed and will serve to demonstrate that protocols, technique and diagnostic criteria are applied as stated. Representative examinations from all laboratory personnell, for the range of diagnostic categories for each area of testing shall be evaluated.

F. Quality Assurance - Diagnostic criteria must be internally validated with a recognized "gold standard" and statistics calculated. Complete documentation of all of the above shall be provided to the accrediting organization for evaluation. A minimum overall accuracy must be required and should generally exceed 85%.

G. Patient Confidentiality - The organization shall have a policy protecting patient confidentiality.

These guidelines shall remain in effect for three years unless extended, revised or rescinded by the SVU Board of Directors prior to that time.

29 August 1999