DIAGNOSTIC ACCREDITATION PROGRAM. Accreditation Process

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1 DIAGNOSTIC ACCREDITATION PROGRAM

2 Table of Contents Introduction... 1 Initial Assessment Process... 2 Spirometry Initial Accreditation... 3 Relocation Assessment Process... 5 Ongoing Accreditation... 6 Fees... 7 Table of Contents i

3 Introduction Accreditation is the longest established and most widely known process for the external evaluation of health-care services. Accreditation enables the College of Physicians and Surgeon s Diagnostic Accreditation Program (DAP) to evaluate and improve the quality of services provided by diagnostic services to their patients and clients, and also provides recognition that the service is meeting provincial standards of quality. All diagnostic facilities and services within the province of British Columbia must be accredited by the DAP. The DAP is the only regulatory body that can confer the Accreditation Award on behalf of the DAP Committee. Award standings are: Full accreditation This award is valid for a period of four years. Provisional accreditation This award is conferred to a new facility/service for a specified period of time, typically twelve (12) months. Within this time frame the facility to subject to completion of a self-assessment and an on-site survey. Accreditation with report This award standing will be conferred to an organization that delivers clinically safe and reliable services but has some requirements to address before it can be granted full accreditation status. Nonaccreditation This award will be conferred to an organization that does not meet the basic requirements of a clinically safe and reliable service as defined by the accreditation standards. A physician in BC may not practise in, nor refer patients to, a nonaccredited facility. Introduction 1

4 Initial Assessment Process All new facilities and services, within an already accredited facility must proceed through the initial assessment process prior to service delivery or patient testing. The following four steps are for all programs: diagnostic imaging; laboratory medicine; neurodiagnostics; polysomnography; and pulmonary function. Note: New facilities providing pulmonary function testing limited to simple screening spirometry without bronchodilators, spirometry before and after bronchodilators, peak expiratory flow rate, and spirometry-forced expiratory with and without bronchodilators, should proceed to the community spirometry section. Step 1: Facility Information Form Physicians and facilities intending to provide a diagnostic service must first complete the appropriate Facility Information for Initial Assessment Information form. Each program has a unique set of forms, which can be found on their respective sections on the College website. After the DAP has received the Facility Information for Initial Assessment form, an accreditation specialist will contact the facility to confirm receipt of the form. Step 2: Evidence Submission for Distance Review Note: This step is not required for laboratory medicine. The facility must complete the Evidence Submission for Distance Review form and submit it with the applicable evidence, prior to scheduling an on-site assessment. It is strongly recommended that the appropriate program's Accreditation Standards for Initial Assessment are reviewed and used in conjunction with the Evidence Submission for Distance Review form. Step 3: On-site Assessment After the DAP has received and reviewed the evidence submission package, an accreditation specialist will contact the facility to schedule an on-site assessment. During the on-site assessment, the assessor will review the physical environment, discuss processes with staff and follow up on any outstanding issues identified during the distance review of the evidence submission. Step 4: Initial Assessment Accreditation Report Following the on-site assessment, the facility/service will be issued an accreditation report. If the facility is not meeting all of the requirements outlined in the Accreditation Standards for Initial Assessment, these deficiencies will be outlined in the accreditation report and will need to be implemented prior to receiving a provisional accreditation award. The provisional accreditation award is valid for one year from when the facility/service successfully implements all of the mandatory requirements outlined in the accreditation report. Initial Assessment Accreditation Fees Please see the fees section. Initial Assessment Process 2

5 Spirometry Initial Accreditation Spirometry accreditation follows a different path from other DAP accreditation programs. In all other cases, the accreditation award is granted by the DAP Committee based on review of the report generated from an on-site assessment. In pulmonary function level 3 (PF3) hospitals where spirometry is performed, spirometry is assessed as part of the PF3 on-site assessment for accreditation. By contrast, pulmonary function level 2 (PF2) facilities conducting only spirometry testing are not assessed on their premises, but rather assessed using a quality control (QC) program (also referred to as a desktop audit). Successful QC performance will lead to the issuing of an accreditation award every four years for these facilities. Where unsuccessful QC performance is observed, it will be escalated to the DAP Committee for decision. Exemption: If the spirometer used exclusively is the COPD-6 Spirometer, as approved by the Medical Services Commission for case finding, DAP accreditation is not required. Resources for Community Spirometry Facilities Initial Accreditation Facility Information for Initial Assessment Facility Form Community Spirometry* Initial Assessment Data Submission Form Community Spirometry Initial Assessment Data Submission workbook Spirometry References *In addition to submitting this completed form, physicians intending to provide spirometry services in the community must submit a credentialing letter confirming that they are credentialed for respirology services. If the physician also performs respirology services within a hospital, the credentialing letter can be requested from the respective health authority. Physicians who only work in a private facility should review and follow the credentialing section on the College's website. Authorization by Ministry of Health Pulmonary function testing is included on the Ministry of Health, Diagnostic Facilities Administrations list of restricted diagnostic service modalities. As such, approval from the Advisory Committee on Diagnostic Facilities (ACDF) of the Medical Services Commission is required prior to billing BC s Medical Services Plan. Approval by ACDF is subject to DAP accreditation. For more information, visit the government of BC website. Ongoing Accreditation Spirometry Quality Control Program Spirometry is a useful diagnostic test commonly performed in a variety of settings; however accurate results are dependent on careful technique, and proper equipment calibration and maintenance. The American Thoracic Society (ATS) and European Respiratory Society (ERS) have recommended a number of procedures to reduce variability including the weekly testing of flow volume measurements and biologic normal subjects. Under the DAP Spirometry Quality Control Program, facility personnel at each site perform quality control procedures, and spirometry measurements on BioQC subjects according to Spirometry Initial Accreditation 3

6 the DAP protocol. The results, which are submitted to the DAP twice each year, give an indication of any areas of concern with the spirometer or performance of the tests. Where unsuccessful QC performance is observed, it will be escalated to the DAP Committee for decision regarding the facility accreditation status. Spirometry Initial Accreditation 4

7 Relocation Assessment Process All facilities relocating to a new address or within their existing building (e.g. facility is rebuilt on the same site) must proceed through the relocation assessment process prior to service delivery or patient testing. The following four steps are for all programs: diagnostic imaging; laboratory medicine; neurodiagnostics; polysomnography; and pulmonary function. Step 1: Notification of Significant Change in Service Form Physicians and facilities intending to provide a diagnostic service must first complete the appropriate Facility Information for Initial Assessment Information form. Each program has a unique set of forms, which can be found on their respective sections on the College website. After the DAP has received the Notification of Significant Change in Service form, an accredited specialist will contact the facility to confirm receipt of the form. Step 2: Evidence Submission for Distance Review Note: This step is not required for laboratory medicine. The facility must complete the Evidence Submission for Distance Review form and submit it with the applicable evidence, prior to scheduling an on-site assessment. It is strongly recommended that the appropriate program's Accreditation Standards for Relocation Assessment are reviewed and used in conjunction with the Evidence Submission for Distance Review form. This is to understand the scope of the suggested evidence. Step 3: On-site Assessment After the DAP has received and reviewed the evidence submission package, an accreditation specialist will contact the facility to schedule an on-site assessment. During the on-site assessment, the assessor will review the physical environment; discuss processes with staff and follow up on any outstanding issues identified during the distance review of the evidence submission. Step 4: Relocation Assessment Accreditation Report Following the on-site assessment, the facility/service will be issued an accreditation report. If the facility is not meeting all of the requirements outlined in the Accreditation Standards for Relocation Assessment, these deficiencies will be outlined in the accreditation report and will need to be implemented prior to receiving an accreditation award for the new location/address. The expiration of the new accreditation award will remain the same as the previous accreditation award and the previously scheduled accreditation activities will not change. Relocation Assessment Accreditation Fee Please see the fees section. Relocation Assessment Process 5

8 Ongoing Accreditation The DAP accreditation processes reflect modern accreditation methodology and best practice. For new facilities and services, an initial assessment process has been developed that requires completion of documentation and an initial on-site visit by the DAP prior to services being provided to patients. Previously accredited facilities and services participate continuously in assessment activities throughout a four-year accreditation cycle. For accreditation manuals specific to a program of the DAP, visit the College website. Ongoing Accreditation 6

9 Fees All accredited diagnostic facilities/services are subject to annual fees. The DAP does not invoice facilities for the costs associated with on-site assessments. New facility application fee: $500 This fee accompanies an application for accreditation by a new non-accredited facility. The $500 application fee includes conducting the on-site initial assessment. A new facility is not subject to annual fees for the current fiscal year in which they are accredited. For example, if a facility applies for accreditation in July 2016, they would not be subject to annual fees until April 1, Initial assessment of new service: $200 This fee applies to an already accredited facility that has expanded service to provide another modality/discipline. For example, a diagnostic imaging department that has already received accreditation for radiology and ultrasound, and now decides to provide CT services would be subject to the initial assessment process and associated fee. Relocation Fee: $200 This fee applies to an already accredited facility that is relocating to another physical location. This applies to moves within the same facility (e.g. relocation to a different section of a hospital or building) and to moves involving a different physical address. In order to be eligible for a relocation visit, the facility must retain the same scope of service and have no significant change to technical, administrative or medical leadership. Fees 7