Ali F. AbuRahma and Dennis F. Bandyk (eds.)Noninvasive Vascular Diagnosis3rd ed. 2013A Practical Guide to Therapy10.1007/978-1-4471-4005-4_1© Springer-Verlag London 2013
1. Improving Quality in Noninvasive Testing by Certification and Accreditation
(1)
Department of Surgery, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza Room 510, Los Angeles, CA 90095, USA
(2)
Department of Neurology and Neurosciences, Medical University of South Carolina (MUSC), Charleston, SC, USA
Abstract
Over the last half century, noninvasive vascular testing has evolved from a research laboratory curiosity to a well-established clinical component in the management of patients with vascular disease. As with any new field, the search for high-quality work is a critical challenge. An important early step was developing appropriate education for the physicians and the technical staff who would ultimately be examining patients. But providing educational opportunities was only the first step in ensuring a quality operation. It was necessary to define prerequisite knowledge and experience, together with a determination of entry-level knowledge. This step was achieved in 1983 by establishing a certifying examination for vascular technologists. The second quality initiative was to define benchmarks for establishing and running of an examining facility. Relevant issues included quality of equipment, ongoing supervision, examination protocols, standardized diagnostic criteria, reporting standards, and validation studies. In 1991, a formal laboratory accreditation was established to provide a structured approach to this side of improved quality. Over the years, the combination of individual certification and laboratory accreditation has led in the effort to improve the quality of noninvasive testing.
Keywords
Noninvasive testingVascular laboratoryCredentialingAccreditationNoninvasive testing had its roots in early research laboratories more than half a century ago. The first facility in this country was established at the Massachusetts General Hospital in 1946, and others appeared over the following years. The work focused on research efforts with little thought about providing routine clinical testing. By the 1960s, arterial reconstructive procedures became increasingly frequent, and there was a surge in interest in the clinical investigation of blood flow. The ability of the early measurement methods to provide objective noninvasive determination of vascular parameters attracted the interest of vascular surgeons, and by the 1970s, there was regular clinical use of a number of tests. What had been quiet (and often esoteric) research laboratories expanded, providing an increasing volume of routine examinations directed toward patient management. By the late 1970s, the majority of hospital-based facilities were dedicated to routine clinical service rather than to research. At the same time, physicians took the testing modalities into the office, thus increasing the availability of these tests.
Education and Training
Physician
The testing in the early laboratories was supervised by the physicians who worked on developing and validating the techniques. These researchers were committed to critical evaluation of the tests being developed and careful work preceded widespread clinical application. Once the value of vascular testing was promulgated, increasing numbers of physicians became interested in the field. The majority of physicians who ran clinical laboratories in the late 1970s and early 1980s lacked the research background and the experience of the original investigators. The newcomers relied on learning what they could from the few published articles and from visits to observe the work done in established laboratories. Over time, there has been an increase in the quality and availability of courses and teaching materials available. Some specialties (including vascular surgery and vascular medicine) require training in vascular testing as part of the core curriculum of residencies. Many programs include didactic presentations, direct participation in examinations, and experience in test interpretation. As the result of these programs, many doctors now complete training much better prepared for vascular testing.
Technologist
With the expansion of vascular testing into the clinical arena and the increasing demand for services came a need for additional personnel and the training of the providers of vascular testing. The most important change was adding personnel whose job was to perform the different testing protocols. People from a variety of technical backgrounds were recruited, including nurses, radiology technicians, and catheterization laboratory specialists. With time, this hybrid group evolved into vascular technologists. Adequate training and supervision became an obvious problem. Initially, the providers of vascular testing were taught the basics by the supervising physician, who might or might not have an adequate background. In general, most technologists learned how to perform the examinations through “on-the-job” training because of the limited availability of formal education. When a knowledgeable physician supervised the experience, a reasonable level of expertise could result, but often trainees were on their own, learning by rote without understanding what was being done. In the past two decades, noninvasive testing has become more complex both in terms of equipment and procedures. Understanding vascular disease and the instrumentation used has become increasingly important.
Dedicated vascular technology educational programs have continued to evolve over the past decade. Their measured development can be attributed partly to inadequate funding and partly to the classification of vascular technology within the allied health specialty of “cardiovascular technology” (CVT). The CVT specialty was formally recognized by the Committee on Allied Health Education and Accreditation of the American Medical Association in 1981. Essentials and Guidelines of an Accredited Educational Program for Cardiovascular Technology were completed in 1983 and adopted by 12 allied health organizations [including the Society of Vascular Ultrasound (SVU)]. While this step gave credibility to the cardiovascular technology profession and established Standards andGuidelines, it failed to recognize the practical specialty of vascular technology. In theory, CVT includes invasive and noninvasive cardiovascular technology as well as peripheral vascular testing. As a result, educational programs in CVT often included very limited didactic or clinical exposure to peripheral vascular testing. However, because vascular testing has continued to grow in clinical, new educational opportunities have developed for vascular technologists and vascular sonographers. Since 1985, the Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT) has reviewed programs seeking accreditation in cardiovascular technology. Currently, 13 Commission on Accreditation of Allied Health Education Program (CAAHEP)–accredited programs in Cardiovascular Technology offer concentrations in Noninvasive Vascular Study. Accredited programs offer certificate, associate, baccalaureate, and master’s degrees or credentials. For detailed information about JRC-CVT-accredited programs, visit www.caahep.org or www.jrccvt.org.
A second pathway for education in noninvasive vascular testing is through the Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS), also accredited by CAAHEP. Fifty-four accredited Diagnostic Medical Sonography programs offer concentrations in vascular testing. Three programs offer dedicated vascular education: Nova Southeastern University and Rush University are baccalaureate programs and Long Island University is a certificate program. Students who graduate from accredited CVT and DMS programs are eligible to sit for certification examinations.
The emergence of “distance” or “Internet” educational programs is also impacting the educational choices of vascular technologists. Although several “online” vascular ultrasound educational programs are currently available, the first bachelor’s degree program in vascular technology was developed in 1992 by the Oregon Institute of Technology (OIT). The program offers a course of studies for a student entering the profession of vascular technology as well as a completion degree pathway for registered vascular technologists. The program currently enrolls 30–40 students on-campus and up to 100 students in the off-campus each year. The Degree Completion Program integrates basic medical science and vascular diagnostic courses with a general college education, allowing students to complete a Bachelor of Science Degree in Vascular Technology. The distance program was developed for vascular technologists desiring a degree without leaving their present employment. The program is available to technologists who lack a bachelor’s degree, and credits are awarded for achieving certification as a Registered Vascular Technologist (RVT). Details of the program are available at the school’s website.
Certification
From the early days of vascular testing, there was concern about the level of knowledge, experience, and competence of the individual technologist. In 1979, the national association of vascular technologists, the Society of Noninvasive Vascular Technologists (SNIVT, which later became the SVU), recognized that validation of the specialty required documentation of competence through certification. The American Registry of Diagnostic Medical Sonographers (ARDMS) was selected to provide the certification examination. Since 1975, the ARDMS developed and administered practice-based examinations in distinct ultrasound specialty areas. The ARDMS has certified more than 70,000 individuals in seven specialty areas for sonographers/vascular technologists and one specialty interpretation examination for physicians. It is recognized and accredited by the International Standards Organization (ISO), the American National Standards Institute (ANSI), and the National Commission of Credentialing Agencies (NCCA) and has become a recognized standard for diagnostic medical ultrasound credentialing worldwide. The ARDMS has well-defined educational and clinical prerequisites for candidates preparing to sit for ultrasound certification examinations.
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