Background
Intersocietal Accreditation Commission Echocardiography accreditation involves a broad-based evaluation of a given echocardiography facility’s daily operation. An in-depth analysis of the most frequent noncompliant accreditation items provides learning opportunities for improvement of echocardiographic practice and facilities.
Methods
Data from 3,260 facilities applying for accreditation from 2011 to 2013 were analyzed to assess five key elements, each including multiple variables. The key elements included staff qualifications, imaging protocols, image quality, reporting, and documentation of quality improvement activities. Site characteristics for each facility were also analyzed.
Results
Sixty-two percent of facilities ( n = 2,020) demonstrated deficiencies resulting in delayed accreditation. Deficiencies were less frequently observed at hospital-based facilities, facilities applying for reaccreditation, and facilities with credentialed sonographers. The most frequent deficiencies were related to reports (48%), followed by staff qualifications (46%), quality improvement (45%), image quality (44%), and protocols (43%). Both reports and image quality had the highest average numbers of deficiencies per facility, with 2.0 ± 1.0 and 1.83 ± 0.82, respectively. The most common deficient variables were lack of documented continuing medical education (25%), incomplete protocols (36%), incomplete interrogation of aortic stenosis from multiple views (34%), incomplete reports (36%), and insufficient annual summary of quality improvement activities (45%).
Conclusions
Accreditation is delayed for a majority of facilities seeking Intersocietal Accreditation Commission Echocardiography accreditation because of major deficiencies or noncompliance. By focusing on staff continuing medical education, adoption and implementation of standard imaging protocols, ensuring acceptable image quality, using standards in reporting, and implementing quality improvement programs, echocardiography facility performance and quality as compared with the Intersocietal Accreditation Commission Echocardiography standards may be improved.
The Intersocietal Accreditation Commission (IAC) has been accrediting echocardiography facilities since 1996. The mission and motto of the IAC are “Improving Health Care Through Accreditation.” Accreditation is an important part of monitoring and improving quality patient care, as the Centers for Medicare and Medicaid Services and private payers increasingly tie echocardiographic examination reimbursement to sonographer credentials and/or laboratory accreditation. Currently there are 5,354 adult transthoracic accredited facilities in the United States, Canada, and Puerto Rico.
Via an online portal, the accreditation process requires facilities to submit electronic documentation of demographic data, sonographer and physician staff qualifications, imaging protocols, and quality improvement efforts. Also required is submission of self-selected case studies and corresponding reports demonstrating a facility’s best work. Transthoracic cases must represent as many staff members as possible (maximum, 12 cases) with 50% of cases demonstrating left ventricular wall motion abnormalities due to coronary artery disease or myocardial infarction and 50% of cases demonstrating aortic stenosis. The total number of medical and technical staff members determines the number of cases submitted.
Each facility is evaluated for compliance with the IAC standards and guidelines for echocardiography, which define the minimal level of quality expected for facility operation in each of the areas noted above. Accreditation is either granted, indicating that no significant deficiencies are identified and the facility is compliant with the standards, or delayed because of significant deficiencies or noncompliance. Delayed facilities are subsequently granted accreditation when items of noncompliance are remedied. Although rare, accreditation may be denied to facilities that do not rectify items of noncompliance within 1 year of application submission or facilities with egregious deficiencies related to safety. Accreditation is granted for a 3-year term. At the conclusion of the 3-year term, the facility must apply for reaccreditation using the standards that are in force at the time of reaccreditation.
An in-depth analysis of the most frequent noncompliant or deficient accreditation items may provide learning opportunities for improvement of echocardiography facilities in general. Thus, we used the IAC Echocardiography accreditation database of facilities applying for IAC transthoracic echocardiographic (TTE) imaging accreditation to identify potential areas for improvement.
Methods
This was a retrospective study evaluating compliance with the IAC Standards and Guidelines for Adult Echocardiography for 3,260 facilities applying for IAC accreditation in TTE imaging between January 1, 2011, and December 31, 2013. Five key elements that are examined as part of the usual facility assessment were extracted and evaluated. Each element included multiple variables as defined by the standards ( Appendix 1 ). These include medical and technical staff qualifications, imaging protocols, image quality of submitted case studies, reporting for submitted case studies, and documentation of quality improvement ( Table 1 ). Twenty-five variables within the five key elements were evaluated as separate deficiencies and tabulated.
| Staff qualifications | Protocols | Image quality | Reports | Quality improvement |
|---|---|---|---|---|
| Medical director not qualified | Incomplete protocol | Incomplete study | Incomplete report | Insufficient annual summary |
| CME medical director | Insufficient time per study | Poor endocardial definition | Incomplete demographics | |
| CME medical staff | Apical images foreshortened | Internal report inconsistency | ||
| Technical director not qualified | TR sought from only one view | Any typographical errors present | ||
| CME technical director | Inaccurate Doppler LVOT measurement | Measurements not reported | ||
| CME technical staff | Interrogation of AS incomplete | Report handwritten | ||
| Poor Doppler technique | Report discrepancy | |||
| Omission of positive findings | ||||
| Sonographer preliminary reports |
Evaluation of site characteristics for each facility included cycle of accreditation application, geographic region of the United States where the facility is located, type of facility, annual volume of TTE studies, number of medical staff members, number of National Board of Echocardiography (NBE)–certified physicians, number of technical staff members (sonographers), number of credentialed sonographers, and TTE imaging accreditation decision.
Facility compliance with IAC Echocardiography standards was determined through application review and evaluation of a minimum of four TTE case studies per facility. Each application and associated case studies were evaluated by two of 41 peer reviewers with expert knowledge of IAC Echocardiography standards and experience in the performance and interpretation of TTE studies. Reviewer disagreement was adjudicated by IAC Echocardiography technical staff members. Reviewer agreement has previously been evaluated by the IAC; an overall rating accuracy of 92% demonstrated excellent reviewer consistency (W. Judd, PhD, personal communication, September 16, 2013).
Statistical Analyses
The data were analyzed using SPSS for Windows version 22.0 (SPSS, Inc, Chicago, IL) and SAS version 9.3 (SAS Institute Inc, Cary, NC). As a preliminary step, site characteristics were summarized as mean ± SD for continuous variables and as numbers and percentages for categorical variables. In addition, the unadjusted frequency of deficiency in each of the areas was summarized. Subsequently, data were examined for outliers, normality of distribution, and correlations.
For each of the five key elements, an aggregate score of 1 was assigned if there was at least one deficiency present in any of the variables. Using generalized linear models, we first assessed the association between deficiency and decision outcome, adjusting for time, geographic location, cycle, and facility. Second, we evaluated differences in site characteristics across each of the five key elements using descriptive analyses (analysis of variance for continuous variables and χ 2 tests for categorical variables).
Subsequently, using a series of generalized linear models, we assessed trends over time in each of the five key elements as well as differences over time in site characteristics.
In addition, differences in the accreditation decision (percentage of granted vs delayed facilities) were evaluated for the five key elements and site characteristics. Statistical significance was determined by χ 2 testing, and the significance level was set a priori at P < .05.
Results
Facility Characteristics
Facility characteristics are detailed in Table 2 . Of interest, the majority of facilities were not hospital based, and accreditation was delayed for 62.0% of facilities. Only 25.3% of facilities were applying for initial accreditation, while the remainder had applied for reaccreditation one or more times.
| Characteristic | n (%) |
|---|---|
| TTE accreditation decision | |
| Grant | 1,240 (38.0%) |
| Delay | 2,020 (62.0%) |
| Facility type | |
| Non-hospital-based | 2,340 (71.8%) |
| Hospital-based | 920 (28.2%) |
| Cycle of accreditation | |
| First-time | 826 (25.3%) |
| Reaccreditation | 2,434 (74.6%) |
| Number of physicians per facility | 5.5 ± 6.25 |
| Number of NBE-certified physicians per facility | 1.23 ± 2.76 |
| Number of sonographers per facility | 3.54 ± 4.07 |
| Number of credentialed sonographers per facility | 2.53 ± 3.53 |
| Annual volume of TTE studies | 1,775 (840–3,752) |
| Number of sites per application | 1.63 ± 1.96 |
| Region | |
| Northeast | 1,147 (35.2%) |
| Midwest | 576 (17.7%) |
| South | 1,167 (35.8%) |
| West | 369 (11.3%) |
Deficiencies by Key Elements
Among facilities receiving delayed accreditation ( n = 2,020), the most frequent deficiencies ( Table 3 ) were related to reports, followed by staff qualifications, quality improvement, image quality, and imaging protocols. Reports and image quality had the highest average numbers of deficiencies per facility at 2.0 ± 1.0 and 1.83 ± 0.82, respectively.
| Element | Total deficiencies | Average number of deficiencies per facility | Number of facilities with deficiencies | Number of facilities with no deficiencies |
|---|---|---|---|---|
| Reports | 1,942 | 2.0 ± 1.0 | 975 (48.3%) | 1,045 (51.7%) |
| Staff qualifications | 1,401 | 1.5 ± 0.77 | 923 (45.7%) | 1,097 (54.3%) |
| Quality improvement | 899 | 1.0 | 899 (44.5) | 1,121 (55.5%) |
| Image quality | 1,630 | 1.83 ± 0.82 | 891 (44.1%) | 1,129 (55.9%) |
| Protocols | 963 | 1.11 ± 0.32 | 866 (42.9%) | 1,154 (57.1%) |
The most common deficient variable for delayed facilities within the staff qualification key element ( Table 4 ) was insufficient continuing medical education (CME) for medical staff members (25.3%). Within the protocol key element, the most common deficiency was incomplete protocols (36.2%). For the image quality key element ( Table 5 ), the most common deficient variables were incomplete studies (33.6%) and incomplete or absent interrogation of aortic stenosis from multiple views (32.7%). Incomplete reports (36.2%) were the most frequent deficiency for the report key element ( Table 6 ). For the quality improvement key element, an insufficient annual summary was present in 44.5% of facilities with delayed accreditation.
| Staff qualifications | n (%) |
|---|---|
| Insufficient CME medical staff | 512 (25.3) |
| Insufficient CME technical staff | 327 (16.2) |
| Insufficient CME medical director | 294 (14.6) |
| Insufficient CME technical director | 206 (10.2) |
| Technical director not qualified | 62 (3.1) |
| Medical director not qualified | 0 |
| Image quality | n (%) |
|---|---|
| Interrogation of AS incomplete | 678 (33.6) |
| Incomplete study | 661 (32.7) |
| TR sought from only one view | 118 (5.8) |
| Poor endocardial definition | 81 (4.0) |
| Apical images foreshortened | 67 (3.3) |
| Poor Doppler technique | 23 (1.1) |
| Inaccurate LVOT measurement | 2 (0.1) |
| Report | n (%) |
|---|---|
| Incomplete report | 731 (36.2) |
| Internal report inconsistency | 442 (21.9) |
| Incomplete demographic data | 275 (13.6) |
| Measurements not reported | 153 (7.6) |
| Omission of positive findings | 124 (6.1) |
| Sonographer preliminary reports | 117 (5.8) |
| Typographical errors | 66 (3.3) |
| Report discrepancy | 20 (1.0) |
| Report handwritten | 14 (0.7) |
Predictors of Delayed Accreditation
Of 25 total key elements, 10 were found to be significant predictors of delayed accreditation ( P < .0001; Table 7 ). For the staff qualification key element, insufficient CME for the medical director, medical staff members, technical director, and technical staff members were all significant predictors of decision to delay (all P < .0001). Neither medical director nor technical director qualification variables were significant predictors.
| Variable | b ∗ | SE † | OR ‡ | P |
|---|---|---|---|---|
| Staff qualifications | ||||
| Medical director not qualified | 0 | 0 | — | — |
| CME medical director | −3.59 | 0.55 | 0.03 | <.0001 |
| CME medical staff | −4.27 | 0.35 | 0.01 | <.0001 |
| Technical director not qualified | −22.79 | 11,543 | <10 −3 | .9984 |
| CME technical director | −3.21 | 0.50 | 0.04 | <.0001 |
| CME technical staff | −2.68 | 0.43 | 0.07 | <.0001 |
| Protocol | ||||
| Incomplete protocol | −5.94 | 0.48 | 0.003 | <.0001 |
| Insufficient time per study | −5.87 | 1.03 | 0.003 | <.0001 |
| Image quality | ||||
| Incomplete study | −2.73 | 0.63 | 0.07 | <.0001 |
| Poor endocardial definition | −18.71 | 7,148.25 | <10 −3 | .9979 |
| Apical images foreshortened | −17.08 | 7,332.02 | <10 −3 | .9981 |
| TR sought from only one view | 2.65 | 1.29 | 14.15 | .0395 |
| Inaccurate Doppler LVOT measurement | −11.62 | 74,580.87 | <10 −3 | .9999 |
| Interrogation of AS incomplete | −4.53 | 0.57 | 0.01 | <.0001 |
| Poor Doppler technique | −19.21 | 14,352.16 | <10 −3 | .9989 |
| Reports | ||||
| Incomplete report | −3.57 | 0.40 | 0.03 | <.0001 |
| Incomplete demographic data | −2.67 | 1.58 | 0.07 | .0899 |
| Internal report inconsistency | −3.24 | 0.86 | 0.04 | .0002 |
| Typographical errors | −18.24 | 8,151.701 | <10 −3 | .9982 |
| Measurements not reported | −0.71 | 1.42 | 0.49 | .6178 |
| Report handwritten | −15.86 | 15,380.26 | <10 −3 | .9992 |
| Report discrepancies | −19.79 | 18,055.99 | <10 −3 | 9991 |
| Omission of positive findings | −2.28 | 1.35 | 0.10 | .0906 |
| Sonographers preliminary report | −23.15 | 7,039.99 | <10 −3 | .9974 |
| Quality Improvement | ||||
| Insufficient annual summary | −5.47 | 0.37 | 0.004 | <.0001 |
∗ b is the regression parameter from the generalized linear model.
† SE is the standard error of b .
Both protocol key element variables (incomplete protocol and insufficient time allotted for each study) were predictive of delayed accreditation ( P < .0001). Image quality variables that were predictive of delayed accreditation included incomplete study (e.g., missing required views) and lack of aortic stenosis systolic velocity evaluation from multiple transducer positions using the dedicated nonimaging continuous-wave Doppler transducer ( P < .0001 for both). Incomplete reports were also predictive of delayed accreditation ( P < .0001). For quality improvement, an insufficient annual summary containing documentation of required quality measures was a significant predictor ( P < .0001).
Facility Characteristics and Accreditation Decision
Evaluation of the differences in accreditation decisions for each of the facility characteristics ( Table 8 ) revealed a significant difference in accreditation decisions for facility type, with more non-hospital-based facilities receiving accreditation delays ( P = .016). Facilities undergoing first-time accreditation had a higher delay rate ( P = .010), as did facilities with no credentialed sonographers on staff ( P < .001). Analyzed by quartiles, a smaller number of medical staff members ( P = .004), a smaller number of sonographer staff members ( P < .001), and a lower annual volume of studies performed ( P = .012) were all associated with a higher percentage of accreditation delay. Geographic region, number of sites per facility, presence of NBE-certified physicians on staff, and year of accreditation did not demonstrate significant differences.
| Variable | Grant (%) | Delay (%) | Total | P |
|---|---|---|---|---|
| Facility type | ||||
| Nonhospital | 860 (37) | 1,480 (63) | 2,340 | |
| Hospital | 380 (41) | 540 (59) | 920 | |
| Total | 1,240 (38) | 2,020 (62) | 3,260 | .016 |
| First time vs reaccreditation | ||||
| First time | 283 (34) | 543 (66) | 826 | |
| Multiple reaccreditation | 957 (39) | 1,477(61) | 2,434 | |
| Total | 1,240 (38) | 2,020 (62) | 3,260 | .01 |
| Number of medical staff members (quartile) | ||||
| 1 (1) | 337 (35) | 623 (65) | 960 | |
| 2 (2 or 3) | 245 (35) | 458 (65) | 703 | |
| 3 (4–7) | 332 (41) | 486 (59) | 818 | |
| 4 (>7) | 326 (42) | 453 (58) | 779 | |
| Total | 1,240 (38) | 2,020 (62) | 3,260 | .004 |
| Number of sonographers (quartile) | ||||
| 1 (1) | 383 (35) | 696 (65) | 1,079 | |
| 2 (2) | 262 (35) | 495 (65) | 757 | |
| 3 (3 or 4) | 261 (39) | 410 (61) | 671 | |
| 4 (>4) | 334 (44) | 419 (56) | 753 | |
| Total | 1,240 (38) | 2,020 (62) | 3,260 | <.0001 |
| Credentialed sonographers | ||||
| No credentialed sonographers | 154 (31) | 345 (69) | 499 | |
| Credentialed sonographers | 1,086 (39) | 1,675 (61) | 2,761 | |
| Total | 1,240 (38) | 2,020 (62) | 3,260 | <.0001 |
| Annual volume of TTE studies (quartile) | ||||
| 1 (<841) | 285 (35) | 531 (65) | 816 | |
| 2 (841–1,775) | 304 (37) | 511 (63) | 815 | |
| 3 (1,776–3,752) | 304 (37) | 511 (63) | 815 | |
| 4 (>3,752) | 347 (43) | 467 (57) | 814 | |
| Total | 1,240 (38) | 2,020 (62) | 3,260 | .012 |
Facility Characteristics and Deficiencies in the Five Key Elements
Comparison of facility characteristics with deficiencies in the five key elements demonstrated significant differences ( Appendix 2 ). A significant difference in staff qualification deficiencies was noted for all facility characteristics except the presence of credentialed sonographers ( P = .154). A significant difference in protocol deficiencies was noted for facility type ( P = .021), number of medical staff members ( P = .001), number of sonographers ( P < .0001), and presence of credentialed sonographers ( P = .018). All facility characteristics compared for image quality deficiencies demonstrated significant differences ( P < .05), including the presence of NBE-certified medical staff members and credentialed sonographers. All facility characteristics compared for reporting deficiencies demonstrated significant differences, except for annual volume of studies ( P = .123). There were also significant differences in facility characteristics with respect to quality improvement deficiencies, except for region of the country ( P = .147) and the number of sites per facility seeking accreditation ( P = .174). Of interest was that for all key elements except protocols, the percentage of facilities with deficiencies decreased between first-time applicants compared with second-time applicants and then with applicants applying three or more times (staff qualification, P = .001; image quality, P < .0001; reporting, P < .0001; and quality improvement, P = .019). Facilities applying three or more times had the smallest number of deficiencies.
Trends over Time
Trends over time (from 2011 to 2013) for deficiencies in the five key elements were evaluated for facilities with delayed accreditation status ( n = 2,020), and unadjusted percentages are presented in Figure 1 . Overall, there were significant differences in the percentage of facilities with deficiencies across the years (testing the null hypothesis that all years were equal). Further evaluation of pairwise changes over time suggested significant changes from year to year in staff qualifications ( P < .05). However, for protocol, reporting, and image quality deficiencies, only changes from 2011 to 2012 were significant ( P < .05). For quality improvement, changes were significant from 2011 to 2012 and from 2012 to 2013 ( P < .05), although 2011 rates were statistically equivalent to those for 2013.
Results
Facility Characteristics
Facility characteristics are detailed in Table 2 . Of interest, the majority of facilities were not hospital based, and accreditation was delayed for 62.0% of facilities. Only 25.3% of facilities were applying for initial accreditation, while the remainder had applied for reaccreditation one or more times.
| Characteristic | n (%) |
|---|---|
| TTE accreditation decision | |
| Grant | 1,240 (38.0%) |
| Delay | 2,020 (62.0%) |
| Facility type | |
| Non-hospital-based | 2,340 (71.8%) |
| Hospital-based | 920 (28.2%) |
| Cycle of accreditation | |
| First-time | 826 (25.3%) |
| Reaccreditation | 2,434 (74.6%) |
| Number of physicians per facility | 5.5 ± 6.25 |
| Number of NBE-certified physicians per facility | 1.23 ± 2.76 |
| Number of sonographers per facility | 3.54 ± 4.07 |
| Number of credentialed sonographers per facility | 2.53 ± 3.53 |
| Annual volume of TTE studies | 1,775 (840–3,752) |
| Number of sites per application | 1.63 ± 1.96 |
| Region | |
| Northeast | 1,147 (35.2%) |
| Midwest | 576 (17.7%) |
| South | 1,167 (35.8%) |
| West | 369 (11.3%) |
Deficiencies by Key Elements
Among facilities receiving delayed accreditation ( n = 2,020), the most frequent deficiencies ( Table 3 ) were related to reports, followed by staff qualifications, quality improvement, image quality, and imaging protocols. Reports and image quality had the highest average numbers of deficiencies per facility at 2.0 ± 1.0 and 1.83 ± 0.82, respectively.
| Element | Total deficiencies | Average number of deficiencies per facility | Number of facilities with deficiencies | Number of facilities with no deficiencies |
|---|---|---|---|---|
| Reports | 1,942 | 2.0 ± 1.0 | 975 (48.3%) | 1,045 (51.7%) |
| Staff qualifications | 1,401 | 1.5 ± 0.77 | 923 (45.7%) | 1,097 (54.3%) |
| Quality improvement | 899 | 1.0 | 899 (44.5) | 1,121 (55.5%) |
| Image quality | 1,630 | 1.83 ± 0.82 | 891 (44.1%) | 1,129 (55.9%) |
| Protocols | 963 | 1.11 ± 0.32 | 866 (42.9%) | 1,154 (57.1%) |
The most common deficient variable for delayed facilities within the staff qualification key element ( Table 4 ) was insufficient continuing medical education (CME) for medical staff members (25.3%). Within the protocol key element, the most common deficiency was incomplete protocols (36.2%). For the image quality key element ( Table 5 ), the most common deficient variables were incomplete studies (33.6%) and incomplete or absent interrogation of aortic stenosis from multiple views (32.7%). Incomplete reports (36.2%) were the most frequent deficiency for the report key element ( Table 6 ). For the quality improvement key element, an insufficient annual summary was present in 44.5% of facilities with delayed accreditation.
| Staff qualifications | n (%) |
|---|---|
| Insufficient CME medical staff | 512 (25.3) |
| Insufficient CME technical staff | 327 (16.2) |
| Insufficient CME medical director | 294 (14.6) |
| Insufficient CME technical director | 206 (10.2) |
| Technical director not qualified | 62 (3.1) |
| Medical director not qualified | 0 |
| Image quality | n (%) |
|---|---|
| Interrogation of AS incomplete | 678 (33.6) |
| Incomplete study | 661 (32.7) |
| TR sought from only one view | 118 (5.8) |
| Poor endocardial definition | 81 (4.0) |
| Apical images foreshortened | 67 (3.3) |
| Poor Doppler technique | 23 (1.1) |
| Inaccurate LVOT measurement | 2 (0.1) |
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