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Facility Accreditation Frequently Asked Questions
APPLICATION
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As the facility Application Administrator (FAA), I received the invitational e-mail with a link to the Administrator’s portion of the application. Why have the other facility personnel not received their links to their portions of the application? |
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Once the FAA has opened his/her portion of the application, the FAA is asked to enter an e-mail address and assign a password for all participating personnel as found on the Applicant tab. The other personnel will immediately receive their invitational e-mails to begin their portion of the application. Hints: Make sure the e-mail address entered is exact. Make sure the internal e-mail account has not bounced to an external e-mail address. If you encounter additional problems, contact the Accreditation Manager at the ISCD office. |
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| Q: |
We entered our DXA make in error. How do we change that to the correct DXA make in the application? |
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As long as the applicant has not closed out their portion of the application, all changes can be made by going back to the screen where the error was made and changing the information entered. Click save. |
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Can a CME/CEU description be uploaded all in one document instead of entering one at a time? |
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Presently, the application is being revised to accommodate this request. However, until that revision is made, participants are asked to enter and save one entry at a time. Too much information uploaded all at once will not save properly. |
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Should personnel with more than one position in the facility uses different passwords for each position? |
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No. The FAA must enter the same e-mail address and assign a password into the FAA portion of the application for one person who has more than one role in the facility (i.e., Principal Technologist, Facility Director, and Principal Interpreter are all one person). |
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Not all participating personnel in our facility have their own e-mail accounts. How can they receive and access their portion of the application? |
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Technologists and Clinicians may use the same e-mail address as the FAA, but the FAA must enter unique passwords in the Applicant tab, of the FAA portion of the application for each participant who does not have his/her own e-mail account. |
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| Q: |
Can we change the mailing option for document submission that was already entered to the upload option? |
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If the application is not closed, it will allow you to override a mailing option (“pending”) in order to upload submissions. If not, contact the Accreditation Manager. |
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| Q: |
Within the application, how do you replace the original FAA who began the application with someone new? |
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Send the new name, new e-mail and new password of the new FAA to the Accreditation Manager. The new FAA will receive an invitation link to their portion of the application. If a large amount of the FAA portion of the application is completed, you may be advised by the Accreditation Manager to continue to use the old e-mail address. |
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| Q: |
Can half the submissions be sent via postal mail and the other half via electronic upload option? |
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The electronic application process was design to help facilities with efficiency of document movement and for cost saving purposes. To help the ISCD manage submissions, we ask that you submit all documentation and scans either via postal mail OR electronically, but not both. Exceptions, such as a facility’s network security restrictions policy, will be reviewed upon written request. |
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| Q: |
Can submissions be sent to the ISCD office via e-mail? |
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No submissions can be submitted via e-mail. The ISCD system is not HIPPA compliant and does not have sufficient capacity to accept very large sized e-mail attachments. |
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| Q: |
Can the facility SOP be submitted via a CD? |
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Yes, the Accreditation Manager can upload an SOP from a CD. |
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| Q: |
Can an SOP be unofficially previewed by an Accreditation Council member? |
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Yes. There is a fee associated with this. Notify the Accreditation Manager of the format the SOP is in. The Manager will notify the appropriate Council member. |
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| Q: |
Can the definitions for the Essential Elements found in the ISCD Statement of Essential Elements be copied word-for-word into our facility’s SOP? |
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The ISCD Statement of Essential Elements supplies the facility with the definitions of the Essential Elements. The facility writes, in their own words, what Standard Operating Procedures are used daily. |
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| Q: |
If the task list within the application indicate “pending” (to be mailed), can the application be closed? |
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The application closes when the applicant has completed all of the steps, even if they have pending items. “Pending” indicates the user has completed all the steps and has chosen to mail outstanding items. When the application closes, the application program generates a list of all the items to be mailed by the Due Date and before assessment can take place. |
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How does the facility know that uploaded CME/CEU items are saved to the facility folder? |
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If the task list checkmark is there, it indicates the CME/CEU was saved successfully to the facility’s electronic folder. |
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| Q: |
What is the best way to proceed in the application once a new Application Administrator replaces one who already entered the Facility’s personnel in the application? |
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The new person can just overwrite any of the original personnel entries. |
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| Q: |
I've only been certified and reading studies for six months. Although I have read both baseline and follow-up studies on patients, I haven't been at this facility long enough to read a baseline and follow-up on the same patient. How should I handle this in terms of submitting the reports? |
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Exceptions are made for cases such as yours. Upload the baselines, follow-ups and the reports on different patients. When you upload the reports, add one more page as a memo of explanation to the file. |
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SATELLITE LOCATIONS
| Q: |
If we have more than one office, is one office considered satellite facility if the same physician reads for both facilities? |
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Yes, satellites and primary locations share and rotate personnel. |
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| Q: |
Is a separate application filled out for each branch of the facility? |
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No. Branch (satellite) offices are considered to be part of the entire facility. Satellite offices are subordinate operations at secondary locations with a different business address. They contain separate DXA machines and may employ separate personnel. In some facilities, personnel are rotated between satellite offices. A disclosure of your satellite office(s) is requested on the registration form. |
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| Q: |
Does each satellite facility need to submit their own Standard Operating Procedure (SOP) Manual? |
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No. Facilities with a satellite(s) submit one application with one SOP that covers the procedures for both the primary and satellite locations. |
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| Q: |
The facility's technologists perform VFA and the clinicians there are interpreting the VFA. The facility sends the VFA images to a radiologist group for report writing. The radiologist group is an affiliate of the facility. The owner of the facility is located at the facility address. There are no owners at the radiologist group location. Given that only the report writing is done at the radiologist group location, is the radiologist group considered to be a satellite of the facility? |
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No. By definition, satellites contain separate DXA machines and may employ separate personnel. Therefore this facility would not pay a satellite add-on fee for the radiologist group. However, four (4) patient reports written by each radiologist must be signed and submitted as part of the application process. We suggest the radiologist be part of the Interpreter/Clinician Case study discussion. |
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| Q: |
We are a mobile unit with a certified technologist. We are owned by a radiologist group who reads and writes reports for us. Are there any special requirements for accreditation we should know of? |
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No. Definition of facility types on the application are: Outpatient Clinic, Private Medical Office, Free standing DXA Center, Mobile DXA Unit, and Hospital. As long as the registration, application and accreditation pre-requisite requirements are met, each of these facility types follow the exact same accreditation process. |
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| Q: |
Our main operation is in our hospital, but we also operate a mobile service. Most of our mobile clients use our interpreting physicians. We then send out a complete report under our name, interpreted by our certified (CCD) interpreter. However, there are a few clients who only want us to provide them with the technical aspect of the DXA test. In that case they do the interpretation and the report does not carry our name. Will this be a problem for accreditation? |
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In general, it should not be a problem for you. It may be a problem if the other clients misrepresent themselves as being accredited. Those clients would need to apply separately for facility accreditation as their bone density reports are not under your direct supervision. |
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ADMINISTRATIVE
| Q: |
Is there a timeframe in which the application must be in? |
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Yes. Applicants are given 90 days from the date that the FAA opens his/her portion of the application. The due date for submission of the completed application is found at the top of each application page. All materials must be uploaded or postal mailed by the assigned due date. |
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| Q: |
How can we request a due date extension? |
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Extensions are accepted by written request only at least 30 days prior to your facility’s due date. State the current due date assigned, the requested extension date and the reasons for the extension. This must be signed by the facility owner. Once received, the written extension request will be sent to the Extension Subcommittee for approval. The facility will be notified in writing. |
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| Q: |
Is the application fee refundable? |
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By sending a written explanation of reasons for withdrawing from the application process, a facility may withdraw at any time. $200 of the application fee is non-refundable. |
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| Q: |
How quickly will a newly hired technologist or interpreter need to meet the educational requirement after the facility is accredited? |
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Within six (6) months to a year. We recommend you notify the Accreditation Manger by submitting a copy of the education attestation form or if the person became certified, a copy of their certificate. |
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| Q: |
If a facility signs the Business Agreement and signs the Business Associate Agreement making ISCD a business associate, and the facility is HIPAA compliant, can patient scans be submitted with identifiers? |
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No. Regardless of the signed agreements, it is the policy of the ISCD Facility Accreditation Program that no identifiers are on scans. If the facility is HIPAA compliant, no identified should be on any scans sent in for the program. |
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| Q: |
We are interested in facility accreditation, however we are a pediatric program and do not see adults. Do you foresee a pediatric accreditation in your program? |
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The development of Facility Accreditation in this area could happen if the ISCD develops a course and/or certification in pediatric densitometry. If this were to happen, it could be 3-5 years before an accreditation in pediatric densitometry could be launched. |
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| Q: |
Our group practice interprets DXA scans sent us by other facilities under a contractual arrangement. This is the only service that we provide in the bone density measurement area. Does my group practice need to be accredited or do our interpreters need to be certified to interpret DXA scans for the other facilities? Are we included in their facility accreditation process? If so, how? |
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Yes, you are involved. The facility choosing to be accredited will be required to answer interpretation questions and submit interpretations and reports from each clinician. The only requirement is that clinicians and technologists in a facility applying for accreditation must demonstrate a mastery of the Body of Knowledge as defined by the ISCD Accreditation Council. We recommend that all clinicians and technologists involved in the process be ISCD certified, or its equivalent, for the facility to receive accreditation. If they do not meet this requirement, an automatic finding requiring such education and/or certification will go into the recommendation letter. |
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PRECISION TESTING
| Q: |
99% of our scans are done by the two technologists who each have done a precision test on our in-house densitometer. We are using a mean of their precision for our LSC. Occasionally I will do a few scans in a fill-in capacity, although most of my work is done on a mobile unit. Do I need to do a precision test on the in-house densitometer? If I do one in-house, should I figure it into the LSC for the facility? If it is considerably better and I average it in, won’t that weight the LSC to a more favorable and inaccurate number, as I actually do only a few per year in a facility that does more than 1800 scans per year? |
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Yes, if you perform exams on a densitometer that is distinctly different from the one you operate in the mobile setting, as each densitometer/technologist will have their own unique precision and with such limited experience on the in-house machine, it would be expected that your precision could be poorer than someone who does scans 40 hours/week. If both scanners are are the same, then one could argue that the only difference in precision would be machine related, not operator related. If both scanners passed daily QA, then no additional precision assessment need be performed and you could use the precision study from the mobile unit. |
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| Q: |
How do we calculate an in-house combined precision? |
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There are three methods, all of which are considered acceptable: |
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- Each technologist scanning the same patients. With four technologists, each patient would need to be scanned four times, once by each technologist. You would also need to compare the mean BMD of each technologist for the entire group of patients to the others using a student t-test for paired means to insure that there is no bias (i.e., one technologist is always getting higher values then the other three, especially if one technologist's mean BMD is more than 0.5% different from the others).
- Randomly select paired or triplicate scans from each of the technologists and input them into the advanced precision calculator on the ISCD Web site, filling in each of the 50 lines, and using a proportion that reflects the relative volumes of each technologist. You should repeat this random selection process (random methods are available in any basic statistics text) several times and take the average value.
- If all the technologists have similar precision errors (all within ±30% of the mean of the individual precisions) then at 30 degrees of freedom, they are not statistically different from one another. If none of them exceed the minimum precision cited in the ISCD Official Positions, then one should use the poorest value as the LSC for the facility. The danger is over-reading changes and calling a gain or loss that is not statistically significant. This is where patient management decisions as to continuing or discontinuing a therapy are made, and has the greatest potential of adversely affecting patient care. Using the worst precision for the group guarantees that this will not happen. If one technologist is substantially worse than the others, then either retraining and a new precision assessment, or a change of personnel is required.
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CURRICULUM VITAE (CV), RESUMES, BIOGRAPHIES
| Q: |
Our technologists do not have Curriculum Vitae, what should we do? |
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Copies of background credentials are required from all technologist and clinicians. A biography or resume is acceptable from technologists. |
REGULATIONS
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The State of Massachusetts has no regulation stating that scans must be acquired by a technologist (anyone can acquire). If a Massachusetts facility has no technologist, but does have doctors reading scans, is that facility still eligible to apply for Accreditation? |
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Yes, but the person acquiring the scan is part of the accreditation process. Someone must acquire the scan. If the doctor has had manufacture’s training and has taken the ISCD Technologist Bone Densitometry Course or its equivalent, that would be acceptable. If a lay person or allied health professional is acquiring scans, they would have to take manufacture’s training and the ISCD Technologist Bone Densitometry Course or its equivalent. These education and training requirements must also be stated in the facility’s SOP. |
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DXA MACHINES
| Q: |
Our facility has two different manufacturer DXA machines. Are their additional requirements for scan and report submissions? |
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At the present time, the application is programmed to upload scan and report submissions for only one manufacturer machine. To fulfill the requirement for submissions of more than one manufacturer, upload submissions from one DXA manufacturer and postal mail the submissions from the second DXA manufacturer. Follow mailing instructions posted on the Web site. |
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Do facilities need to notify the ISCD Accreditation Manager if a new machine is purchased for the facility or if one is replaced? |
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Yes. The facility is required to notify ISCD with a copy of the State Registration form, if applicable. |
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| Q: |
Is our Prodigy Advance DXA going to be an issue for receiving accreditation? This model takes one scan with no block. It scans the lumbar and immediately goes to the hip. |
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The Facility Accreditation Council has determined that, “The facility will be held to the standards of scanning indicated in the Essential Elements.” (Decisions that apply to upgrades will go to the Assessor Team and Acceptance Committee to determine what submission exceptions, if any, are required from the facility.) |
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RECORD-KEEPING
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Are the archived scan printouts and all other information kept in patient files acceptable as the second location archive? Or must it be on the electronic format (magnetic optical, super disc, CD, Zip, Jaz, floppy )? |
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According to the electronic record keeping section of HIPAA, it is our understanding that one method of disaster recovery is to keep a second copy of electronic medical data in a second location, not a paper printout in a second location. We are referring to a second copy of the patient scans in the proprietary format of the DXA machine, not the printouts as a PDF or Word document which cannot be reanalyzed if it is necessary to fix an inconsistency or other error. Two electronic copies of the scans are required. However, the second copy can be on a different type of storage media, or even copied to a hospital or facility server where the IT department maintains its own backups that are HIPAA compliant. The key is that the second copy should be in a file format that can be restored and reanalyzed by the scanner software. |
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We are in the process writing a Standard Operating Policy and Procedure (SOP) manual for our bone density department. Are there any guidelines for the length of time required to retain scans. In our mammography department, it is clearly stated they must be retained for a minimum of 10 years. I'm wondering if the ISCD has a policy. |
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ISCD does not have a policy or recommended position on record retention. Record retention is usually clearly spelled out by state regulations or your state medical board. |
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CASE STUDY REPORTS
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What is the format for submission of Case Study Reports? |
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You are being asked to produce a standard DXA report in the format you currently use for your DXA scans at your facility based on the scans and related information provided. These are to be submitted on the facility letterhead. The interpreter’s signature is required. Unsigned reports will be returned. |
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Where in the application are the Case Studies found? |
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Once the Principal Technologist or Principal Clinician has entered the DXA model into the application, case studies are immediately randomly generated into the facility’s application and can be found in the Case Study Element. |
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GE Technologist Case Studies 0003 and 0004 are scans of the same patient. Is this correct? |
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Yes, this is the same patient, but different scans are being compared. |
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Is there an official Clinician’s Case Study Report format or template within the application? |
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No. Submit the samples of the clinician’s patient reports on your facility’s usual report form. |
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CLINICAL
| Q: |
For a hyperparathyroid (HPT) patient, according to the ISCD Official Positions, if the diagnosis changes, how long do you keep doing the forearm? When is it acceptable to not have to do the forearm? |
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The official positions also state that no scan should be performed unless the results can affect patient management. If a patient is diagnosed with HPT and has a forearm scan done that is normal, and then still goes on to have a parathyroidectomy, one forearm scan a year post surgery that shows no significant loss is all that is needed, unless the patient again develops symptoms. There is not any statement in the ISCD Official Positions saying that the forearm must be measured in follow-up scans for patients with HPT, but it does state that peripheral sites “should not be used for monitoring.” |
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PREVENTATIVE MAINTENANCE
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Does the staff technologist do 10 more phantoms after the service technician/engineer leaves? |
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The 10 (minimum) phantom scans should be done BEFORE the service engineer leaves, to verify that the machine is still in calibration. Most field service engineers know to scan the phantom 10-20 times before they leave and it may even be a part of the service call so they can document that they fixed the scanner. (This is especially important for facilities that are NOT on a service contract who want their scanner fixed for free.) |
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Are the 10 scans done prior to preventative maintenance done on the same day consecutively? Can it be done over 10 days? |
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Either way should be acceptable. Note, if a scanner has failed, it will be impossible to do 10 scans before the service engineer works on the system, so the average of the last 10 daily phantoms while the scanner was still operating correctly are fine. |
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PATIENT SCAN SUBMISSIONS
| Q: |
For patient scan submissions, what skeletal sites/regions of interest will our facility be required to submit in order to satisfy the Essential Element of Accreditation called Acquisition and Analysis? |
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Facilities will be required to submit patient scans of analyzed lumbar spine, femur and forearm and the follow-up scans for those patients. |
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Are both left and right femur submissions required for patient submissions? |
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Either left or right is fine. We will not return the scan if dual femur is sent to us. |
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| Q: |
Our facility is uncertain how to submit our documentation and samples of patient scans. How can we submit them? |
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There are four possible methods to submit documentation and scans. Three are electronic methods and the fourth is via postal mail. Contact the Accreditation Manager to request written instructions called, “4 Ways to Submit Documents, Scans and Reports” or download the document located in the Facility Accreditation, Resources section of the ISCD Web site. |
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Our facility cannot find a baseline scan and follow-up scan acquired by the same technologist. In many cases the reports are not read by the same clinician. How will this affect our accreditation assessment? |
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The application requests that both baseline and follow-up patient scans be acquired by the same technologist. This is the preferred criteria for submission. However, in facilities where all or some of the patient scans are not acquired or read by the same personnel, it is acceptable to submit baseline scans from one technologist and the follow-up acquired by another, as long as the patient is the same. This also holds true for the reading (interpreting) clinicians. Since this is a situation that is out of the ordinary, uploading a memo to the file from your facility is necessary. |
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Our facility does not acquire forearm scans on a regular basis and has no LSC for forearm. How do we answer questions related to forearm and submit required number of forearm scans? |
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All forearm requirement issues must be submitted in writing to the Accreditation Manager. Accreditation Council members will answer each facility on a case-by-case basis. |
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