Frequently Asked Questions on Accreditation
1. What is the Practice Site Accreditation Program?
2. What is the Credentialling Program?
3. What is the Link Between Credentialling and Practice Site Accreditation?
4. When Does the Practice Site Accreditation Program Officially Take Effect?
5. What is the Practice Site Accreditation Process?
6. What are the Requirements for Personal Supervision?
7. What is Required to Achieve Practice Site Accreditation?
8. Is Practice Site Accreditation Linked with Medicare Eligibility?
9. Powers and Obligations of Those Involved in the Site Accreditation Program
10. Who May Apply to Become an Accreditation Site Assessor?
11. What is Commonwealth Indemnity?
12. Will the RANZCR Apply the Same Standards for Nuclear Medicine Practices?
13. When do Practices Need to Apply for Interim Accreditation?
14. What are the Fees for Practice Site Accreditation?
Introduction
The ANZAPNM (“the Association”) has been working towards a quality assurance program over the last few years. The program consists of two parts: the nuclear medicine practice site accreditation program, and the individual nuclear medicine specialist credentialling program.
Implementation of the credentialling program commenced late in 2000, with distribution, completion and return of credentialling application forms by specialists. The nuclear medicine practice site accreditation program commenced its pilot phase implementation with distribution of the information/application forms and Standards documents in late April 2001.
The Standards for Nuclear Medicine Practice Accreditation - November 2000 have been endorsed by Council at its April 2001 meeting as the first set of Standards for the practice site accreditation program.
The Standards are the result of work over the second half of 2000, which takes account of a wide range of issues raised by Members both at the AGM and at various other times. Members are assured that the changes incorporated in these Standards reflect the diversity of views received. Members’ views have not been ignored in this version of the Standards being used to commence the pilot phase of implementation of the nuclear medicine practice accreditation program.
To assist Members in understanding the Association’s quality assurance process, we have prepared this list of common questions and answers. If you require further information, please contact the ANZAPNM Secretariat.
1. What is the Practice Site Accreditation Program?
The Nuclear Medicine Practice Site Accreditation Program assesses the standards of nuclear medicine practices through a combination of self-assessment questionnaires and site visits (see below). This program is being managed by the Nuclear Medicine Practice Site Accreditation Implementation Committee (AIC).
The main focus of the practice site accreditation program is on the standards of practices, rather than individuals. While Principle 1 of the Standards for Accreditation does focus on professional qualifications, the standards listed are those which accompanied the credentialling application, e.g. training in nuclear medicine, personal supervision etc. Therefore those Members who have applied for credentialling will have already addressed these criteria.
The practice site accreditation program is a Declared Quality Assurance Activity, as is the credentialling program (see Indemnity below). This Declaration was made because it is important to protect those involved, and the associated process, from possible litigation.
The practice site accreditation program has no requirement to report identifying details, or provide lists, of individual practices to any outside organisation.
Download Nuclear Medicine Practice Site Accreditation Documents.
2. What is the Credentialling Program?
The Nuclear Medicine Specialist Credentialling Program commenced in September 2000, and most Members have already participated in this. If you have done so, you will recall completing a one-page questionnaire last year. This was accompanied by a document setting out Principle 1 (the professional principle) from the Standards for Accreditation of Nuclear Medicine Practices. This Principle covers issues such as training in nuclear medicine, licence to use radioactive substances, personal supervision etc.
The credentialling program is managed by the Joint Nuclear Medicine Credentialling and Accreditation Committee (JNMCAC) of the Royal Australasian College of Physicians (RACP) and the Royal Australian and New Zealand College of Radiologists (RANZCR).
You will note from the document that accompanied the credentialling questionnaire that a list of names of credentialled specialists is to be provided by the JNMCAC to the Health Insurance Commission (HIC). This situation is not peculiar to nuclear medicine: other specialties require credentialling and must provide a list of specialists’ names to the HIC (e.g. physicians credentialled for sleep medicine services, radiologists providing MRI services), or must provide evidence of credentialling to a public or private hospital (gastroenterologists providing endoscopy services).
It is important to note that the HIC is subject to strict privacy requirements and that it is not legal for the HIC to provide this data to any government institution, including the Department of Health and Aged Care (DHAC).
The credentialling program is a declared quality assurance activity under Commonwealth Legislation, and those involved with it, including members of the JNMCAC, are protected from suit under this legislation (see Indemnity below).
The credentialling program has been one response of the Association to concerns of its Membership that specialists who do not practice appropriately should not be afforded the same level of Medicare recognition as those who do practice appropriately.
Download Application Form for Credentialling as a Specialist in Nuclear Medicine
3. What is the Link Between Credentialling and Practice Site Accreditation?
As part of the site visit component of the practice site accreditation program, assessors will briefly verify the Standards of Principle 1, which concern professional qualifications as stated in the credentialling application. This may include, for example, sighting of relevant licences etc. and will include a brief review of (de-identified) patient records or reports. It is important to remember that the purpose of the latter is merely to audit a process - it is not intended to review any specialist’s reporting techniques.
Apart from the above, the practice site accreditation program is not concerned with individual specialist credentialling. Neither the AIC nor any assessor nor any Accreditation Review Panel (ARP) has the authority to add or remove any specialist’s name from the list of credentialled specialists. This listing is the sole responsibility of the JNMCAC.
4. When Does the Practice Site Accreditation Program Officially Take Effect?
The nuclear medicine practice site accreditation program will take effect officially from the first day after the deadline date for receipt of applications for interim accreditation (see Q. 12). Therefore the official date the program takes effect is 2 July 2001.
The program will commence with a pilot phase implementation period expected to take a minimum of 12 months from 2 July 2001. This pilot implementation will allow aspects of the program to be assessed, and will provide opportunities for input into this assessment.
Practice site accreditation is a prospective process, therefore practices will be assessed on their operation as of the official date of implementation of the accreditation program. There will not be any assessment of how practices have been operating prior to this date. De-identified patient records or reports that are viewed by assessors will be taken from those created as of 2 July 2001.
5. What is the Practice Site Accreditation Process?
The process of practice site accreditation comprises:
- application for interim accreditation
- site visit
- formal review of site visit report and vote on accreditation
In addition, there is an appeals process open to practices in the event that they are denied accreditation (see Q. 7 below).
Practice site accreditation will apply for a four-year period, during which the practice will undergo one site visit, and will be required to report annually on any changes that have occurred that might affect accreditation status.
The first step in the accreditation process is completion of the application form and checklist. This will be followed by one site visit every four years.
Practices will be notified in advance of the site assessor appointed to visit the practice, and may appeal against this appointment, in writing and stating the grounds for such appeal, within 21 days of notification of the site visit. All those involved in assessing sites or reviewing assessors’ reports will be required to declare any conflict of interest.
Following confirmation of a suitable assessor and time, the practice contact person will be asked if he/she would like to arrange for relevant staff to accompany the assessor at each stage of the visit. Alternatively, the practice contact person may prefer to assign just one or two people (e.g. because one person is unavailable for the duration of the visit) to accompany the assessor.
Note that it is not intended to hold any review of practice staff. The option of having relevant staff accompany the assessor during each stage of a visit is intended to facilitate answering of questions and provision of any additional data if required. This will help to expedite the visit and provide more time at the close of the visit for general discussion and questions (see below).
The site visit is expected to take up to half a day (4 - 5 hours), and will follow the format of the application form and checklist, i.e. the assessor will consider the application form, then the Standards of Principle 1, Principle 2 and so forth. At the close of the visit, the assessor will hold a brief summary conference with practice staff, during which the staff may ask questions, and provide any additional explanations if desired.
It is important to bear in mind that site visits allow assessors to see the actual workings of a practice and also allow practice directors/staff the opportunity to explain issues in more detail than is possible on a questionnaire.
This personal interaction is intended to be positive for both sides as it enables assessments to be made on a more realistic level than can be done solely by perusal of a questionnaire. Since the assessors are intended to be drawn from the ranks of the ANZAPNM Membership, they will be in a better position than any outsider to balance the requirements of best practice with the needs of Members and the realities of running a nuclear medicine practice.
6. What are the Requirements for Personal Supervision?
Additional explanation on this issue was given in the document (dated September 2000) that accompanied the credentialling application form, and is also given in the Standards for Accreditation of Nuclear Medicine Practices - November 2000.
The Standards document (p. 5, Standard 3, Explanation and Guidelines in Relation to Personal Supervision) states in part:
“Although each component of the nuclear medicine service requires personal supervision this does not imply direct physical attendance by the specialist during the entirety of each component.
For every patient the specialist must complete the report on site, and there must be consultation with the patient. The specialist must take responsibility to ensure that each of the other components is completed satisfactorily. Mostly this will require the physical presence of the specialist at some time during each component, although this will vary from patient to patient, and from study to study. The attending specialist will be required to take these matters into consideration and take responsibility for whatever decision he or she takes in a particular case.”
7. What is Required to Achieve Practice Site Accreditation?
There are certain questions (marked “!”) that do require a “Yes” answer in order to permit accreditation. These questions reflect the essence of the Association’s own Code of Conduct, as agreed to by Members in 1995.
However, “No” answers to these questions do not mean that a practice would not, ultimately, be accredited. In such cases, recommendations would be made as to appropriate action that should be taken by the practice within a period of two months from the date of advice. Following advice that such action has been taken, the practice could then be accredited.
Ideally, the remaining questions should be answered with a “Yes” but again, “No” answers do not preclude accreditation, and it is not expected that practices give 100% “Yes” answers. One of the main reasons for commencing with a phased implementation program (see Q. 5), including pilot site visits, is to allow time to clarify those issues relating to assessment of applications which are better able to be assessed once the program is running.
However, it is expected that most practices will receive a straightforward accreditation, and the few that may not initially will be given every opportunity to achieve accreditation by being advised of appropriate action that may be taken.
In the unlikely event that accreditation is denied ultimately, the practice has recourse to an appeals process as explained in the Information document that accompanies the Application and Checklist form. The appeals process is under the sole jurisdiction of the AIC; there is no involvement by the HIC or the DHAC.
8. Is Practice Site Accreditation Linked with Medicare Eligibility?
The nuclear medicine practice site accreditation program does not have any requirement to report to the HIC, nor is it required to report any details of individual practices to either the DHAC or the HIC. The non-identifying reporting requirements of the AIC are noted below under Indemnity.
Members need to be aware of the difference here between the practice site accreditation program and the individual specialist credentialling program. As explained in Q. 2 above, the credentialling program, in which many Members have already participated, does require a list of the names of credentialled specialists to be provided to the HIC. As mentioned, this situation is not unique to nuclear medicine.
9. Powers and Obligations of Those Involved in the Site Accreditation Program
Site assessors, and members of each Accreditation Review Panel (ARP), are required to sign a declaration that they have no conflict of interest when assessing any site or reviewing any assessor’s report. As noted in Q. 5, practices may appeal against the appointment of an assigned assessor.
Site assessors do not have the power to accredit or to deny accreditation. They can only visit a site, complete a formal report, and make a recommendation on accreditation. The assessor’s report is then reviewed by the ARP appointed for that site; it is the ARP that passes the vote on accreditation. This vote may, in turn, be appealed against by the practice, through the appeals process as noted above.
As explained under Indemnity below, any documentation collected or produced as part of the site accreditation program will be protected from subpoena, and those involved in the program will be protected from suit.
Denial of practice site accreditation is not intended as a means to close any nuclear medicine practice, and no one involved with the program has the authority to close any practice.
10. Who May Apply to Become an Accreditation Site Assessor?
You will note from the Information document that any recognised specialist in nuclear medicine may apply to become a certified accreditation assessor. Members are encouraged to apply, as assessment by members of our own profession has many advantages, and will help to keep the accreditation process in our own hands. Members will be sent application forms which should be returned to the ANZAPNM Secretariat.
All accreditation assessors will be required to participate in a short training program prior to receiving certification, and will attend one site visit as an observer before undertaking site visits in their own right. Assessors will be reimbursed for all reasonable costs incurred for practice site visits, e.g. airfares, ground transport, meals, accommodation etc.
Assessors will also form the pool from which each site Accreditation Review Panel (ARP) will be constituted. Each ARP will be chaired by a member of the AIC.
11. What is Commonwealth Indemnity?
As noted above, both the specialist credentialling program and the practice site accreditation program are Declared Quality Assurance Activities, and the JNMCAC and the AIC and others involved in these programs are protected from suit under Commonwealth legislation.
Granting of, or application for, Commonwealth indemnity does not mean surrender of control of the credentialling/accreditation programs to government.
The purpose of Commonwealth indemnity is to encourage participation in quality assurance activities where people would be reluctant to participate because of concern about disclosure of identifying information. Commonwealth indemnity therefore provides protection for both those participating in the activity and those managing the activity; it does this by ensuring confidentiality of documents and information and protection from suit. Since both the credentialling and practice accreditation programs are covered by this indemnity, the Association’s Membership is protected from possible suit, and any documents created for these programs are protected from subpoena.
It is common procedure for quality assurance committees to seek this form of legislative protection under either State or Commonwealth legislation, to avoid the costs and trouble involved in possible suit. Examples of other accreditation/quality assurance activities protected by this legislation include: the Australian Incident Monitoring Study (AIMS); Australian GP Accreditation; AMADA Medical and Dental Accreditation; the Maintenance of Professional Standards Program of the RACP; the Maintenance of Professional Standards Program of the Australian & New Zealand College of Anaesthetists; the Surgical Audit of the Royal Australasian College of Surgeons; the Quality and Accreditation Program of the RANZCR; RCPA Continuing Professional Development; and Accreditation of General Practices.
Commonwealth indemnity additionally helps to protect accreditation applicants, by helping to guarantee legal confidentiality of any documents obtained or created for the purposes of the program. Such documents are protected from subpoena - and in this way, identifying information relating to individual specialists or practices is protected from disclosure.
With any declared activity, there is a requirement for a) advising of any substantial change to the activity or to the committee that manages the activity, and b) providing non-identifying information to the Minister for Health and Aged Care (who makes the Declaration). Because declared quality assurance activities take place in the health sector, and therefore are in the public interest, the Minister requires this information in order to be satisfied that the declared activity is actually undertaken each year that the Declaration is in force.
With respect to the practice site accreditation program, the notification to Government will be the number of applications for accreditation Australia-wide, with a breakdown into numbers of successful, pending and unsuccessful applications Australia-wide. The purpose of this report is to simply demonstrate that the accreditation program has actually taken place during the year. Because the report will provide only Australia-wide figures, it will not be possible to trace or identify any nuclear medicine practice through the information provided in this report.
It is also worth noting that the RACP will not participate in, or lend its name to, any quality assurance activity for which such Declaration has not been sought.
The DHAC has further information about the Declared Quality Assurance Activity scheme.
12. Will the RANZCR Apply the Same Standards for Nuclear Medicine Practices?
The RANZCR has given a commitment to implement the same Standards for nuclear medicine practice as the Association. As noted in the Standards document (p. 3) there will be an independent audit program run over the first two years of the accreditation program, to ensure the Standards are being applied equally by both the Association and the RANZCR.
Those Fellows of RANZCR who provide nuclear medicine services have submitted the same applications for credentialling as Members of the Association, and are therefore bound by the same professional Standards. Names of these specialists will be included with those of Association Members in the same list the JNMCAC will provide to the HIC.
The intention is to implement the nuclear medicine practice accreditation programs simultaneously, and the RANZCR has also indicated that it will undertake implementation of its site visit program in parallel with the Association. However, it is worth noting that the RANZCR has (as of April 2001) already completed its paper processes ahead of the Association.
13. When do Practices Need to Apply for Interim Accreditation?
If you wish to apply for practice site interim accreditation, please contact the Accreditation Coordinator at ANZAPNM Secretriat.
Please note that if your practice operates at more than one site (e.g. at private premises or at a hospital site), or you open a new practice site, you will need to apply for interim accreditation for that site.
14. What are the Fees for Practice Site Accreditation?
Council has approved a fee for interim accreditation of $250.00 plus GST. Practices applying for interim accreditation will be sent a tax invoice for payment of this fee. The interim accreditation fee will be deducted from the full accreditation assessment fee, which is yet to be finally determined.
Information and Application Forms:
Nuclear Medicine Practice Site Accreditation Application Form, Checklist and Information
Application Form for Credentialling as a Specialist in Nuclear Medicine
| Attachment | Size |
|---|---|
| Practice_Accreditation_Checklist.pdf | 123.64 KB |