Medical Imaging Unit 3

What is the definition of Accreditation?

Formal, independent verification that a program or institution meets established quality standards and is competent to carry out specific conformity assessment tasks

What may a Conformity assessment include?

Testing, inspection, or certification

Is Accreditation voluntary or Involuntary?

Voluntary

What are the 3 points of Education Accreditation?

1. Sets the condition under which new members qualify for entry into the profession.

2. Programs satisfactorily demonstrated compliance with educational standards developed by and for the profession.

3. Standards set by organizations that sponsor the accrediting agency.

What are the 3 points of Healthcare Accreditation?

1. External review that shows a healthcare provider is meeting regulations and standards set by external accreditation organization.

2. Helps the organization highlight strengths, reaffirm commitment to compliance, drive continuous improvement.

3. Stimulates continuous improvement and raises community confidence in the services provided.

What is the Mission Statement of the Joint Review Committee on Education in Radiologic Technology (JRCERT)?

Promotes excellence in education and elevates the quality and safety of patient care through the accreditation of educational programs in radiology, radiation therapy, MRI, and medical dosimetry.

What is the Vision Statement of the Joint Review Committee on Education in Radiologic Technology (JRCERT)?

Assures all medical imaging and radiologic science programs achieve excellence in education through programmatic accreditation.

What are the 4 modalities that JRCERT accredits?

Radiography, Radiation Therapy, MRI, Medical Dosimetry

JrCERT grants recognition for programs that meet what specific criteria?

Essentials & Guidlines, Standards

What are the 6 steps of the JRCERT Accreditation Process?

1. Application from the program

2. Self study by the program according to the “standards” published by the JRCERT

3. Site visiting conducted to verify the info in the self study

4. Site visiting team submits a report to accrediting agency

5. Report presented to the Board of Directors

6. Vote on recommended accreditation status

How many years is the maximum initial accreditation of JRCERT?

3 years

How many years is the maximum continuing accreditation award of JRCERT?

8 years

What are some additional Education Accreditation Organizations?

• JRC on Education in DMS

• Commission on Accreditation of Allied Health Education Programs

• JRC on Education in NM

Who is the largest programmatic accreditor in the health sciences field?

Commission on Accreditation of Allied Health Education Programs

What are the benefits of Accreditation for Students?

• Provides students assurance that the educational program will provide them with the necessary knowledge, skills, and values to competently perform the range of professional responsibilities expected by potential employers nationwide.

• Assures students they will have the foundation knowledge to continue to develop as professionals in the various fields of the radiation sciences by requiring programs to teach the entire curriculum developed by the ASRT.

• Assures that graduates can sit for the ARRT registry exam.

What are the benefits of Accreditation for Patients?

• Assures patients that students who perform procedures have appropriate supervision during the educational process.

• Also assures them that graduates will have met the minimum level of competency as defined nationally by the profession.

What is the mission of The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)?

To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations, inspiring them to excel in providing safe and effective care of the highest quality and value

What does JCAHO focus on?

• Offers inspection and accreditation of the quality of operations

• Focuses on quality of care and safety

• Recognized for symbol and quality of performance standards

Who performs on-site survery?

The Joint Commission survey team

What is the purpose of the Joint Commission?

Evaluation of organizations’s performance of functions and processes that they are aimed at continuously improving patient outcomes

What do the Joint Commission’s standards address?

The hospital’s performance in specific areas and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment

Through the Joint Commission, what are some of the Benefits of Accreditation?

1. Improves patient safety and quality of care by strengthening safety efforts and providing structured standards.

2. Builds trust and credibility with patients, the community, insurers, and third parties.

3. Enhances organizational performance through better risk management, reduced liability, and improved business operations.

4. Supports staff development and recruitment by offering education, professional guidance, and a strong workplace framework.

5. Provides regulatory and financial advantages such as Medicare certification (deeming authority), potential insurance cost reduction, and meeting state requirements.

Through the Joint Commission, what are some Performance Improvement Dimensions?

• Efficacy- achieved outcomes

• Appropriateness- relevant to clinical need

• Availability- accessible

• Timeliness- beneficial

• Effectiveness- achieve desired outcomes

• Continuity- activities and intervention coordinated

• Safety- associated risks

• Efficiency- relationship of outcomes & resources

• Respect and caring- patient involvement

What is Certification?

Voluntary process through which an agency grants recognition to an individual on demonstration, usually by examination, of specialized professional skills.

What is Licensure?

Process by which governmental agency, usually a state. grants permission to individuals to practice their profession.

What is the American Registry of Radiologic Technologists (ARRT)?

World’s largest organization offering credentials in medical imaging, interventional procedures, and radiation therapy

Who is the world’s largest organization that offers credentials in Radiology procedures?

ARRT

What is the purpose of ARRT?

Certifies and registers technologists in a range of disciplines by overseeing and administering education, ethics, and examination requirements

What are some extra points about ARRT?

The mission is to promote high standards of patient care by recognizing qualified individuals in medical imaging, interventional procedures, and radiation therapy. This is achieved by establishing and maintaining rigorous educational requirements for entry into the profession, upholding standards of professional behavior appropriate to the responsibilities of practice, and developing examinations that assess the knowledge and skills necessary for competent performance. After completing the certification (board) examination, individuals are officially registered and placed on a registry, identifying them as certified professionals in their field.

Which modalities does the ARRT certify?

Radiography, VI, Mammo, DMS, MRI, Breast Sonography, RT, CT, Vascular Sonography, NM, Bone Densitometry, Cardiac IR, Radiology Assistant

What are the certification criteria for ARRT?

• Graduate x-ray school (accredited program)

• Associates degree

• Comply with ethical standards

• Pass exam

What are the criteria needed to register to maintain ARRT certifications annually?

1. Agree to comply with the ARRT rules and regulations

2. Continue to comply with the ARRT standards of ethics

3. Meet the continuing education requirements for renewal of registration

4. Pay annual renewal fee

What are the continuing education requirements for renewal of registration?

24 hours of continued education required in 2 year period

How often must your CQR be renewed?

Every 10 years

What are some continuing education opportunities?

• Collegiate/educational programs

• Self learning activities

• Professional conferences

• Applications training

• Publishing

What is the purpose of Continuing Education Qualification Requirements (CQR)

Evaluation that the individual has remained qualified within the profession

What does it mean to remain qualified within radiology profession?

• Advancements in healthcare and the healthcare environment

• Identify and remediate where knowledge and skills may not meet entry level qualification standards

• Patients can be assured that Radiologic Technologists ate remaining competent throughout their careers

What is the American Registry of Diagnostic Medical Sonographers (ARDMS)?

Voluntary certification of Sonographers and Vascular Technologists

What is the Nuclear Medicine Technology Certification Board (NMTCB)?

Found in 1977, establishes and maintains a voluntary program for certification of nuclear medicine technologists

T/F: Each state is responsible for granting the authority to perform medical imaging, interventional procedures, and radiation therapy.

True!

Does PA require or not require separate state licensure?

PA does not require

Some states offer exams as state licensure, such as:

• Limited scope of practice

• Bone density and fluoroscopy

Is certification voluntary or involuntary?

Voluntary

Do requirements to practice radiologic technology vary from state to stte?

Yes, they vary

What is found on ARRT in terms of holding certification for Radiologic Technology?

RT(R)

What is the purpose of Professional Societies/Organizations?

Represent the interests of various groups to the public and to governmental bodies

What is the function of Professional Societies/Organizations?

Publish professional journals, magazines, conduct educational meetings, offer continuing education verification, special reports, information networking, recruitment, promotional material, member discounts, etc.

What is the professional association for medical imaging and radiation therapists?

American Society of Radiologic Technologists (ASRT)

What is the mission statement of the American Society of Radiologic Technologists (ASRT)?

To advance the professions of Radiologic Technology and imaging specialities to maintain high standards of education, to enhance the quality of patient care and to further the welfare and socioeconomics of radiologic technologists

What are the ASRT Practice Standards?

• Define the practice of radiography and

establish general criteria to determine

Compliance for those who work in imaging

• Provide authoritative statements

established by the profession, through

evidentiary documentation, for evaluating

the quality of practice, service, and

education provided by individuals within

the profession.

Can be utilized to develop job descriptions

and practice parameters by the individual

facilities

What is the Practice Standards Format?

1. Introduction: defines the practice

2. Education and Certification describes the minimum qualifications for the education and certification of individuals, in addition to an overview of the specific practice

3. Scope of Practice: delineates the parameters of the specific practice

4. Standards: incorporate patient assessment and management with procedural analysis, performance, and evaluation. Define the activities of the individual responsible for the care of patients and delivery of medical imaging and radiation therapy procedures: in the technical areas of performance, such as equipment and material assessment, safety standards, and total quality management, and in the areas of education, interpersonal relationships, self- assessment, and ethical behavior

5. Advisory Opinion Standards: provide explanations of practice standards and are intended for clarification and guidance for specific practice issues

6. Glossary: defines terms used in the practice standards document.

What is the Scope of Practice?

Outlines the parameters and boundaries of practice by identifying the tasks appropriate for individuals who are educationally and clinically prepared for the profession.

What are the ASRT Position Statements?

Statements reflect the beliefs or standing of the ASRT, issues outside of practice, and are not considered as strong as practice standards and scopes of practice.

Who encourages the exchange of teaching concepts?

Association of Educators in Imaging and Radiologic Sciences (AEIRS)

Who is in charge of development of collegiate educational processes in Radiologic Technology?

Association of Collegiate Educators in Radiologic Technology (ACERT)

Who are technologists specializing in Cardiovascular & Interventional Radiography?

Association of Vascular and Interventional Radiographers (AVIR)

Who promotes, advances, and educates its members and the medial community in the sciences of Diagnostic Medical Sonography and controls the enhancement of patient care?

Society of Diagnostic Medical Sonographers (SDMS)

Which organization supports nuclear medicine technologists and promotes ongoing education and advancement in the field?

Society of Nuclear Medicine and Molecular Imaging -Technologist Section (SNM)

What is the name of the International Radiology Organization?

International Society of Radiographers/Radiologic Technologists (ISRRT)

What is the purpose of the International Society of Radiographers/Radiologic Technologists (ISRRT)?

Relations to the WHO, facilitate communication between technologists worldwide, advance the profession, identify and meet the needs of technologist in developing nations

What is the purpose of the Pennsylvania Society of Radiologic Technologists (PSRT)?

to advance the professions of radiation and imaging disciplines and specialties; to assist in maintaining high standards of education; to enhance the quality of patient care; and to further the welfare and socioeconomics of Radiologic Technologists​

The Philadelphia Society of Radiologic Technologists has their mission based on 3 pillars, which are:

1. Technologists/students​

2. Ethics: support the ethics of the profession​

3. Enrichment: networking and professional opportunities​

(External Agency) What is the purpose of the Joint Commission on Accreditation of Healthcare Organizations? ​

VOLUNTARY: Regulates the safety and quality of care of patients, and the way the organization is supervised and operated​​

(External Agency) What is the purpose of the State Health Departments​? ​

INVOLUNTARY: Define rules to protect the health and safety of patients served by healthcare facilities.​

(External Agency) What is the purpose of the Nuclear Regulatory Committee​?

Ensures safe use of radioactive materials and protects people and the environment​; control's equipment and Technologists​

(External Agency) What is the purpose of the Occupational Safety and Health Administration (OSHA)​?

Federal agency - establishes standards for safety in the workplace​

(External Agency) What are the purposes of the American College of Radiology (ACR) Accreditation and the Mammography Quality Standards Act (MQSA)?

• Mammography Accreditation ​

• Ensure consistent quality among providers utilizingscreening mammography​

• The certification of administrative, professional, andtechnical aspects of mammography is provided bythe American College of Radiology​

What is the Health Insurance Portability & Accountability Act (HIPAA – 1996)?​

• National standards for protection of personal health information​

• Some facilities have a privacy officer​

• Covers electronic personal information as well​

What are the responsibilities of the HIPAA privacy officer (CPO)

Oversees the development, implementation, maintenance of, and adherence to privacy policies and procedures regarding the safe use and handling of protected health information (PHI) in compliance with federal and state HIPAA regulations.​

(Internal Agency) What is the Safety Committee?

Hospitals that are required by the Joint Commission on the Accreditation of Healthcare Organizations to have a safety committee that does the following:

• Directs the education of employees on safety policies/procedures​

• Ensures safe operation of the facility for patients/employees ​

• Clinical patient safety​

• Medical errors and adverse drug events​

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(Internal Agency) What is the Infection Control Committee?

Regulates infection control policies and procedures and conducts studies on the spread of diseases​

Who requires the Radiation Safety Committee (RSC)?

Required by the Nuclear Regulatory Commission or state

radiation governing body, and the Joint Commission on the

Accreditation of Healthcare Organizations​

What are the responsibilities of the Radiation Safety Committee?

• Regulates hospital activities for radiation safety andnuclear medicine activity ​

• Define safe handling of radioactive materials and careof patients/staff exposed to radiation​

• Radiation Safety Officer​

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(Internal Agency) What is the purpose of Pharmacy and Therapeutics Committee?

Responsible for reviewing drugs and their use in the hospital

What is the goal of Risk Management?

To manage and control the amount of legal and financial risk to the organization and ensure that a hospital continues to remain in good standing with its reputation within the community​

Why was Risk Management developed?

Keep the organization, employees, and patients free from any risks that may hinder the quality of care and to guarantee the safety of all its customers​

Who is a Risk Manager?

• Hospital-employed risk manager or team​

• Anonymous Hotline ​

• Quality assurance programs​

• Hospital committee​

• Each student or staff imaging professional​

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What is the goal of Compliance?

To prevent an organization from committing healthcare fraud; with federal, state, and insurance regulations​

What will effective compliance programs include?

• Written policies/procedures​

• Compliance professional training​

• Effective communication​

• Internal monitoring​

• Enforcement of standards​

• Prompt response​

• No retaliation

What are the 3 employment considerations?

1. Geography Mobility – Location to home, rural or urban area, type of facility.​

2. Economic Factors – ​Stability of facility, union, benefits, salary, reputation, etc.​

3. Manpower issues –​ Staffing, retention rate, hours, etc.​

What are characteristics of a good employee?

• Technical knowledge​

• People skills​

• Customer service​

• Interpersonal communication skills with co-workers​

• Ability to handle customer complaints​

• Practicing with a smile​

• Striving to meet or exceed expectations of all patients/physicians​

• Ability to problem solve and utilize critical thinking skills​

• Continuing Education​