Frequently Asked Questions on Accreditation

1.  What is the AANMS Nuclear Medicine Practice Accreditation Program?
2.  What is the practice site accreditation process?
3.  What are the requirements for personal supervision/specialist attendance?
4.  What is required to achieve practice site accreditation?
5.  What are the powers and obligations of those involved in the Program?
6.  What is reciprocal recognition of practice accreditation?
7.  Is nuclear medicine practice site accreditation linked to Medicare eligibility?

1. What is the AANMS Nuclear Medicine Practice Accreditation Program?

The AANMS Nuclear Medicine Practice Accreditation Program is a voluntary accreditation program that assesses nuclear medicine practices against the AANMS Standards for Accreditation of Nuclear Medicine Practices through a combination of self-assessment questionnaires and site visits (see below). This program is being managed by the AANMS’s Nuclear Medicine Practice Site Accreditation Implementation Committee (AIC).

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2.  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 4 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 every four years by a site visit conducted by two practice accreditation assessors, who will normally be selected from interstate.

Practices will be notified in advance of the site assessors appointed to visit the practice, and may appeal against these appointments, 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 suitable assessors and time for the visit, 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, 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 approximately 2 – 3 hours maximum, and will follow the format of the application form and checklist, i.e. the assessors will consider the application form, then the Standards of Principle 1, Principle 2 and so forth. At the close of the visit, the assessors 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 will be nuclear medicine specialists themselves, they will be in a good position to balance the requirements of best practice with the realities of running a nuclear medicine practice.

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3.  What are the requirements for personal supervision/specialist attendance?


The Standards document (pp 8 - 9, 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."

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4.  What is required to achieve practice site accreditation?

The AANMS Nuclear Medicine Practice Accreditation Program is a voluntary program of peer assessment.  As such, each practice is assessed on its own merits in the light of current Australian nuclear medicine practice and the Standards. The emphasis of the Program is on assisting all practices to become accredited, should such assistance be necessary. In the event that a practice is ultimately denied accreditation and wishes to appeal this, there is an appeals process available, as described in the accreditation Information, Application Form and Checklist, p. 5.

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5.  What are the powers and obligations of those involved in the 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 2 above, practices may appeal against the appointment of any 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 assessors’ 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 in 7 above.

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6.  What is reciprocal recognition of practice accreditation?

Reciprocal recognition of practice accreditation means that a nuclear medicine practice that has achieved accreditation through either the AANMS or the Royal Australian and New Zealand College of Radiologists (RANZCR) Accreditation Program will be recognised by the other organisation as having achieved nuclear medicine practice accreditation, and will not be required to apply for accreditation to both organisations.

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7.  Is nuclear medicine practice site accreditation linked to Medicare eligibility?

The Australian Department of Health and Ageing (DHA) has determined that, from 1 July 2010, all practices providing diagnostic imaging services will need to participate in the expanded Diagnostic Imaging Accreditation Scheme in order to maintain Medicare eligibility.

This means that all nuclear medicine practices need to participate in the Stage 1 Diagnostic Imaging Accreditation Scheme by 1 July 2010 in order that Medicare benefits can continue to be paid for their nuclear medicine services. 

Further information is available from the DHA at: di.accreditation [at] health.gov.au, or from the DHA website at: 
http://www.health.gov.au/internet/main/publishing.nsf/Content/diagim-accred4

The AANMS’s Nuclear Medicine Practice Accreditation Program is a voluntary program that enhances quality care and risk management for all nuclear medicine practices. The AANMS is seeking the agreement of the DHA to ensure that all practices that participate in this Practice Accreditation Program are deemed to have met all the standards for the DHA’s Diagnostic Imaging Accreditation Scheme without the provision of additional paperwork. Further information on this matter will be provided by the AANMS as it becomes available.

Documents available for download:

•  AANMS Standards for Accreditation of Nuclear Medicine Practices (pdf 200Kb)
•  Accreditation Information, Application Form and Checklist (pdf 124 Kb)
•  Instructions for completing the application form and checklist electronically

 
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