DOS 752 - Week 3 Discussion/Activity
Finally, can this job description effectively be used for an employee professional development plan (PDP)?
Post: Accreditation at Loyola
In a conversation with Teresita McCoo (November 18, 2015), the Practice Director of the Department of Radiation Oncology at Loyola University Medical Center, I learned about Loyola's many layers of accreditation. She explained that each layer covered a different scope and and a more focused scope.
At the top level is accreditation by The Joint Commission (TJC). It covers the entire hospital and covers broad standards of care. She explained how it covers aspects most people don't think about, including lighting, humidity, air pressure, safety, infection control standards and practices, medication dispensation practices (and even the shorthand names and acronyms used), staffing levels, documentation, and so on. It is not just evaluating the care providers, but also the entire environment of care. Loyola sought TJC accreditation because it is seen as a benchmark for the standard of care for hosptils. More practically, TJC accreditation is required for Medicare & Medicaid reimbursement. The Department of Radiation Oncology is included in TJC's survey and accreditation evaluation, but the accreditation is for the entire organization.
Drilling down to a smaller scope, Teresita said Loyola's constellation of services for cancer care are accredited by the Commission on Cancer (COC). This of course covers the Radiation Oncology and Medical Oncology groups, but it also includes every service that cancer patients may interact with, including nursing, nutrition support, physical therapy, counceling and mental services, diagnostic imaging, scheduling, records management, and so on. The process for COC accreditation is very similar to the process for the American College of Radiology (ACR), so the groundwork performed in preparing the department for ACR accreditation is also used for COC accreditation.
The ACR provides accreditation for many disciplines relating to the use of patient imaging, including specific accreditations for MRI, CT, PET, ultrasound, mammography, and even breast MRI and breast ultrasound. Radiation Oncology is also one of the disciplines for which the ACR provides accreditation services. ACR accreditation is another layer of scope down from the COC, and it is the first accreditation layer that specifically covers our department. The ACR primarily examines prescription writing, planning, and quality assurance (QA) practices and documentation. They want to see not only that we are providing quality care, but that we are adequately and appropriately documenting everything that we do.
Drilling down to the next level of scope, all of our services involving radioactive materials and radiation-producing equipment (linacs and imagers) are governed and accredited by the Illinois Emergency Management Agency. This accreditation covers the appropriate use of these materials and systems, as well as emergency planning for events such as a lost radiation source or radioactive contamination.
Services involving radioactive sources are also governed by entities like the Environmental Protection Agency (EPA) and the Department of Transportation, but these are not agencies that provide accreditation.
When I asked Teresita about her role and the role of others during these various accreditation processes, she explained that she and other department heads primarily take on facilitative roles for the inspectors. As the Practice Director, she also has the responsibility of making sure that everyone is prepared for inspections. She makes sure all of the documentation is in order and that staff is trained on all appropriate standards. She drafts policies for each group in conjunction with the leaders of each group, and she runs test audits ahead of the real audits associated with accreditation.
Some of the other groups have specific roles in accreditation processes. The front desk staff takes the lead in HIPAA issues involving patient privacy, and the nursing staff examines documentation of all aspects of care not specifically involving radiation, including pain assessments, triage, nutrition, medication, counceling, social services, mental services, and lab work. The physics group is responsible for providing documentation of calibration and preventative maintence of the radiation delivery systems. Calibration documentation involves periodic testing and submission of results to the Radiologic Physics Center (RPC), which is a third party standards organization.
The process of accreditation is an extremely involved one. There are many moving parts that have to interact at many levels of scope and complexity. The benefits are often invisible, but the problems that would prevent accreditation are not. Like anyone who is good at their job, they make it look easy when they are doing it well.