Why should my laboratory seek accreditation?
The AANEM EDX Laboratory Accrediation Program:
- Demonstrates clinical excellence in EDX medicine
- Proves a laboratory's commitment to providing the highest quality health care and a safe environment for patients
- Provides patients, referral sources, and payers with a credible measure to differentiate the laboratory's qualify of care
What types of practices can apply for accreditation?
Accreditation is available to all types and sizes of practices based in the United States, including:
- Private Practices
- Solo or Group Practices
- Academic Institutions
- Hospital Based Practices
- Independent Diagnostic Testing Facilities
What does the EDX Laboratory Accreditation Program evaluate?
The standards used for accreditation evaluate the diagnostic services and clinical operations essential to providing quality patient care, including clinical staff qualifications and continuing education, the physical facilities, the EDX equipment, protocols for performing EDX studies, patient reports, and the policies in place for ensuring the health and safety of every patient.
Will my ABEM certification be recognized by the accreditation program?
Yes, Accreditation with exemplary status is the highest level of accreditation recognized by the AANEM. Exemplary status is granted to laboratories where 100% of the practicing neurologists and physiatrists are certified by at least one of the following boards:
- American Board of Electrodiagnostic Medicine (ABEM)
- American Board of Psychiatry and Neurology (ABPN) in Clinical Neurophysiology or Neuromuscular Medicine
- American Board of Physical Medicine & Rehabilitation in Neuromuscular Medicine
How long will our lab remain accredited once we achieve the designation?
The AANEM accredits laboratories for a 5-year period. The program is designed to facilitate continuous improvement through periodic reviews to ensure ongoing compliance with accreditation standards.
What is the Electrodiagnostic Laboratory Accreditation Program?
The Electrodiagnostic (EDX) Laboratory Accreditation Program is a peer review process that evaluates EDX laboratories against standards developed by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Achieving accreditation demonstrates that a significant milestone in patient care has been attained.
How much will it cost to apply for accreditation?
Applicant laboratories will purchase an application for $75. The application will be customized based on the staff composition of each laboratory. The accreditation review fees will be based on the structure of the EDX practice. Each accreditation applicant laboratory will pay the base fee of $1000 for up to three physicians. There is a $200 charge for each additional physician (4 physicians or more). Each satellite laboratory applying for accreditation with a main laboratory is $200.
Why will there be a separate charge for accrediting satellite locations?
Rather than require each location to apply independently (which would be more costly and time consuming), a lesser fee is charged that recognizes the crossover of policies, procedures, and staffing that exists with satellite locations.
What will happen after the application is submitted?
A diagram of the process is available. Members of the AANEM Accreditation Committee will review the application. The Accreditation Committee will submit its recommendation to the AANEM Board of Directors as to whether the laboratory is granted accreditation, provisional accreditation, or denied accreditation. The AANEM Board of Directors will have the final approval.
What will happen if a laboratory is denied accreditation?
The goal of the program is education. Laboratories with minor problems will be granted provisional accreditation. The laboratory will have 6 months to resolve any concerns identified by the Accreditation Committee.
Will there be site visits?
No, site visits will only be performed if the Accreditation Committee reviewers are concerned about the accuracy of the information submitted in the application.
What is required for Accreditation with Exemplary status?
To be eligible for Accreditation with Exemplary Status all of the neurologists and physical medicine and rehabilitation physicians performing studies in the laboratory must (1) complete 3 months of training in EDX medicine as part of an ACGME or RPSC residency or fellowship program and (2) demonstrate certification by the American Board of Electrodiagnostic Medicine or the American Board of Psychiatry or Neurology's subspecialty certification in Clinical Neurophysiology or Neuromuscular Medicine. This status will be the highest level of accreditation recognized by the AANEM.
All laboratories that are not eligible for Accreditation with Exemplary Status may apply for Accreditation Status.
If at any time a laboratory and its physicians are eligible for exemplary status they may contact the AANEM office and request a reevaluation of their status.
Is the accreditation program accepting applications from laboratories outside of the United States?
At this time the accreditation program is only available to US EDX laboratories. The AANEM intends to accredit EDX laboratories internationally, but has not identified a timeline.
What types of activities can demonstrate “quality improvement”?
Quality improvement activities in the laboratory may include:
- Distributing patient satisfaction survey and review the responses
- Peer review,
- Meeting with colleagues to discuss difficult studies.
Does the AANEM have a model HIPAA Compliance Policy we can adopt?
Laboratories seeking accreditation in the AANEM's EDX Laboratory Accreditation Program must demonstrate a commitment to compliance with all privacy, security and electronic transaction code requirements of the Health Insurance Portability and Accountability Act (HIPAA). In order to demonstrate this commitment, applicant laboratories must submit a HIPAA Compliance Policy with their applications.
The AANEM has not created a model HIPAA Compliance Policy. However, there are a great number of resources available online, both free and for fee services, which may help you create a policy that is appropriate for your laboratory. The American Health Care Association has a comprehensive HIPAA Policy and Procedure Manual available for download on its website at http://www.ahcancal.org/facility_operations/hipaa/Pages/HIPAAPolicyProcManual.aspx.
AANEM does not warrant that the policy created by the American Health Care Association will be suitable for a laboratory's particular purposes or comply with any local, state, and/or federal law. Before adopting a particular policy, they should be reviewed by a counsel knowledgeable concerning federal and state privacy laws related to the use of medical records.
How do I determine if our laboratory qualifies as a satellite laboratory?
To qualify as a satellite laboratory, (1) the same organizational policies, including medical record retention, human resources, and laboratory procedures must be used, and (2) the individual designated as the Laboratory Medical Director at the main laboratory must also manage the satellite facility, and (3) the physicians practicing in the main laboratory must staff the satellite laboratory. Satellite laboratories not meeting this standard must apply as a main laboratory site.
Does the AANEM have a model policy that I can adopt?
The AANEM has not created a model HIPAA Compliance Policy. However, there are a number of resources available online, both free and fee-based services, which may help you create a policy that is appropriate for your laboratory. The Agency for Health Care Administration (AHCA) has a comprehensive HIPAA Policy and Procedure Manual available for download on the HIPAA website, which may provide guidance when drafting a HIPAA Compliance Policy for the accreditation program.
Please be advised that the AANEM does not warrant that the policies created by the AHCA will be suitable for a laboratory’s particular purposes or comply with any local, state, and/or federal law. Before adopting a particular policy, an applicant laboratory should be reviewed by an attorney knowledgeable with federal and state privacy laws related to the use and storage of medical records.
Does the AANEM have any guidance on what is needed for the reports we submit?