Accreditation,Credentialing,and Quality Improvement in Diagnostic Medical Sonography: A Literature Review

Abstract

There are few regulations regarding facility accreditation and individual credentialing in diagnostic medical sonography (DMS), although it is known that the quality of examinations in the field can vary based by the operator. This literature review summarizes the findings from 19 research studies on accreditation, credentialing, and quality improvement and includes illustrative quotes from 23 position papers and 42 editorials. The review uncovered large differences in facility accreditation status based on sonography specialty and geographical area. The findings included many examples of positive correlations between accreditation and improved quality and also a positive correlation between credentialing and improved image quality. The survey studies revealed overwhelming support for accreditation and credentialing. Many articles raised concerns about the unknown quality of sonograms performed in nonaccredited facilities or by uncredentialed sonographers. If facility accreditation and/or individual credentialing could be implemented nationwide in DMS, it may lead to increased quality within the field.

Keywords

sonography accreditation credentialing quality

It is well known that the field of diagnostic medical sonography (DMS) is operator dependent,^1–8 and there can be variability in the quality of sonography examinations.^{1,2,4,5,7,9–12} The Medicare Improvements for Patients and Providers Act of 2008 mandated accreditation for reimbursement for nonhospital facilities that provide computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine (NM) imaging^13–15; however, there are few regulations regarding facility accreditation and individual credentialing in the field of DMS.^{1,5,7,9,10,13}

There are multiple agencies that accredit diagnostic imaging facilities. The American College of Radiology (ACR), Intersocietal Accreditation Commission (IAC), Joint Commission, and RadSite accredit general diagnostic imaging facilities that perform CT, MRI, and NM studies.^10,13,15 Within the field of DMS, there are two accrediting agencies for general sonography (ACR and American Institute of Ultrasound in Medicine [AIUM]), two for vascular sonography (ACR and IAC), and one for adult/pediatric echocardiography (IAC).^{5,7–10,13,15} There are three agencies that offer credentials to sonographers: the American Registry for Diagnostic Medical Sonography (ARDMS), Cardiovascular Credentialing International, and American Registry of Radiologic Technologists.^7,8 Many health care insurance companies do not yet mandate accreditation or credentialing for general sonography reimbursement; however, some private and federal insurers have started requiring accreditation or credentialing for cardiovascular reimbursement.^{3,7–10,12–20} Although accreditation and credentialing are still mostly voluntary for the DMS field, this movement toward linking accreditation or credentialing with reimbursement will likely have ramifications for both facilities and sonographers soon. This literature review summarizes the findings from articles on DMS accreditation, credentialing, and quality improvement.

Methods and Materials

A comprehensive search of the PubMed, Ovid MEDLINE, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases was performed using the following search terms: sonography accreditation quality, sonography credentialing quality, ultrasound accreditation quality, and ultrasound credentialing quality. A search of the Journal of the American Society of Echocardiography (JASE), the Journal of Diagnostic Medical Sonography (JDMS), the Journal of Ultrasound in Medicine (JUM), and the Journal for Vascular Ultrasound (JVU) was then performed using the same search terms. Finally, the reference list of each article was reviewed to determine if any pertinent articles had inadvertently been overlooked. There were no limits on the date range of the literature searched, but the search concluded in November 2018.

A total of 23 084 results were initially found (PubMed, 650; Ovid MEDLINE, 112; CINAHL, 1409; JASE, 13 597; JDMS, 1556; JUM, 5678; and JVU, 82). Duplicate entries were removed, and results whose titles were not concentrated on accreditation, credentialing, or the DMS field were excluded. The search produced a total of 222 articles, which included editorials, position papers, meta-analyses, and original research studies. Fifty-six articles that focused exclusively on general health care and 82 articles that solely emphasized the role of the physician, improved scanning efficiency, internal quality improvement processes, automated scanning protocols/measurements, appropriate use criteria, patient outcomes/satisfaction, and education were excluded from the study. A diagram of the literature search process is shown in Figure 1.

Figure 1.

Diagram of the literature search process. CINAHL, Cumulative Index of Nursing and Allied Health Literature; JASE, Journal of the American Society of Echocardiography; JDMS, Journal of Diagnostic Medical Sonography; JUM, Journal of Ultrasound in Medicine; JVU, Journal for Vascular Ultrasound.

Eighty-four articles that highlighted the impact of accreditation and credentialing on quality improvement in DMS were included in the study. The publication date of the included articles ranged from 1988 to 2018, and the breakdown of the article type was as follows: 19 research articles, 23 position papers/statements, and 42 editorials. The research articles constitute the bulk of this literature review, but the position papers and editorials are included to highlight the prevalence of this topic in health care publications. This literature review did not involve research on human subjects; therefore, review and approval from an institutional review board were not needed.

Results

General Information on the Articles

This literature review included analysis of 19 research articles related to accreditation, credentialing, and quality improvement in DMS that were published between 2003 and 2018.^{1–16,21–23} Research questions, methodology, sample size, and findings are listed in Table 1. Eight of the articles are retrospective reviews of data,^{5,6,8–10,16,21,22} six of them are correlational studies,^{1,3,4,11,12,23} and five of them are analyses of surveys.^2,7,13–15 Seventeen of the articles focus on cardiovascular imaging (nine on vascular,^{2,4–6,10,11,13,21,22} seven on echocardiography,^{3,8,9,12,14,16,23} and one on both¹⁵), one on obstetrics and gynecology (OB/GYN),¹ and one on all DMS specialties.⁷ Sixteen articles focus on the IAC accreditation process (formerly known as the Intersocietal Commission for the Accreditation of Vascular Laboratories [ICAVL] and Intersocietal Commission for the Accreditation of Echocardiography Laboratories [ICAEL]),^{3–6,8–16,21–23} one on the AIUM accreditation process,¹ one on multiple accreditation processes (ACR, AIUM, ICAVL, and ICAEL),⁷ and one does not refer to a specific accreditation process.²

Table 1.

Summary of Research Articles Included in the Literature Review.^a

Author(s), Year	Research Question	Methodology	Sample Size	Findings: General Themes
Abuhamad et al., 2004¹	Does the AIUM accreditation process improve compliance with OB/GYN guidelines?	Retrospective correlational study	179 studies	Accreditation findings Accreditation delays Unknown quality Potential conflicts of interest
Behera et al., 2017²³	Does pediatric echocardiography (with congenital heart disease) IAC accreditation increase image quality?	Retrospective correlational study	236 studies	Accreditation findings Potential conflicts of interest
Boswell et al., 2003²	What do vascular technologists and sonographers report regarding scan volume, repeat studies, and the value of credentialing and accreditation?	Survey	Limited information provided other than 30% response rate	Opinions about accreditation and credentialing Unknown quality
Bremer, 2016³	Does sonographer credentialing correlate with echocardiography clinical scanning skills?	Retrospective correlational study	15 264 studies	Accreditation delays Credentialing findings Unknown quality Potential conflicts of interest
Brinza et al., 2016¹³	What do vascular laboratory staff members report as the value of IAC accreditation?	Survey	7289 surveys sent and 882 responses for a 12.1% response rate	Opinions about accreditation and credentialing
Brown et al., 2004⁴	How does the reliability of carotid ultrasound results differ between from nonaccredited and ICAVL-accredited labs and how does this affect patient management?	Retrospective correlational study	174 bilateral studies	Accreditation findings Unknown quality
Brown et al., 2016⁵	In a sample of cerebrovascular studies billed to Medicare, how frequently are studies performed in IAC-accredited outpatient facilities? Are there geographical differences in accreditation, variations in accreditation between the different examination types, or differences between the primary diagnostic codes billed and accreditation status?	Retrospective review	Nearly 39 000 studies	Accreditation characteristics Unknown quality Potential conflicts of interest
Brown et al., 2018⁹	In a sample of echocardiography studies billed to Medicare, how frequently are studies performed in IAC-accredited outpatient facilities? Are there geographical differences in accreditation or variations in accreditation between the different examination types?	Retrospective review	Nearly 1 900 000 studies	Accreditation characteristics Unknown quality Potential conflicts of interest
Farrell et al., 2017⁶	How well do labs applying for IAC transcranial Doppler accreditation comply with the standards?	Retrospective review	97 applications including 318 studies	Accreditation delays Credentialing findings Unknown quality Potential conflicts of interest
Farrell et al., 2018²¹	What are the most frequent reasons why vascular labs applying for IAC accreditation receive a delay for deficiencies in complying with the standards?	Retrospective review	603 applications	Accreditation delays Credentialing findings Potential conflicts of interest
Having et al., 2011⁷	In a sample of sonography facilities that bill to Medicare and Medicaid, what is the accreditation status of the facility (including ACR, ICAEL, ICAVL, or AIUM accreditation) and the credentialing status of their sonographers?	Survey	2000 final surveys sent and 323 responses for a 16% response rate	Accreditation characteristics Credentialing findings Unknown quality Potential conflicts of interest
IAC Staff, 2018²²	How do vascular labs applying for IAC accreditation compare in demographics and accreditation success rates?	Retrospective review	283 facilities	Accreditation delays Potential conflicts of interest
Lopez et al., 2017¹⁴	What do IAC-accredited echocardiography lab personnel report regarding the value accreditation?	Survey	10 455 emails sent with 999 responses for a 9.6% response rate	Opinions about accreditation and credentialing Potential conflicts of interest
Manning et al., 2014¹⁵	What do IAC-accredited facilities (vascular, echocardiography, nuclear medicine, computed tomography, and magnetic resonance imaging) report regarding the value of accreditation?	Survey	25 298 surveys sent with 1858 responses for a 7% response rate	Opinions about accreditation and credentialing Potential conflicts of interest
Nagueh et al., 2015¹⁶	What are the most frequent reasons why echocardiography labs applying for IAC accreditation receive a delay for deficiencies in complying with the standards?	Retrospective review	3260 applications	Accreditation delays Unknown quality Potential conflicts of interest
Parker et al., 2017⁸	How does physician certification and sonographer credentialing correlate with accreditation status in the initial IAC echocardiography application process?	Retrospective review	1921 applications	Accreditation delays Credentialing findings Unknown quality Potential conflicts of interest
Rundek et al., 2014¹⁰	In a sample of vascular studies billed to Medicare, how frequently are studies performed in IAC-accredited outpatient facilities? Are there geographical differences in accreditation?	Retrospective review	13 462 facilities	Accreditation characteristics Unknown quality Potential conflicts of interest
Stanley, 2004¹¹	How does the accuracy of vascular ultrasounds differ between nonaccredited and ICAVL-accredited labs?	Retrospective correlational study	437 studies	Accreditation findings Unknown quality
Thaden et al., 2017¹²	How does the quality of echocardiography studies (with valvular heart disease) differ between nonaccredited and IAC-accredited labs?	Prospective correlational study	335 studies	Accreditation findings Unknown quality Potential conflicts of interest

Abbreviations: ACR, American College of Radiology; AIUM, American Institute of Ultrasound in Medicine; IAC, Intersocietal Accreditation Commission; ICAEL, Intersocietal Commission for the Accreditation of Echocardiography Laboratories; ICAVL, Intersocietal Commission for the Accreditation of Vascular Laboratories; OB/GYN, obstetrics/gynecology.

Includes research question, methodology, sample size, and findings—general themes.

During the course of the research, 23 position papers/statements that focus on accreditation, credentialing, and quality improvement in DMS/diagnostic imaging were found.^23–46 These papers were published between 1995 and 2018, and they follow the pattern noted above in that most of them focus on vascular imaging and echocardiography. Descriptions and illustrative quotes from each paper are listed in Table 2. It is noteworthy that some statements advocating sonographer credentialing were published nearly 20 years ago, and credentialing is still not mandatory for sonographers nationwide.^41,44

Table 2.

Summary of Position Papers/Statements Related to Accreditation, Credentialing, and Quality Improvement in Sonography.^a

Author(s), Year	Description	Illustrative Quotes
ASE, 1995²⁴	Recommendations on continuous quality improvement in echocardiography from the ASE	“The quality of patient care resulting from the performance of echocardiographic examinations is directly related to the competence and education of the cardiac sonographer.”²⁴
ASE, 2010²⁵	Communication regarding sonographer licensure from the ASE	“Registered sonographers may have their credentials revoked, yet still work in the field because many laboratories do not require credentialing . . . .”²⁵
ASUM, 2017²⁶	Statement of minimum sonographer education and training from the ASUM	“Low costs and lack of regulation mean that diagnostic ultrasound equipment may be used by operators without adequate training. The use of diagnostic ultrasound by individuals without proper training and experience increases the likelihood of unnecessary examinations and misdiagnosis.” “ASUM is concerned that patient outcomes are potentially being compromised by ultrasound practitioners who do not have appropriate training in Ultrasound.”²⁶
Benacerraf et al., 2018²⁷	Communication about Beyond Ultrasound First Forum that included multiple professional organizations	“Ultrasound facilities . . . are less compliant with accreditation since it is not currently mandatory. This lack of accreditation may have contributed to the wide degree of quality with ultrasound imaging.”²⁷
Bierig et al., 2006²⁸	Statement of minimum sonographer standards from the ASE	“The ASE firmly supports sonographer credentialing . . . as a crucial component of overall quality efforts, along with laboratory accreditation . . . .” “ASE also recommends that a cardiac sonographer who performs ultrasound in other modalities (eg, vascular, abdominal, obstetric) acquire the appropriate credential in each area of practice.”²⁸
Douglas et al., 2006²⁹	Structure, process, and outcomes of quality in cardiovascular imaging	“By remedying inconsistent adherence to published standards and guidelines, accreditation can ensure an objective baseline level of care and provide a mechanism for implementing quality improvement initiatives.” “The ASE recommends mandatory laboratory accreditation . . . as a requirement for reimbursement, recommends image acquisition by credentialed sonographers . . . .”²⁹
Douglas et al., 2009³⁰	Cardiovascular imaging quality	Recommendations for “structured reporting using standardized data elements . . . strengthening laboratory accreditation . . . and more robust imaging research, especially related to outcomes.”³⁰
Eskandari et al., 2016³¹	Statement on quality in cardiovascular imaging	“Quality control is pervasive in most modern business, but, surprisingly, is in its infancy in medicine in general—and cardiovascular imaging in particular.”³¹
Heller et al., 2008³²	Accreditation of cardiovascular imaging facilities	“Statements released by the predominant cardiovascular professional societies in recent years strongly advocate accreditation.” “So far [Medicare] has not adopted a national coverage policy.”³²
Johnson et al., 2009³³	Quality initiatives in radiology	“The ultimate goal is a cultural shift in which all departmental workers assume responsibility for quality and safety improvements . . . .”³³
Jones et al., 2004³⁴	Recommendations regarding accreditation and credentialing from the SVU Government Relations Committee	“We have consistently supported the concept that personnel credentialing and/or laboratory accreditation were the best methods available to ensure not only high-quality testing for our patients but the appropriate utilization of noninvasive vascular examinations.”³⁴
Kabnick et al., 2016³⁵	Description of IAC vein center accreditation	“Licensure, certification, and accreditation are complementary approaches that serve to identify and to promote care to meet at least minimum quality standards.”³⁵
Mark et al., 2014³⁶	Statement on noninvasive cardiovascular imaging from multiple professional organizations	“Accreditation of laboratories and certification of personnel who perform and interpret imaging . . . are structural quality elements in the conceptual quality model . . . .”³⁶
Picard et al., 2011³⁷	Recommendations regarding echocardiogram quality from the ASE	“Sonographer credentialing helps ensure quality by verifying knowledge of technology, image acquisition, and manifestations of disease.” “Laboratory accreditation verifies institutional practices relating to image acquisition, by mandating consistent and complete imaging protocols.”³⁷
Popescu et al., 2009³⁸	Recommendations regarding echocardiogram quality from the European Association of Echocardiography	“It is clear that quality measurement and monitoring are needed beyond accreditation because accreditation typically reflects conditions during a snapshot in time and it would be desirable to implement continuous monitoring for quality control and improvement.”³⁸
Rose and Weissman, 2014³⁹	Description of IAC accreditation	“Payers have not only begun to accept accreditation as a surrogate for quality but also to expect it as a condition for payment.”³⁹
Rosenbloom et al., 2001⁴⁰	Communication on echocardiography licensure	“Opportunities also exist for the advancement of the profession. The efforts of individual members and local societies are increasingly important in shaping decision making at local and national levels.”⁴⁰
SDMS, 2000⁴¹	Statement on the sonographer scope of practice from the SDMS	“Certification is considered the standard of practice in ultrasound. Individuals who are not yet certified should reference the Scope as a professional model and strive to become certified.” “The Diagnostic Ultrasound Professional maintains professional credentials that are specifically related to the currently practiced discipline(s).”⁴¹
SDMS, 2015⁴²	Statement on the sonographer scope of practice from multiple professional organizations	“Demonstration and maintenance of competency through certification by a nationally recognized sonography credentialing organization is the standard of practice in sonography, and maintenance of certification in all areas of practice is endorsed.”⁴²
Sloper and Katanick, 2011⁴³	Description of the IAC accreditation process	“Facility accreditation offers the means necessary to demonstrate that commitment to quality in patient care, quality in imaging, quality in interpretation, quality in reporting and, most of all, the overall quality of the facility.” “Accreditation is a “long-term commitment to quality and self-assessment . . . the foundation to create and achieve realistic quality care goals.”⁴³
St. Vrain et al., 1998⁴⁴	Statement regarding credentialing and multicredentialing from the ASE	“It is the position of the ASE that, above all, persons who perform cardiac ultrasonography should be fully trained and credentialed in cardiac sonography.” “If a person is multi-skilled . . . he or she should be appropriately trained and credentialed in that discipline as well.” “Multiskilling of persons, without insistence that such persons demonstrate competence in all areas in which they practice by earning the appropriate credentials in those areas, may not constitute effective, efficient use of personnel and has the potential to undermine established standards of quality patient care . . . .”⁴⁴
Wiener, 2014⁴⁵	Recommendations on improving quality in cardiovascular imaging	“Hierarchical model for the value of imaging: technical efficacy, diagnostic accuracy efficacy, diagnostic thinking efficacy, therapeutic efficacy, patient outcome efficacy, and societal efficacy.”⁴⁵
Wilson and Cooley, 2006⁴⁶	Description of a sonographer career ladder	“Our profession must also evolve with well-qualified sonographers, because diagnostic sonography is significantly more than images and equipment.” “It is the belief of this committee that the more educated a sonographer becomes, the more competent and the higher level of accountability for quality and effectiveness to which the employee will hold himself or herself responsible.”⁴⁶

Abbreviations: ASE, American Society of Echocardiography; ASUM, Australasian Society for Ultrasound in Medicine; IAC, Intersocietal Accreditation Commission; SDMS, Society of Diagnostic Medical Sonography; SVU, Society for Vascular Ultrasound.

Includes description and illustrative quotes.

In addition, 42 editorial articles that focused on accreditation, credentialing/licensing, and quality improvement in DMS/diagnostic imaging were found.^47–88 These editorials were published between 1988 and 2019, and they follow the pattern noted above in that most of them focus on vascular imaging and echocardiography. Three of the editorials were published more than 30 years ago, supporting the concept that the sonographic quality has been a topic for many years.^47,53,58

Several overarching themes were found during the review of the research articles. These general themes include accreditation characteristics, findings, and delays; credentialing findings; opinions about accreditation and credentialing; unknown quality; and potential conflicts of interest. Details about the articles that fall under these themes are outlined below.

Accreditation Characteristics

In the four articles that reported the percentages of accredited facilities, there was large variation (range from 13% to 99.6%), with the lowest percentages reported for vascular and the highest reported for echocardiography.^5,7,9,10 When evaluated by the percentage of studies performed in accredited centers, a large variation was again noted (range, 37% to 99.8%), with the same exact pattern of the lowest percentages reported in vascular sites and the highest in echocardiography sites.^5,7,9 Interestingly, the highest percentage of vascular accredited centers were noted in the Northeast and the lowest in the West,^5,10 while the highest percentage of echocardiography accredited centers were noted in the South and Midwest and the lowest in Puerto Rico.⁹

Accreditation Findings

Five articles compared findings between accredited and nonaccredited facilities. One article found that accredited facilities applying for reaccreditation in OB/GYN were significantly more likely to have higher case study scores when compared with facilities that were applying for initial accreditation.¹ Two articles found the concordance between accredited and nonaccredited vascular studies to be closer to 50%,^4,11 while two other articles found it to be close to 80% for echocardiography studies.^12,23 There was large variation in the percentage of incorrect studies that led to changes in clinical decision making (range, 18%–55%).^4,11,23 In two studies, most errors were overestimation of disease,^4,12 while one study found it to be underestimation.²³ The reasons most cited for discordant results were inaccurate image interpretation, technique, and criteria.^4,12,23 Four articles in this section concluded that there was a positive correlation between higher-quality studies and accreditation,^1,4,11,12 and one article mentioned that study comprehensiveness and report completeness improved significantly after accreditation but that there was no difference in image quality or diagnostic accuracy.²³

Accreditation Delays

Accreditation delays were very common for IAC accreditation, as six of the studies reported delays for more than 61% of the applications.^{3,6,8,16,21,22} Fewer accreditation delays were noted for the AIUM OB/GYN accreditation process, but still there were significant delays (approximately 50%).¹ Four of the most common reasons for delays were issues with the report, staff qualifications, quality improvement, and image quality. Four articles specifically commented that facilities that have undergone multiple accreditation cycles have fewer deficiencies.^1,8,16,21

Credentialing Findings

The five studies that cited credentialing statistics found that the vast majority of the sonographers in their samples were credentialed in at least one sonography specialty (range, 79.5%–93.9%).^3,6–8,21 If specific credentialing was mandatory for performed examinations, one study found that 36.5% of sonographers would need to obtain an additional specialty credential.⁷ One study focused specifically on evaluating the correlation between sonographer credentialing and echocardiography scanning skills and determined that credentialed sonographers received higher image quality scores for almost all of the comparisons.³

Opinions About Accreditation and Credentialing

The three survey studies that elicited opinions about accreditation found overwhelming support for the process (range, 92%–94.3%),^13–15 and the one survey study that elicited opinions about accreditation and credentialing combined also found that respondents strongly favored the practice of accreditation (98%).²

Unknown Quality

Seven articles highlighted the important point that quality efforts are unknown in facilities that are not accredited,^{4,5,6,7,9,10,16} and two articles mentioned that quality efforts for uncredentialed sonographers are unknown.^2,7 Furthermore, five studies found a positive correlation between accreditation and high-quality studies,^1,4,8,11,12 and two studies found a positive correlation between credentialing and high-quality studies.^3,8

Potential Conflicts of Interest

It is important to note that potential conflicts of interest were noted in 15 of the 19 articles.^{1,3,5–10,12,14–16,21–23} Nine articles disclosed that at least one author was an IAC employee,^{5,6,9,10,14–16,21,22} nine articles disclosed that at least one author was an IAC board member,^{3,5,6,9,10,14–16,21} eight articles disclosed that they were supported by grants (seven IAC grants^{5,6,8–10,12,23} and one SDMS grant⁷), one article disclosed that an author was the immediate past president of the IAC Board of Directors,¹² one article disclosed that an author was an IAC consultant,⁸ and two articles disclosed that an author was an ARDMS board member.^5,10 Furthermore, one article was conducted by a sonography organization and subsequently published in the journal that is associated with that organization.¹

Discussion

The results of this literature review demonstrate that there are many DMS facilities that are not accredited^5,7,10 and there are commonly delays with obtaining accreditation and reaccreditation.^{1,3,6,8,16,21,22} This result was somewhat unexpected considering that the standards of practice for accrediting agencies are widely published, and facilities typically submit their best cases for the accrediting agencies to review. Not surprisingly, though, those facilities applying for reaccreditation were found to have fewer deficiencies.^1,8,16,21 The vast majority of sonographers were credentialed in at least one specialty^3,6–8,21; however, almost all of these studies were reviews of accreditation databases, and the actual number of credentialed sonographers nationwide may have been overestimated.

Multiple articles found correlations between quality and accreditation/credentialing,^{1,3,4,7,8,11,12} and many raised concerns about the unknown quality of sonograms performed in nonaccredited facilities or by uncredentialed sonographers.^{2,4–7,9,10,16} Figure 2 illustrates this concept of known and unknown quality in the field of DMS.

Figure 2.

Diagram of quality in diagnostic medical sonography (DMS). Individuals with sonography credentials and/or facilities with sonography accreditation have met a known quality standard. Individuals without credentials and facilities without accreditation have unknown levels of quality.

Individuals with sonography credentials and/or facilities with sonography accreditation have met a known quality standard. Individuals without credentials and facilities without accreditation have unknown levels of quality. Only one article found no correlation between accreditation and image quality/diagnostic accuracy, and this article focused on pediatric echocardiography.²³ Perhaps since pediatric echocardiography is a very specialized area of DMS, facilities that perform the studies are already completing them with a high level of accuracy and quality. The surveys in this literature review found overwhelming support for accreditation and credentialing,^2,13–15 but the response rates ranged from 9.6% to 30%, and this may have introduced bias.

The literature review revealed that echocardiography was found to have a much higher percentage of accredited facilities and a much higher concordance rate of studies performed in accredited versus nonaccredited facilities.^4,11,12,23 During the literature search process, the echocardiography-specific journal (JASE) produced the most results for the search terms, and the number of results found was more than double that of the next closest journal. Furthermore, 17 of the 19 research articles included in this review focused on cardiovascular sonography.^{2–6,8–16,21–23} Increasingly, private and federal insurers require accreditation or credentialing for cardiovascular reimbursement.^{3,7–10,12–20} This may have resulted in increased scrutiny of quality in cardiovascular sonography.

Many of the retrospective review studies in this literature review were done by evaluating accreditation databases.^{1,3,6,8,16,21,22} The information provided is extremely helpful, but the sample size is limited to facilities that are accredited or applying for accreditation. This may have introduced a bias because many of these facilities are already focused on quality improvement. The quality of examinations in nonaccredited imaging centers is largely unknown. Considering the high percentage of facilities that are not accredited in some of these studies,^5,7,10 there are many imaging centers in which the focus on quality improvement is unknown.

Future Directions

The findings of the present study uncovered many areas that require additional information through future research. There are an extremely limited number of published research studies on accreditation, credentialing, and quality improvement in general sonography (abdomen, OB/GYN, small part imaging, etc.), and this is an area that should be further evaluated. Potential options for future research would be to evaluate the number of billed general sonography studies that have been performed in accredited facilities or evaluate how credentialing correlates with general sonography scanning skills.

Although this review contained a number of articles on vascular imaging, the resulting data were not as extensive when compared with echocardiography. In addition, in-depth data on vascular imaging could be collected with continued research. Furthermore, although none of the conflicts of interest definitively pose actual conflicts, additional studies on accreditation and credentialing conducted by a wider range of authors and institutions would provide even more robust evidence of the impact on quality improvement in the field of DMS.

This search found no research studies that have compared the outcomes of the sonographer-training pathways. Sonography students can obtain their knowledge and experience through multiple options, ranging from on-the-job clinical training to a dedicated DMS educational program. Furthermore, there are optional, accreditation pathways that some DMS educational programs choose to pursue to demonstrate their commitment to high-quality education and continuous improvement. Future research correlating the outcomes of these different training pathways (on-the-job clinical training, nonaccredited DMS programs, and accredited DMS programs) would be beneficial. A potential option for a study would be to evaluate the differences in credentialing pass rates or job placement rates between applicants who had undertaken the different training pathways.

Conclusion

This literature review summarizes the findings from 19 research studies on accreditation, credentialing, and quality improvement and includes illustrative quotes from position papers and editorials. The review uncovered large differences in facility accreditation status based on sonography specialty and geographical area; however, it found that most sonographers are credentialed in at least one specialty. The findings included many examples of positive correlations between accreditation and improved quality and also a positive correlation between credentialing and improved image quality. The survey studies revealed overwhelming support for accreditation and credentialing. Many articles raised concerns about the unknown quality of sonograms performed in nonaccredited facilities or by uncredentialed sonographers.

In 1989, Craig asked, “how badly do we all want quality diagnostic ultrasound?”⁵⁸ Then in 1998, a Primetime Live segment broadcast instances of poor-quality sonograms and the low certification rate of sonographers (50%).⁶⁶ Nearly 20 years after that broadcast, the field of sonography is still grappling with the same issue of how to ensure quality. There is still a lot of variability in the quality of sonograms, but it is promising to see that research on accreditation, credentialing, and quality improvement is being undertaken to address and improve the situation. If facility accreditation and/or individual credentialing can be implemented nationwide in DMS, it may lead to increased quality within the field.

Footnotes

Acknowledgements

The author would like to acknowledge and thank Merri L. Bremer, EdD, RN, ACS, RDCS, for her assistance in planning this project and reviewing drafts of the manuscript. The author would also like to acknowledge and thank Angelo Sorrentino, MS, for his assistance with creating the figures in this document.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported in part by a Society of Diagnostic Medical Sonography Foundation Research Grant.

References

Abuhamad

Benacerraf

Woletz

Burke

: The accreditation of ultrasound practices: impact on compliance with minimum performance guidelines. J Ultrasound Med. 2004;23(8):1023–1029.

Boswell

Jones

Benge

: Practice patterns and membership opinion about the value of credentialing and accreditation: results of a membership survey. J Diagn Med Sonogr. 2003;19(6):387–390.

Bremer

: Relationship of sonographer credentialing to Intersocietal Accreditation Commission echocardiography case study image quality. J Am Soc Echocardiogr. 2016;29(1):43–48.

Brown

Bendick

Bove

, et al: Reliability of extracranial carotid artery duplex ultrasound scanning: value of vascular laboratory accreditation. J Vasc Surg. 2004;39:366–371.

Brown

Wang

Dong

, et al: Intersocietal Accreditation Commission (IAC) accreditation status of outpatient cerebrovascular testing facilities among Medicare beneficiaries: the VALUE (Vascular Accreditation, Location & Utilization Evaluation) study. J Ultrasound Med. 2016;35:1957–1965.

Farrell

Choi

Cockroft

: Characteristics of accredited transcranial Doppler ultrasound laboratories in the United States. J Neuroimaging. 2017;27:210–216.

Having

Barwick

Collins

: Lab accreditation and credentials in sonography: a demographic assessment of facilities receiving federal reimbursements. J Diagn Med Sonogr. 2011;27:243–251.

Parker

Sobieraj

Coleman

: Credentials of professionals performing echocardiography: insights from the Intersocietal Accreditation Commission—echocardiography database. J Diagn Med Sonography. 2017;33(2):91–99.

Brown

Wang

Dong

, et al: Accreditation status and geographic location of outpatient echocardiographic testing facilities among Medicare beneficiaries: the VALUE-ECHO study. J Ultrasound Med. 2018;37:397–402.

10.

Rundek

Brown

Wang

, et al: Accreditation status and geographic location of outpatient vascular testing facilities among Medicare beneficiaries: the VALUE (Vascular Accreditation, Location & Utilization Evaluation) study. Vasc Med. 2014;19:376–384.

11.

Stanley

: The importance of Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) certification for noninvasive peripheral vascular tests: the Tennessee experience. J Vasc Ultrasound. 2004;28(2):65–69.

12.

Thaden

Tsang

Ayoub

, et al: Association between echocardiography laboratory accreditation and the quality of imaging and reporting for valvular heart disease. Circ Cardiovasc Imaging. 2017;10(8).

13.

Brinza

Zhu

Lill

, et al: Accreditation is perceived to improve the quality of vascular testing facilities. J Vasc Ultrasound. 2016;40:63–69.

14.

Lopez

Farrell

Choi

, et al: Accreditation is perceived to improve echocardiography laboratory quality: results of an Intersocietal Accreditation Commission survey. J Diagn Med Sonogr. 2017;33(3):163–171.

15.

Manning

Farrell

Bezold

, et al: How do noninvasive imaging facilities perceive the accreditation process? Results of an Intersocietal Accreditation Commission survey. Clin Cardiol. 2015;38:401–406.

16.

Nagueh

Farrell

Bremer

Dunsiger

Gorman

Tilkemeier

: Predictors of delayed accreditation of echocardiography laboratories: an analysis of the Intersocietal Accreditation Commission database. J Am Soc Echocardiogr. 2015;28:1062–1069.

17.

Intersocietal Accreditation Commission: IAC Echocar-diography—CMS Payment Policies. Ellicott City, MD: Intersocietal Accreditation Commission; 2018. https://www.intersocietal.org/iac/reimbursement/policies/IACEcho_CMSPaymentPolicies.pdf. Accessed January 7, 2019.

18.

Intersocietal Accreditation Commission: IAC Echocar-diography—Payment Policies. Ellicott City, MD: Intersocietal Accreditation Commission; 2018. https://www.intersocietal.org/iac/reimbursement/policies/IACEcho_PaymentPolicies.pdf. Accessed January 7, 2019.

19.

Intersocietal Accreditation Commission: IAC Vascular Testing—CMS Payment Policies. Ellicott City, MD: Intersocietal Accreditation Commission; 2018. https://www.intersocietal.org/iac/reimbursement/policies/IACVascular_CMSPaymentPolicies.pdf. Accessed January 7, 2019.

20.

Intersocietal Accreditation Commission: IAC Vascular Testing—Payment Policies. Ellicott City, MD: Intersocietal Accreditation Commission; 2018. https://www.intersocietal.org/iac/reimbursement/policies/IACVascular_PaymentPolicies.pdf. Accessed January 7, 2019.

21.

Farrell

Hutchisson

Lilly

Vickery

Gornik

: Reasons for delay of accreditation for vascular testing laboratories applying for accreditation by Intersocietal Accreditation Commission. J Vasc Ultrasound. 2018;42(3):116–119.

22.

IAC Staff: IAC vascular testing facility accreditation issues. J Vasc Ultrasound. 2018;42(1):36–39.

23.

Behera

Smith

Tacy

: Impact of accreditation on quality in echocardiograms: a quantitative approach. J Am Soc Echocardiogr. 2017;30(9):913–922.

24.

American Society of Echocardiography: Recommendations for continuous quality improvement in echocardiography. J Am Soc Echocardiogr. 1995;8(5)Pt2:S1–S28.

25.

American Society of Echocardiography: Sonographer’s communication: sonographer licensure update. J Am Soc Echocardiogr. 2010;23(6):A22.

26.

The Australasian Society of Ultrasound in Medicine: Minimum education & training requirements for ultrasound practitioners. Australas J Ultrasound Med. 2017;20:132–135.

27.

Benacerraf

Minton

Benson

, et al: Proceedings: Beyond Ultrasound First Forum on improving the quality of ultrasound imaging in obstetrics and gynecology. Am J Obstet Gynecol. 2018;218(1):19–28.

28.

Bierig

Ehler

Knoll

Waggoner

: American Society of Echocardiography (ASE) minimum standards for the cardiac sonographer: a position paper. J Am Soc Echocardiogr. 2006;19:471–474.

29.

Douglas

Iskandrian

Krumholz

, et al: Achieving quality in cardiovascular imaging: proceedings from the American College of Cardiology-Duke University Medical Center think tank on quality in cardiovascular imaging. J Am Coll Cardiol. 2006;48:2141–2151.

30.

Douglas

Chen

Gillam

, et al: Achieving quality in cardiovascular imaging II: proceedings from the Second American College of Cardiology—Duke University Medical Center think tank on quality in cardiovascular imaging. JACC Cardiovasc Imaging. 2009;2(2):231–240.

31.

Eskandari

Kramer

Hecht

Jaber

Marwick

: Evidence base for quality control activities in cardiovascular imaging. J Am Coll Cardiol Img. 2016;9:294–305.

32.

Heller

Katanick

Sloper

Garcia

: Accreditation for cardiovascular imaging: setting quality standards for patient care. JACC Cardiovasc Imaging. 2008;1:390–397.

33.

Johnson

Krecke

Miranda

Roberts

Denham

: Quality initiatives: developing a radiology quality and safety program: a primer. Radiographics. 2009;29(4):951–959.

34.

Jones

Schroedter

: The Society for Vascular Ultrasound Government Relations Committee: impact on practice, standards, and reimbursement. J Vasc Ultrasound. 2004;28(3):168–170.

35.

Kabnick

Passman

Zimmet

Blebea

Khilnani

Dietzek

: Exploring the value of vein center accreditation to the venous specialist. J Vasc Surg Venous Lymphat Disord. 2016;4(1):119–124.

36.

Mark

Anderson

Brinker

, et al: ACC/AHA/ASE/ASNC/HRS/IAC/Mended Hearts/NASCI/ RSNA/SAIP/SCAI/SCCT/SCMR/SNMMI 2014 health policy statement on use of noninvasive cardiovascular imaging: a report of the American College of Cardiology Clinical Quality Committee. J Am Coll Cardiol. 2014;63:698–721.

37.

Picard

Adams

Bierig

, et al: American Society of Echocardiography recommendations for quality echocardiography laboratory operations. J Am Soc Echocardiogr. 2011;24:1–10.

38.

Popescu

Andrade

Badano

, et al: European Association of Echocardiography recommendations for training, competence, and quality improvement in echocardiography. Eur J Echocardiogr. 2009;10:893–905.

39.

Rose

Weissman

: Demystifying imaging laboratory accreditation. JACC Cardiovasc Imaging. 2014;7(2):212–214.

40.

Rosenbloom

Dempsey

Gillam

, et al: Licensure of the cardiac sonographer: an overview of issues and activities. J Am Soc Echocardiogr. 2001;14(12):1212–1219.

41.

Society of Diagnostic Medical Sonographers: Scope of practice for the diagnostic ultrasound professional. J Diagn Med Sonography. 2000;16:206–211.

42.

Society of Diagnostic Medical Sonographers: Scope of practice and clinical standards for the diagnostic medical sonographer. J Diagn Med Sonography. 2015;31(4):198–209.

43.

Sloper

Katanick

: IAC accreditation: setting the standard of care in diagnostic imaging. J Med Pract Manage. 2011;26:248–253.

44.

St Vrain

Skelly

Waggoner

, et al: Multiskilling and multicredentialing of the health professional: role of the cardiac sonographer. Sonographer Council of the American Society of Echocardiography. J Am Soc Echocardiogr. 1998;11(11):1090–1092.

45.

Wiener

: Achieving high-value cardiac imaging: challenges and opportunities. J Am Soc Echocardiogr. 2014;27(1):1–7.

46.

Wilson

Cooley

: The implementation of a sonographer’s career ladder. J Diagn Med Sonography. 2006;22(3):191–199.

47.

Adams

Kisslo

: Credentialing of the cardiac sonographer: the need for unification. J Am Soc Echocardiogr. 1988;1(1):100–102.

48.

Altman

: Laboratory accreditation: who needs it? J Diagn Med Sonogr. 2006;22(5):345–348.

49.

Andrist

Schroedter

: Standards for assurance of minimum entry-level competence for the diagnostic ultrasound professional. J Diagn Med Sonogr. 2001;17:307–311.

50.

Andrist

Boswell

Sarraille

Squier

: Licensure for sonographers: panacea or problem? J Diagn Med Sonogr. 2003;19(5):323–325.

51.

Arger

: Facts you may not know—and opinions you may not have considered—about the AIUM’s voluntary accreditation program. J Ultrasound Med. 1996;15(8):611–612.

52.

Baker

: Issues facing sonography. J Diagn Med Sonogr. 1997;13:3S–9S.

53.

Berman

: Mandatory licensure for sonographers. J Diagn Med Sonogr. 1989;5(4):191–191.

54.

Bierig

: Recognizing the importance of credentialing. J Am Soc Echocardiogr. 2009;22(4):A35.

55.

Byrd

: ASE 2013-14: working to improve the quality and consistency of echo worldwide. J Am Soc Echocardiogr. 2013;26(7):A21–A22.

56.

Coon

: Focus on sonography credentialing: the adult congenital sonographer. J Am Soc Echocardiogr. 2015;28(12):A19.

57.

Coffin

: The continuous improvement process and ergonomics in ultrasound department. Radiol Manage. 2013;35(1):22–25.

58.

Craig

: Should there be mandatory licensure for sonographers in the USA and around the world? Would an international licensure be possible? J Diagn Med Sonogr. 1989;5(4):192–194.

59.

Cyr

: Sonography credentialing in a time of change. J Diagn Med Sonogr. 2018;34(1):1–2.

60.

Douglas

: Improving imaging: our professional imperative. J Am Coll Cardiol. 2006;48(10):2152–2155.

61.

Douglas

: Quality in echocardiography: choosing to succeed. J Am Soc Echocardiogr. 2008;21(9):1016–1017.

62.

Douglas

Picard

: Healthcare reform for imagers: finding a way forward now. JACC Cardiovasc Imaging. 2013;6(3):385–391.

63.

Hamburg

: Evolutions in quality in training and accreditation for vascular imaging. J Am Soc Echocardiogr. 2015;28(8):A18.

64.

Jasa

Kirkland

: Customizable ultrasound career ladder: a preliminary report. J Vasc Ultrasound. 2009;33(4):203–207.

65.

Knoll

: Sonographer licensure: collaborative efforts. J Am Soc Echocardiogr. 2008;21:21A–3.

66.

Krotz

: Ultrasound accreditation raising quality standards. Diagn Imaging. 1998;20(7):37.

67.

Kuntz

: Accreditation of sonography programs: building a house of cards. J Diagn Med Sonogr. 2004;20(2):144–146.

68.

Lindner

: Defining value for echocardiography: why and how? J Am Soc Echocardiogr. 2018;31(10):A23–A24.

69.

Lopez

: Pediatric echocardiography quality improvement. J Am Soc Echocardiogr. 2012;25(12):22A–23A.

70.

Mackensen

Nicoara

: Improving the quality and reporting of perioperative echocardiography. J Am Soc Echocardiogr. 2018;31(8):A22–A23.

71.

McIlwain

: Advocacy: it’s important for sonographers too! J Am Soc Echocardiogr. 2014;27(1):21A.

72.

Musarra

: Sonographer career development. J Am Soc Echocardiogr. 2018;31(3):A34–A35.

73.

Pai

: Echocardiographic laboratory accreditation: the pains and pleasures. Echocardiography. 2016;33:344–345.

74.

Pearlman

Adams

Kraft

Witt

: Advancing recognition of the responsibilities of cardiac sonographers. J Am Soc Echocardiogr. 2009;22:1414–1416.

75.

Pearlman

Gardin

: Improving quality in echocardiography laboratories. J Am Soc Echocardiogr. 2011;24(1):11–14.

76.

Popp

: The challenge of quality versus quantity in echocardiography. J Am Soc Echocardiogr. 1992;5(1):1–4.

77.

Poppiti

: Accreditation gaining insight. J Diagn Med Sonogr. 1997;13(4):195–197.

78.

Rampoldi

Bienvenu

: How to implement ASE Guideline Standards into your lab. J Am Soc Echocardiogr. 2018;31(7):A30–A31.

79.

Rigolin

: Quality matters. J Am Soc Echocardiogr. 2017;30(9):A17–A18.

80.

Robbin

Lockhart

Weber

, et al: Ultrasound quality and efficiency. J Ultrasound Med. 2011;30:739–743.

81.

Rose

Johnson

: Laboratory accreditation: why this quality matter matters. J Am Soc Echocardiogr. 2017;30(9):923–925.

82.

Soriano

Rudberg

Stevenson

: Going beyond right and wrong: building the framework for quality improvement in congenital echocardiography—you can’t manage what you don’t measure. J Am Soc Echocardiogr. 2014;27(6):624–626.

83.

Swaminathan

Nicoara

: Quality in perioperative echocardiography: it’s about time. J Am Soc Echocardiogr. 2014;27(7):A20.

84.

Waggoner

Skelly

: The profession of cardiac sonography and the status of professionalization of cardiac sonographers. J Am Soc Echocardiogr. 1999;12:335–342.

85.

Waggoner

Stevenson

: The value of sonographer credentialing: an important first step. J Am Soc Echocardiogr. 2016;29(1):49–50.

86.

Weiner

Picard

: Quality in echocardiography: does it make a difference? J Am Soc Echocardiogr. 2013;26(3):243–245.

87.

Wilson

: What does government regulation really mean? J Diagn Med Sonogr. 2009;25:88–92.

88.

Wilson

: Legislation approaching sonography. J Diagn Med Sonography. 2011;27(4):191–197.