IAC Echocardiography Fetal

Add-on Supplemental Form

An additional testing area (or areas) may be added to a facility’s current accreditation at any time during the three-year accreditation cycle. Accreditation is granted only for the specific testing areas for which a facility has applied and submitted an application. Though facilities may be performing other testing in the facility, those areas are not covered under the accreditation until an application for the specific testing type is submitted and granted accreditation. The following form is to be used for supplemental testing only. If your facility is not currently accredited in Echocardiography,please contact the IAC.

Please answer all questions, required attachments will be indicated by the  symbol. Case studies requirements are listed on page two.

Name of institution (as listed in the IAC Accreditation Agreement):

(This institution name will be tracked in the IACdatabase and will receive all IAC correspondence)

Department:

Street Address 1:

Street Address 2:

City:

State: Zip code:

Location of echocardiography facility:

Hospital (number of beds: )

Private Office

Freestanding imaging center

Independent facility

Other (specify):

1)Enter the total number of procedures performed in the facility (or facilities) annually by type of examination
(this includes all sites and mobile locations):
Fetal Echocardiography:

2)Does the Medical Director interpret fetal echocardiography exams in this facility?
Yes No

3)Enter the average annual volume of fetal studies interpreted by the Medical Director in this facility
(Applicable Standard: Part 3.3B):

4)Please list the medical and technical staff that performs or interprets fetal studies and their annual volumes:

Interpreting Physician / Fetal Volumes

Enter how many minutes are allotted for each of the following echocardiogram procedures from patient encounter to patient departure in the facility(Applicable Standard: 3.5.2B):

Initial complete fetal echocardiogram:

Follow-up or repeat fetal echocardiogram:

 Submit a copy of the facility-specific, step-by-step fetal echocardiography protocol.

5)Which sites should be included in the add-on testing area?

IMPORTANT: The staff count you enter on this page is used to determine the overall number of fetal echocardiography case studies you will be required to provide.

To review how the value you enter impacts the number of required case studies, refer to the following instructions for fetalechocardiographycase studies.

Enter the number of medical and technical staff members you have interpreting/performing Fetal Echocardiography exams:

Fetal Echocardiography Case Studies:

  • The required fetal case studies are based on the total number of staff (medical and technical) in an applicant facility. Following are the required number of fetal case studies per facility:
  • 5 or fewer = 4 cases per facility (1 shunt, 1 simple obstruction, 1 case with an indication or finding of fetal arrhythmia and 1 case of hypoplastic ventricle)
  • 6 to 8 staff = 6 cases per facility (2 shunts, 2 simple obstructions, 1 case with indication or finding of fetal arrhythmia and 1 case of hypoplastic ventricle)
  • 9 to 15 staff = 8 cases per facility (4 shunts, 2 simple obstructions, 1 case with an indication or finding of fetal arrhythmia and 1 case of hypoplastic ventricle)
  • 16 to 25 staff = 10 cases per facility (4 shunts, 3 simple obstructions, 1 complex defect, 1 case with an indication or finding of fetal arrhythmia and 1 case of hypoplastic ventricle)
  • >25 staff = 12 cases per facility (4 shunts, 4 simple obstructions, 2 complex defects, 1 case with an indication or finding of fetal arrhythmia and 1 case of hypoplastic ventricle)
  • Multiple Sites: 1 abnormal fetal case study from each applicant site must be submitted.
  • Cases submitted with the application must not be independently performed by sonographer or physician trainees.
  • All cases must be selected from within the past 12 months from the date of application filing.

IAC EchocardiographyFetal Add-On Supplemental Form 1

Reviewed 9/2016