Accreditation of Epilepsy Centers.

In 2012, the Institute of Medicine recommended that a formal process be developed for the accreditation of epilepsy centers in the United States. This article provides some of the background and processes that led to the criteria by which epilepsy centers are now accredited.

Since its formation by physician leaders in 1987, the National Association of Epilepsy Centers (NAEC) has focused its efforts on developing standards of epilepsy care. National Association of Epilepsy Centers published its first Guidelines for Essential Services, Personnel, and Facilities in Specialized Epilepsy Centers in 1990,[1] with updated iterations published in 2001[2] and 2010.[3] In its early days, centers would submit an annual survey to NAEC as part of a self-designation process to be recognized as a level 3 or 4 center.

In 2012, the Institute of Medicine of the National Academies, in the sentinel publication of “Epilepsy across the Spectrum” charged the NAEC in collaboration with the American Epilepsy Society (AES) to develop a model by which epilepsy centers could be accredited (recommendation 6).[4] This directive stated that the criteria by which centers would receive accreditation should have independent external review mechanisms. The Board of Directors of the 2 organizations determined that the NAEC would take the lead on developing the accreditation process and standards with potential for endorsement by the AES once complete. The purpose of this document is to memorialize the process that was undertaken to develop this accreditation model.

Prior to the formulation of the current accreditation model, recognition as a level 3 or 4 epilepsy center was based on voluntary compliance with the published guidelines.[1-3] There was no independent external review but rather the medical director attested to the veracity of the data submitted in its center’s annual report. Self-designation was heavily driven by the number of admissions to the center’s epilepsy monitoring unit and surgical cases. Due to the lack of independent verification of the data, the numbers of cases provided by our centers were often suspect.

Before the development of the current criteria for accreditation, the Board of the NAEC undertook a period of study during which different models of accreditation were reviewed. These included a model similar to that of the Joint Commission and other professional societies with on-site assessment of whether an organization meets accreditation criteria. This model was rejected as relying too heavily on surprise or in-person scheduled visits to institutions and the requisite need for significant personnel and high costs to support the effort. Rather, the Board decided to set criteria and then require centers to provide proof via documentation to validate that a center was meeting them. NAEC would also seek independent validation, when possible, such as by verifying individuals’ board certifications directly with relevant credentialing bodies.

When the time came to develop the actual standards by which centers would be accredited, the board and standard setting committee was provided an article about the standard setting process that would be used.[5] When we convened, this author led the group through this modified Delphi process. Specifically, each member of the standard setting committee, which included current and former Board members, reviewed each item included in the most recent NAEC guidelines[3] that describe the services, personnel, and facilities required for level 3 and 4 centers (approximately 40 items). Participants were asked to respond individually to the question, “In an accredited center, which of these essential features ‘would’ they have, not ‘should’ they have?” The group had surprising unanimity on the majority of the items. Items for which there was not initial unanimity were considered during a second round of discussion. Ultimately, the group was able to reach consensus on the accreditation standards to define level 3 and 4 centers.

Once the group agreed on the criteria, NAEC member centers and sister epilepsy organizations were offered the opportunity to comment on the proposed standards. The response to this request was universally positive and included a formal endorsement by AES. The accreditation process was then phased in over 2 years. In the first year, centers completed the new process but were not held accountable to the new standards. They were given a report card identifying any deficiencies to address. The new standards took effect for all centers in 2016. Now, centers must complete an online Center Annual Report and upload required documents to a secure, electronic system to validate their responses, such as curricula vitae of key personnel, deidentified patient reports for key services, and copies of safety and treatment protocols. The final piece of the accreditation puzzle was to determine for how long a center would be accredited. The committee determined that a 2-year cycle would be appropriate for centers that were 100% in compliance with the standards. Centers with deficiencies would receive provisional 1-year accreditation and would be required to meet all standards in the following year. This was an attempt to be inclusive and not cause any center to lose their status for a minor interruption or loss of a single key staff person.

The NAEC board was concerned about centers rejecting this process but in fact the number of accredited centers is greater than prior to this process being in place. Each year, the NAEC Board and Accreditation Committee (piloted in 2018 and formalized in 2019) meet to discuss and revise the accreditation criteria to incrementally raise standards. Like the transition to the new accreditation system itself, major criteria and process changes are open for comment from NAEC members and are phased in over time. The process continues to have support and validity from NAEC members and the broader epilepsy community, as well as recognition by US News and World Report in its assessment of the best neurology and neurosurgery programs in the nation.