ACE Accreditation Process for Cardiac Catheterization Labs Kelly Cross, RN SUNYIT November 22, 2013

What is accreditation?  ACE- Accreditation for Cardiovascular Excellence  An approach intended to improve quality outcomes.  ACE process is an internal gap analysis and an external review of all processes that impact this particular distribution of patients.  It is a structured template of evidenced based metrics your facility is measured against to become accredited.

Background…why do this?  Accountability to state regulating bodies to demonstrate quality measures in place; e.g. Appropriate Use Criteria (AUC)  Demonstrate to community and administration the quality commitment and process of care  Interventional cardiology is under a spotlight due to inappropriate use of stents in various states; Maryland, Texas, Pennsylvania to name a few.

Benefits  Future of healthcare is lean based, quality driven excellence from multidisciplinary team.  Value based purchasing will effect your facility

Benefits  Validation  Appropriate patient selection  Quality care  Internal peer processes  Reduced costs  Independent state reviews with no fines  Insurance coverage  Increased patient satisfaction

Benefits  Enhanced:  Facility reputation  Program reputation  Physician reputation  Staff and Physician morale  Brand recognition and community support

Concerns….  Was your stent unnecessary? Highly litigious industry with lawyers seeking out patients for financial gain.  Loss of trust physicians, healthcare, pharmaceutical industries  Loss of revenue patients can sue if deemed inappropriate use, lost wages, payer challenges, loss of referrals.  Increased costs legal fees, insurance reviews, media coverage

Concerns…..  Public Reporting  Multiple public sites  Increased pressure to report American College of Cardiology (ACC) statistics to other regulating bodies that effect revenue  Affordable Care Act  Appropriate Use Criteria (AUC)

A comprehensive look at everything !  Policies  Competencies  Documentation  Facility  Equipment  Leadership structure  Staff (Nurses,CVT’s,RT’s)  Quality/Peer Review/Cath Conference Standards  Radiation Safety  Outcomes  Procedure indication, consents, preparation and code of conduct

Road to Accreditation  Initial Application reviewed by nurses, physicians and quality experts, to include:  Outcome Measures  Policies and Procedures  Quality Reviews  Internal peer review process  Demographics, AUC, standard quality metrics

Road To Accreditation  Nurse Site Visit:  Validation of all date entered into the National Cardiovascular Data Registry (NCDR)  Process and facility review  Medical records audits  Critical review of every procedure done over past 2 years

Road to Accreditation  Physician Date and Angiographic Review  Physician site visit  Deficiencies and corrective action plans  Root Cause Analysis Recommendation may be Provisional, Accredited or Denied

Submission Process  10 cases per performing physician  Hospital notes, office notes, previous cath reports, lab results, supportive non- invasive testing  Data transferred into data metrics spreadsheet from ACE.  All characteristics met ACE standards  Partially Met standard  Not Meeting standard  Met standard

What did we learn ?  Site Not yet reviewed.  Application in process  Expectations are well above what is currently documented  Policies and Protocols are deficient  Opportunities identified to improve physician oversight

What did we learn ?  Non-invasive documentation needs to be fortified.  Physician reporting not standardized  Medical staff policies are not enforced

Next Steps  Ongoing processes to standardize policies and procedures and protocols.  Quality oversight for physicians to reinforce medical staff policies  Institute culture that embraces ACE accreditation standards  Educate the staff

References  ACE accreditation for Cardiovascular Excellence. (2013). Retrieved online on 11/22/13 from  Medical Malpractice lawyers. (2013). Maryland case settled. Retrieved online on 11/23/13 from unnecessary-stent-claim/  National Cardiovascular Database registry. (2013). Retrieved online on 11/22/13 from