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

ValidationAppropriate patient selectionQuality careInternal peer processes

Reduced costsIndependent state reviews with no finesInsurance coverageIncreased patient satisfaction

Benefits

Enhanced:Facility reputationProgram reputationPhysician reputationStaff and Physician moraleBrand 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 ReportingMultiple public sitesIncreased pressure to report

American College of Cardiology (ACC) statistics to other regulating bodies that effect revenue

Affordable Care ActAppropriate 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 MeasuresPolicies and ProceduresQuality ReviewsInternal peer review processDemographics, 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 reviewMedical records auditsCritical review of every procedure done

over past 2 years

Road to Accreditation

Physician Date and Angiographic ReviewPhysician site visitDeficiencies and corrective action

plansRoot Cause Analysis

• Recommendation may be Provisional, Accredited or Denied

Submission Process

10 cases per performing physicianHospital notes, office notes, previous cath

reports, lab results, supportive non-invasive testing

Data transferred into data metrics spreadsheet from ACE.

All characteristics met ACE standardsPartially Met standardNot Meeting standardMet standard

What did we learn ?

Site Not yet reviewed.Application in process

Expectations are well above what is currently documented

Policies and Protocols are deficientOpportunities identified to improve

physician oversight

What did we learn ?

Non-invasive documentation needs to be fortified.

Physician reporting not standardizedMedical 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

http://www.cvexcel.org/Default.aspx

Medical Malpractice lawyers. (2013). Maryland case settled. Retrieved online on

11/23/13 from https://www.medicalmalpracticelawyers.com/blog/tag/

unnecessary-stent-claim/

National Cardiovascular Database registry. (2013). Retrieved online on 11/22/13

from https://www.ncdr.com/WebNCDR/