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TABLE OF CONTENTS (quick links)
Application Process
The Accreditation Tool and the Requirements for Accreditation
Applying for Accreditation Review
The Facility Information Booklet
The Process after an Application is Received
The Process after the Accreditation Review Committee Issues an Accreditation Status determination
Accreditation Tool and Accreditation Review Items
APPLICATION PROCESS
Q. How do I learn more about Accreditation?
A. Start by obtaining an Accreditation Manual. This can be done in two ways: 1) purchase a Manual, 2) attend a Regional Accreditation Workshop. Facilities that are committed to, or are considering, applying for chest pain center accreditation, are strongly recommended to take advantage of the educational offerings provided by the Society to prepare them for a successful review.
Q. What is the contact information for the Society of Chest Pain Centers?
Mailing/Shipping Address:
Society of Chest Pain Centers
770 Jasonway Avenue, Suite 1B
Columbus, Ohio 43214
Attn : Accreditation Department
Phone: 614-442-5950
Fax: 614-442-5953
Email: Accreditation Process Questions: accreditation@scpcp.org
Email: Accreditation Tool Questions: kholmes@scpcp.org
Website: www.scpcp.org
Accreditation: www.scpcp.org/accreditation
Accreditation Manual Order Form: www.scpcp.org/accreditation
Accreditation Education: www.scpcp.org/Accreditation/Workshops
Congress: www.scpcp.org/congress
Q. What is in the Accreditation Manual?
A. The Accreditation Manual contains the following:
Letter from our Accreditation Manger
Application Form (enclosed in left pocket of manual)
Society information
Accreditation Process information
Accreditation Tool
Explanation of the Accreditation Tool
Accreditation Facility Information Booklet
Performance Improvement Explanation
Resources
CD ROM with materials
Q. How do I order an Accreditation Manual?
A. To order the Accreditation Manual, please go to the our website at www.scpcp.org/accreditation.
Chest Pain Center Accreditation Educational Courses
Q. What do you learn by attending Accreditation courses?
A. You learn about the Society, our mission and why we have undertaken this responsibility. You also learn exactly what the Accreditation process involves, how to get started, how to read the Tool, and what is expected of your facility to be successful in obtaining Accreditation status. The Review Tier Items are discussed in detail, often by a member of the Accreditation Review Team. You will be given specific examples of documentation you may submit to support each Tier Item.
Q. Is an Accreditation course a requirement?
A. No, however,facilities that participate in accreditation education generally save time, are better prepared, understand the site review process more thoroughly, and have fewer returned applications.
To make our accreditation education more accessible, it is now available as an online windows media video. Viewers will learn the review criteria and the process of accreditation and other information needed to have a successful review. Any facility that has purchased an accreditation manual can view the online education at no additional fee. This is a departure from the $200 fee that had been charged for teleworkshops. The video may be viewed at any time that is convenient. You will be able to start, stop, fast forward and rewind the video. And you may revisit the video as often as you like, by as many members of your facility as you like. We hope that with this new convenience and fee waiver, all facilities will take advantage of accreditation education. Facilities also have the option of attending regional workshops.
Q. How do I register for Accreditation Courses?
A. To register click here.
The Accreditation Tool and the Requirements for Accreditation
Q. What is the Accreditation Tool?
A. The Accreditation Tool contains all Accreditation Review Items. Each Review Item represents a desirable condition that may or may not be present in a facility. The facility utilizes the Tool in several ways. First, the facility can do a self-assessment, then a gap analysis by checking off all Review Items currently present. We suggest you start with Tier IV Items (red) in each Key Element and work your way up through the Tool. As you check off Items you believe your facility has met, make yourself a note what documentation will demonstrate meeting a Tier Item. If the facility elects to apply for a Site Review, the facility will need to provide documentation to support each item checked in the Tool.
Q. How do I read the Accreditation Tool?
A. The Accreditation Tool is organized hierarchically into four Tiers. The most basic Tier, represented in blue, is called a Key Element. The Society has identified eight Key Elements of a Chest Pain Center. They are more specific than the Tier I Key Elements. Tier II Items are supported by more specific Tier III Items, represented in green. Some Tier III Items are supported by Tier IV Items, represented in red.
Q. What is required for Provisional Accreditation status?
A. To receive Provisional Accreditation, a facility must demonstrate that all Tier I items have been met and be willing to make a commitment to achieve any Tier II Items that may be missing, within 12 months. A provisional facility may not call itself an "Accredited Chest Pain Center" or use the seal of accreditation. A provisionally accredited facility may call itself only a "Provisionally Accredited Chest Pain Center".
Q. What is required for Full Accreditation status?
A. To receive Full Accreditation status, a facility must demonstrate that all Tier I and Tier II Items have been met.
Q. How do I "check off" or mark "yes" for a Tier II Item?
A. To "check off" a Tier II Item, you will usually need to check at least one supporting Tier III or Tier IV Item. Documentation of Tier III and Tier IV items support the other Tier items.
Q. Do I need to have all the Items checked to receive Full Accreditation status?
A. No, to receive Full Accreditation status, you need to have all Tier I and Tier II Items checked and supported. In practice, this means you will likely need to have at least one but not all, Tier III or Tier IV Items that support the Tier II Item.
Q. Is it difficult to apply for Accreditation?
A. The best way to assess what is required is to do a self-assessment/gap analysis with the Accreditation Tool. This will help you determine what Items have been met in your facility. Generally most facilities find there are only a few Items that need to be addressed to bring up to standards. After that, provide documentation to support the Items. Only the bare minimum documentation is required. We strongly recommend that you read and follow the Suggested Steps under the Explanation of the Tool tab provided in your manual.
Q. How do we determine the likelihood that our facility will receive Accreditation if we apply for a Review?
A. If you are trying to assess the likelihood of receiving Accreditation, we recommend you call the Society office to discuss it. We welcome your questions. The Society has a philosophy of collaboration and collegial respect and will help guide you to resources and samples of best practice. Again, the best way to determine if your facility will qualify for Accreditation is to do a self assessment/gap analysis with the Accreditation Tool.
Q. Our facility does not perform Percutaneous Coronary Intervention (PCI). Can we still qualify for Accreditation?
A. Yes, if the facility has a well-defined and well-established strategy for reperfusion (e.g. lytic drug administration, expeditious transfer to a facility capable of coronary interventions, facilitated PCI or other reperfusion strategy of choice supported by research). The facility must define its strategy of choice in the accreditation application; Chest Pain Accreditation or Chest Pain Accreditation with PCI. In order to receive the designation of Chest Pain Center with PCI a facility must have on-site 24/7, cath lab capabilities and meet the ACC/AHA standard for minimal number of primary PCI procedures for STEMI per year. A facility does not need to provide PCI to be accredited; however, they must have a well-defined process in the event an ACS patient arrives at their facility. This includes STEMI, NSTEMI, UA and low risk. This process orientation makes the Society's Accreditation unique.
Q. We do not have dedicated observation beds. Can we still qualify for Accreditation?
A. Yes. The facility must demonstrate a well-defined process to evaluate moderate and low risk patients that minimizes unnecessary admissions and inappropriate discharges. That process need not be based on dedicated beds.
Q. We don't have a Chest Pain Center in the ED. Can we still qualify for Accreditation?
A. There is a common misconception that a Chest Pain Center is merely an observation unit or a room within the Emergency Department. While chest pain strategies may enlist observation and the ED, a Chest Pain Center is an operational model for the treatment of ACS that encompasses the entire facility and is a team approach to the care of the ACS patient. A Chest Pain Center focuses on the processes of ACS care.
Q. What is a Chest Pain Model?
A. The Chest Pain Center Model is an operational process for the care of acute coronary syndrome (ACS) patients. It begins when a patient activates EMS, continues through patient discharge, and encompasses the entire facility. The Chest Pain Center (CPC) integrates an inter-departmental team working toward one common goal - to effectively and efficiently improve processes to assess, diagnose, and treat ACS and acute decompensated heart failure (ADHF) patients.
Applying for Accreditation Review
Q. How do I apply for an Accreditation Review?
A. The process begins when the facility obtains an Accreditation Manual. The Accreditation Manual contains the Accreditation Review application form. A Manual can either be purchased directly from the Society or by registering for a regional workshop. Complete the application form, which is located in the left hand pocket of the Accreditation Manual.
The facility will need to provide documentation for all Items checked on the Tool and include the corresponding Item Number(s) the documentation supports. For your convenience, the Society has provided self-adhesive labels with all Item Numbers, in the right hand pocket of the Accreditation Manual. Send the completed documentation, along with your facility's check and all other required Items, to the Society. There is a checklist of required Items on the application provided in the Accreditation Manual.
Q. What must be included with the Review application?
A. The Accreditation Manual contains a checklist of required Items. Be sure to fill out the application form completely and have it signed by an appropriate authority. Unsigned applications or applications without their suggested earliest site visit date will be returned to the facility for completion. Required are: 1) the application form, 2) a check for the appropriate fee, 3) documentation supporting the accreditation Tool, and 4) the Accreditation Facility Information Booklet. Please make sure you mark on the application the type of accreditation for which you are applying.
Q. Should we designate a Key Contact?
A. Yes, the Key Contact will be responsible for all communications between the facility and the Society, he/she will provide additional documents requested by the Accreditation Review Team, and manage the site visit. This individual should be involved with the CPC as well as have the availability to handle these tasks.
Q. What dates should a facility put down for their site visit?
A. The earliest site visit date, which is a requirement on the application, should be the first date that your facility will be fully prepared to go through the site review process. Indicate other site visit dates as convenient. Of course, the Society Accreditation Manager and the facility Key Contact will work together to determine the best site visit date for all parties.
Q. How and where do I send the Review application?
A. We strongly advise you to overnight the manual with application and check. We also recommend that you call the Society once you have shipped so that we know to expect your package. Ship to the following location:
Society of Chest Pain Centers
770 Jasonway Avenue, Suite 1B
Columbus, Ohio 43214
614-442-5950
Attn: Accreditation Department
Q. When is the last date that a facility can purchase a Cycle II Manual?
A. October 31, 2008.
Q. When is the first date that a facility can purchase a Cycle III Manual?
A. May 1, 2008.
Q. When is the last date that a facility can apply for a Cycle II Accreditation Review?
A. All Cycle II applications must be received in the Society's office by December 1, 2008. We highly recommend you submit your application well in advance of this date to be assured your site visit will be timely.
Q. What is the first date a facility may apply for a Cycle III Accreditation Review?
A. The first date that Cycle III applications will be accepted is January 1, 2009. The first date that a Cycle III site visit can be scheduled is January 1, 2009.
Q. If we apply for our first-time review after January 1, 2009, do we apply for a Cycle II Review or a Cycle III Review?
A. After January 1, 2009, facilities applying for their first-time Accreditation Review, must apply for a Cycle III Accreditation Review.
Q. How do we maintain ongoing Accreditation status so that our Accreditation does not expire?
A. To maintain ongoing Accreditation status, you must apply for the next cycle's Accreditation Review a minimum of six (6) months in advance of your Accreditation expiration date.
Q. What if our Accreditation expires before reaccreditation is established?
A. Some aspects of the review process are beyond the Society's control. Therefore, we cannot guarantee the date of your site visit or when Accreditation status is determined. We will attempt to meet the facility's goals; however, the Society recommends you submit your application a minimum of six (6) months prior to your Accreditation expiration date.
Q. What if we are reaccredited prior to the expiration of our current Accreditation date. Do we still get a full 3 years of Accreditation?
A. Yes. If your reaccreditation date precedes the expiration of your current Cycle Accreditation, the new Accreditation period will extend a full three years beyond the expiration of your current Accreditation. Your facility will receive the full 3 years of the current Accreditation and a full 3 years of the subsequent Accreditation.
Q. If we qualify for the designation "Accredited Chest Pain Center with PCI", when do we receive the designation?
A. If granted, your designation is effective on the date the Accreditation Review Committee makes its finding. In the case of a reaccrediting facility, the designation may take effect prior to the expiration of their current Accreditation date.
The Facility Information Booklet
Q. What is the Facility Information Booklet and do I need to include it with the Review Application?
A. Yes, you need to include the completed booklet. The Facility Information Booklet is a survey of your facility. It is for the internal use of the Society to gain a better understanding of Chest Pain Center practices for the benefit of the community.
Q. Do we need to provide documentation with the Facility Information Booklet?
A. No, the Facility Information Booklet does not require documentation, although a brief description may be requested in parts.
Q. What if we don't have the information you request in the Facility Information Booklet or it would be extremely difficult to attain?
A. Indicate that the information is unavailable and leave the section blank. We do ask that you complete the Facility Information Booklet to the best to your ability.
Q. What if we are not sure we have given the right answer or provided exactly what you requested?
A.. Do the best you can. We understand you may not be precise on every question.
Q. What is "rescue angioplasty"?
A. Angioplasty initiated after failed fibrinolytics.
Q. We have more recent data for the Facility Information Booklet than you are requesting. Should we use the more recent data?
A. Yes, our database does accommodate current information. Please include three years of information.
The Process after an Application is Received
Q. What happens when the Society receives your application?
A. When we receive your application for Accreditation Review we log the date and time of receipt of your application and place your facility into the Accreditation queue. If any required Items on the check list are missing, your application will not be logged in. At that time the Society will notify the Key Contact and address the problem. If you send in the required Items separately, the application is not logged in until all required Items are received.
Your application will be given to the Accreditation Review Team. A member of the Accreditation Review Team will contact the Key Contact to establish a date for the site visit. The Accreditation Review Team will inspect your application in detail and may contact you for additional documentation.
Q. If the Accreditation Review Team finds Items that do not meet requirements, do we fail?
A. Once your application is reviewed, the Accreditation Review Team may find documentation that they believe may not support the intended review Items or find that your facility practice does not meet the requirements. In that event, the Accreditation Review Team will notify the facility's Key Contact and request additional documentation. If the facility's practice or policies need revision, the Accreditation Review Team will work with the facility to provide resources to assist the facility with the needed changes. If necessary, the site visit date may be changed until the Accreditation Review Team is prepared to make a recommendation for Accreditation.
Q. What happens during a site visit?
A. The Accreditation Review Team will drive through the facility campus to inspect the flow of traffic and signage. The facility will be asked to demonstrate the macro care processes that have been mapped. The Review Team will do a walk-through of the ED and cath lab to observe patient flow. You should plan on a two-day site visit. The first day is generally devoted to a demonstration of the macro processes; the second day is a discussion of findings and recommendations. The time commitment for the facility is approximately four hours the first day and five hours the second day.
Q. Who should participate in the site visit?
A. All facility personnel who contribute materially to the success of the Chest Pain Center should participate. At the bare minimum, we recommend the following individuals participate: Chest Pain Center Director, Chest Pain Center Coordinator, CEO or President, Cardiovascular Administrator, ED Director, Cardiology Director, Chief of Staff, Nursing Director, members of the multidisciplinary committee, local EMS directors, Education Director, Outreach Director, and Process Improvement Officer. It is to the facility's benefit to have this representation. The various constituencies and administration are present as a third party expert makes observations and recommendations. Facilities indicate that this is highly valuable.
Q. Can a facility "fail" the site visit?
A. As part of the Society's collaborative philosophy, we are here to assist you and walk you through the process. We want you to succeed; therefore, if the Accreditation Review Team believes the facility's application is lacking, they will delay the site visit and work with the Key Contact to help the facility put into place the lacking items. Any outstanding items not supported in the documentation submitted with the Accreditation application must be supported at the site visit. If they are not supported, or the physical facilities or demonstrated care processes do not reflect the Items checked in the Tool, the facility may fail to achieve all Items required for Accreditation. One of the primary purposes of the site visit is for the Accreditation Review Team to discuss their findings and recommendations with the key personnel of the Chest Pain Center. A facility that does not meet the criteria for full accreditation, may be eligible for provisional accrediation.
Q. What happens after the site visit?
A. The Accreditation Review Team will issue a report to the Accreditation Review Committee. The Accreditation Review Committee will review the report and request any additional clarification or documentation if needed before issuing its finding. This typically takes two to four weeks after the site visit. The facility will receive one of the following designations: 1) Accredited Chest Pain Center, 2) Provisionally Accredited Chest Pain Center, 3) Accredited Chest Pain Center with PCI, or 4) No Accreditation.
A letter from the Accreditation Review Committee with their findings and a detailed report will be sent via overnight courier to the Key Contact after the Accreditation Review Committee makes its recommendations.
The Process after the Accreditation Review Committee Issues an Accreditation Status Determination
Q. What happens after a facility receives Full Accreditation Status?
A. If the facility receives the designation of Full Accreditation status, a report will be overnighted to the key contact and the facility will be listed on the Society's website's list of accredited facilities. A framed certificate will be sent to the facility. We will work with your marketing personnel to assist with a press release. The facility may request the seal of accreditation to use in its communications.
Q. What happens if a facility receives Provisional Accreditation?
A. Provisionally Accredited Chest Pain Center is the designation given to a healthcare facility that has met all Tier I standards, has completed a site visit, but some Tier II and Tier III Items remain incomplete (that is, “No”). The Tier II and III Items that are insufficient will be detailed in the report from the Accreditation Review Committee. A provisional facility may not call itself an "Accredited Chest Pain Center" or use the seal of accreditation. A provisionally accredited facility may call itself only a "Provisionally Accredited Chest Pain Center".
The facility makes a written commitment to implement the recommended changes within a 12 month timeframe. It is the responsibility of the facility to fulfill the requirements and schedule a return site visit, if necessary, within the time allotted. We strongly recommend that the facility submit the application for reevaluation at least 6 months prior to the expiration of their provisional accreditation.
There will be additional fees assessed for evaluating a provisional facility for full accreditation. Fees will vary depending on whether a return site visit is warranted. Should provisional accreditation expire prior to the facility being found deserving of full accreditation, the facility will need to start over, resubmit an original application for accreditation review and pay the full associated fees to obtain accreditation.
Q. What happens if a facility is not granted Accreditation?
A. If the facility wishes to become accredited, it will need to reapply for an Accreditation Review and start the process over including paying the Review fee again.
Q. How long is the life cycle of Accreditation?
A. Each Cycle of Full Accreditation status has a three year life span from the date that the Accreditation Review Committee issues its findings. Provisional Accreditation has a twelve month life span or until the facility receives Full Accreditation status.
Q. How does a facility maintain Accreditation status after 3 years?
A. To maintain ongoing Accreditation status, a facility will need to apply for the next cycle's Accreditation review well in advance of their current expiration date. The Society recommends that the application be submitted a minimum of six (6) months prior to the current Accreditation expiration date to assure there will be no gaps in Accreditation status.
Q. What are the Accreditation Review Cycle dates?
A. Each Cycle has a three year time span that begins on January 1st and ends on December 31st.
Cycle I 2003-2005
Cycle I I 2006-2008
Cycle III 2009-2011
Cycle IV 2012-2014
Cycle V 2015-2017
Q. Will the Review criteria be the same in each cycle whether a facility applies or reapplies for Accreditation?
A. No. The Review Items in the Accreditation Tool will remain constant only during the current Cycle. Each Accreditation Cycle has a three year life span. When you apply for Accreditation or reaccreditation, you will be reviewed under the next Cycle's Review criteria, with different Items within a different Tool. The Society will "raise the bar" with each subsequent Cycle. The standards that a facility must meet or exceed to receive Accreditation will be more rigorous.
ACCREDITATION TOOL and ACCREDITATION REVIEW ITEMS
Q. Does the Society of Chest Pain Centers require preferred protocols?
A. No, the Society is an accrediting organization. There are known guidelines organizations, such as the American Heart Association/American College of Cardiology and the European Society of Cardiology, that create guidelines for many ACS care processes.
Q. We are looking for help. How can we find the best solutions (protocols and procedures, etc.) for our needs?
A. A facility's approach to providing care for ACS will be based on its unique characteristics and needs. However, you do not need to reinvent the wheel. The staff at the Society will refer you to appropriate resources, such as expert opinion and contacts at previously accredited facilities that are willing to share their findings and solutions with you. These referrals have proven to be valuable to other facilities seeking assistance with their application and related protocols.
Q. How should the support documentation be organized?
A. Facility collects documentation for every “Yes” Item in the accreditation Tool. Documentation is organized in the same order as the Tool in a three ring binder utilizing the provided tabbed separator sheets. Documentation is labeled with the provided Item number self adhesive labels in the upper right hand corner of each document. Each page of documentation is numbered in the lower right hand corner. This numbering enables the reviewers and the facility to easily communicate about specific documentation. NOTE: Do not use plastic page protectors.
Q. How detailed should the documentation be?
A. The bare minimum documentation that supports the Item is all that is needed. For example, if you wish to document that meetings are occurring, you do not need to include all of the meeting minutes. In many cases, just the policy is all that is necessary.
Q. How long must an Item be present before it can be considered?
A. The Society's Accreditation is forward looking therefore, the goal of Accreditation is to assist the facility in creating the processes that will help it continue to improve care for ACS. In almost all cases during Cycle II, the Item must be able to demonstrate a history. It must be demonstrated that the Item currently exists or you have a plan or process in place to meet the Tier Item before the site visit.
Key Element 1- Emergency Integration with the Emergency Medical System - Cycle II
Q. Item 1.1.1.0 - What kind of written plan is the Society looking for here?
A. If you approach the written plan in the form of a charter or letter of understanding, you can include many of the Tier III and Tier IV Items under 1.1.0.0, 1.2.0.0 and 1.3.0.0
Q. Item 1.3.0.0 - What type of metrics are other facilities measuring?
A. Some examples include: First point of EMS patient contact to ECG or time of first patient contact to reperfusion. Each facility needs to determine what metrics will add value to their processes and improve patient care. This may largely depend on what type of EMS service is in your area. If you are a rural or urban facility with traffic issues that prolong time in the field, what you decide to measure to improve performance may be different than a suburban facility. Make sure you are using metric to support improving processes and care of the patient for your facility.
Key Element 2 - Emergency Assessment of Patients with Symptoms of ACS - Timely Diagnosis and Treatment of ACS - Cycle II Element 2
Q. Item 2.1.0.0 - How do we incorporate symptom based ACS into our triage protocol?
A. The type of triage system you use, be it 3, 4 or 5 system, is up to your facility. We are looking for the integration of ACS-specific symptoms in the protocols. Remember women tend to present differently than men. The older patient or diabetic may complain of weakness and slight shortness of breath. The Society is looking to see that age and gender, as well as specific ACS criteria, is addressed.
Q. Item 2.1.5.0 - All of our nurses completed triage training in orientation; does this meet this TIER Item?
A. We are looking for something beyond the initial orientation in triage. We want to see a written criterion that validates what a nurse must achieve to be able to successfully work in triage. In addition, if the nurse doesn't meet the requirements, what type of remedial training do they need to complete?
Q. Item 2.2.7.0 - Where does the emergency physician need to document his or her interpretation?
A. We are looking for an accountability statement that the physician writes the ECG interpretation NOT what the wave form looks like and the time they received the ECG to assure it is in the doctor's hand within 10 minutes. The emphasis here is on the policy or process to require a written interpretation by the physician. You may include this in your flow diagram and it will meet this Item. It is up to the facility where this documentation occurs. Many facilities have the doctor write on the top of the ECG, some choose to have it in the case report.
Q. Item 2.3.1.0 - What do you mean by actual time of arrival of the patient?
A. The time of arrival is when the patient enters the doors. Many facilities have a nurse located at the entrance to do their triage assessment but they document the time of arrival as the time when the patient is registered. This is where process and flow charting become important. Map out what really occurs when a patient arrives in your facility and observe the time that is recorded. Most facilities have a variance in actual time of arrival. This could be up to each employee's interpretation which will create a variance in your process. This is where common clock and clock synchronization becomes important especially if you are looking at your metrics for variances and want to improve your performance.
Q. Item 2.4.4.0 -How do you want this documented?
A. This is another accountability statement that we are looking for. It can be documented as part of your flow diagram if you choose. The specific reason for not attempting reperfusion must be documented; for example, the patient refused.
Q. Item 2.7.0.0 - My facility just opened a cath lab. Can we apply for Accreditation with PCI?
A. Only if you meet the requirement of an on-site 24/7 primary PCI facility and meet the American College of Cardiology guidelines defining the minimum number of primary PCI procedures for STEMI per year.
Q. Item 2.9.0.0 - What type of metrics are you looking for here?
A. The type of metrics you choose to track monthly are entirely up to your facility. We would highly recommend you look at the ACC/AHA guidelines to help you make this decision. Most facilities track door to reperfusion time. Just as important as tracking metrics, is what you do with the metrics afterwards. How did you change processes/ policy/protocols based on the metrics? Did you identify staff educational needs, were your variations due to equipment problems? Or did your variances occur at a particular time of day or shift? You need to drill down on the data in order to understand why your variances are occurring.
Q. Item 2.12.2.0 - What are time-specific and action-specific instructions?
A. The requirement for discharge instructions must include time-specific and action-specific directions. The patient should be instructed on what action to take, when to take it, and what to do if certain conditions apply. For example, "contact your doctor immediately if you experience chest pains". The patient should know what medications to continue, discontinue or commence, and if the dosages have changed, etc. Please include examples of discharge forms from the ED or inpatient.
Key Element 3 - Assessment of the Patient with Low Risk for ACS and No Assignable Cause for their Symptoms - Cycle II
Q. Item 3.4.0.0 - What approach to cardiac biomarkers should we use?
A. Again, this is a decision your facility needs to make based on best practice. The Society wants to see what your protocol or policy is for approaching serial cardiac markers. This could be included in an order set.
Q. Item 3.8.0.0 - How do we demonstrate appropriate stress test selection?
A. Many facilities submit a copy of their standing orders with facility specific guidelines. Your facility may also have a policy that could demonstrate the facility meets this requirement.
Q. Item 3.11.0.0 - What "discharge instructions" are required?
A. The pathway needs to include a requirement for discharge instructions that are time- specific and action-specific. The patient should be instructed on what action to take, when to take it, and what to do if certain conditions apply. To meet the innovation Items 3.11.2.1.and 3.11.2.2, you must have specific instructions based on that individual patient's needs. For example: if the patient is a smoker the facility would include information about smoking cessation and the telephone number for a follow up smoking cessation class.
Q. Items 4.0.0.0-4.5.2.3 - What are you looking for in this section?
A. We want to see a flow chart developed for five processes:
1. 911 to EMS to ED arrival
2. Walk-in possible ACS patient
3. STEMI
4. NSTEMI
5. Non-cardiogenic cause for pain
We would like to see your actual process flow charted and your ideal process flow charted. When we do the macro process drill during the site visit we will compare what we see with your submitted actual and ideal flow chart and make suggestions how you can get to your ideal process.
Q. How detailed does the Society want to see the flow charts? This is a new concept for our facility.
A. We suggest you start by mapping out your process. You may want to consider engaging someone to help with mapping that doesn't know ED, like an OB nurse. This eliminates any preconceived ideas and allows an outside neutral person to see the "true picture". From there develop your flow charts. Mapping involves following actual patients through the care process. Mapping the entire ACS care process involves following a patient through each unique process (STEMI, UA/NSTEMI, low risk, various shifts, weekends, etc.).
The Society would like you to provide a flowchart of your actual process and of your ideal process. During our site visit we will ask the facility to demonstrate three of the five macro processes you submitted flow charts for. We will compare the flow chart you have submitted to what we see and give you suggestions to get your ideal process based on best practice and what we have seen work in other facilities. Remember every facility is unique. What works at one may not work at another. Make your flow diagram factual and detailed enough so it can be used for future education of your staff and to utilize for process improvement activities. Q. Item 4.4.0.0 - What documentation is required for Care Process beyond the ED?
A. You may submit admission/discharge criteria or scope of care policy in the CCU, ICU, and telemetry. Order sets may also fulfill this Item. Please do not provide Interqual criteria. This does not meet the requirement. Key Element 5 - Personnel, Competencies, and Training - Cycle II Q. Item 5.3.0.0 Physicians - All other physicians caring for patients with possible ACS or with the diagnosis of ACS are board certified or can demonstrate ten (10) hours of CMS in the past three (3) years related to the path physiology, diagnosis or treatment - What physicians are included in this requirement? A. This includes any physician caring for ACS patients. Including Internal Medicine, Family Practice, Hospitalist, etc. Many facilities admit all ACS patients to Cardiology. Realizing each facility is unique and has different resources; facilities that do not meet this requirement must submit documentation to verify their processes and how the facility assures the best practice and the care of the ACS patients meet ACC/AHA guidelines. Please keep in mind these are stand alone items and must be met to obtain accreditation. Q. Items 5.5.0.0 and 5.7.0.0 - What are acceptable position descriptions? A. The position descriptions as they relate to the entire facility include specific responsibilities and accountabilities of these individuals. Medical Director of Service Line and Unit Manager are not acceptable. Q. Item 5.9.0.0 - Annual Nursing Competencies - All nurses caring for patients with symptoms or diagnosis of ACS. Question- What is the Society looking for here? A. All nurses that care for the ACS patient regardless of where the care is provided e.g.: cath lab, telemetry unit, Chest Pain Unit, Emergency Department, must do one common competency annually throughout the organization. The competencies are listed in Tier Items 5.9.1.0-5.9.8.3 Q. Item 5.11.1.0 - What do you mean a letter is to be submitted? A. If only nurses do ECGs in your facility, the Society would like a letter stating this. If ancillary personnel perform ECGs, they need to meet one of the Tier Items 5.11.1.0 or 5.11.2.0. Q. Item 5.12.0.0 - What is meant by "all personnel" in this Tier Item? A. Your entire facility's work force. The Society feels very strongly that each facility needs to start by educating their personnel first. The hospital staff becomes the community after hours. We suggest you incorporate some type of ACS education into your hospital orientation program. Many resources are available on the Early Heart Attack Care web site (www.EHAC.org) and can be downloaded for free. Key Element 6 - Organizational Structure and Commitment - Cycle II Q. Item 6.1.1.0.and 6.2.1.0 - What form should the administration resolution and medical staff resolution take? A. It should indicate that the administration medical staff of the facility support the Accreditation and are committed to improving the processes and care of the ACS patient on a continual basis. Q. Item 6.3.0.0 - Can our Chest Pain Center Committee be a subgroup of another committee? A. The structure of this committee is up to your facility. We highly recommend a separate and distinct committee so goals are very clear. We like to see a membership roster that includes all functional areas such as; pharmacy, lab, radiology, marketing, etc. Key Element 7- Functional Facility Design - Cycle II Q. Item 7.1.0.0 - Campus signage and traffic patterns. Why does the Society think this is so important? A. The first step in saving heart muscle is getting to the Emergency Department; time is muscle. Most people don't go to an ED unless they are in distress, which produces anxiety. Trying to find the ED entrance increases that anxiety. Also, many of the patients the ED serves are elderly. Their senses, visual etc. are usually diminished. Q. Item 7.4.1.0 - Clocks are synchronized within the main ED, triage area, 12-lead ECG machines and Cath lab. This has been very difficult for our facility. Any ideas to make sure this happen? Why does the Society put so much emphasis on this?
A. We have seen a number of creative solutions. Including:
You can only be assured your data and/or metrics are real and accurate if the processes involved are based on the same time. The surveyors have been in facilities where the clocks are off by as much as 30 minutes.
Key Element 8 - Community Outreach - Cycle II
Q. Item 8.0.0.0 - What type of documentation are you looking for regarding community education?
A. Any of the following:
