Hi, welcome everybody. Good afternoon. Hope everybody enjoyed lunch. Are y'all fueled up ready to go and learn more about the NCDR, the registries and accreditation? Great. So this afternoon's session is titled a breezy conversation with accreditation experts and on the stage here I have four of my fellow reviewers and one of our hospitals, accredited hospitals with a longevity since cycle two back when we had the big binders way back when. So let me just introduce my team here. To my right I have Jamie Hayman. Jamie is from Chesapeake Regional Medical Center in Chesapeake, Virginia. Jamie was actually the very first hospital when I started 10 years ago as an accreditation review specialist and she was doing a version for cycle four back then and what's great about Jamie's hospital is they have had the exact same team since cycle two when it comes to accreditation. So no change in leadership, no change in directorship and they've really have grown the program so well and I'm glad to have Jamie here on the stage with me. Now I'm going to introduce our accreditation review team. To Jamie's right I have Kevin Worley. Kevin actually has is the the longest longevity of the accreditation review team, 15 plus years and he specializes in the procedural areas so cath lab, EP and transcatheter valve. He also does do chest pain center accreditations. Next to him is Lisa Nichols and she is actually focuses on the heart failure accreditations as well as the chest pain center accreditations. Followed by that is Bridget Gilley. She's actually one of my team my co-team leader of the accreditation team and she also does the heart care center distinction of excellence designation as well as chest pain center accreditation. And last on the panel is Leila Beers and she focuses strictly on the procedural areas so cardiac cath lab, EP and transcatheter valve. My name is Carolyn Heron and I'm one of your moderators today. As I mentioned I'm an accreditation review specialist and also one of the team leaders. And then I also have in the front row Michelle Wood here and she is our director of field operations for the field team staff. So she will be manning all of your questions that you are entering into the app. So this session is really going to be talking about accreditation. I know early this morning it was registry generated so this is accreditation. This is our first time presenting at a quality summit so what we chose to do is pull all of the very common questions that we get from accreditation customers and hopefully we'll be able to clear the air, address all those, clarify those concerns and questions. So how many in the room are current accreditation customers? About 50 percent. The other 50 percent I really hope after today's session you're going to take this back to your leadership team and consider taking your facility to the next level by meshing your registry with an accreditation to improve those patient outcomes even more. How many of our accredited customers use a registry as their only data source for their accreditation? Okay so that means the rest of you might use a combination of the registry as well as the ACD tool and then the others use strictly the ACD and we'll get into that later on down the road here. If you happen to have a question please enter that and here are the instructions. Go ahead to your app, click on the happening now or the full schedule tile and then at the bottom of the presentation there's a Q&A button and hopefully we'll have about 10-15 minutes at the end of our conversation to you know address some of those other questions that have been developed. So today's session we will start about accreditation in general. We're going to start about you talk about some of the roles and responsibilities of the team. We're going to highlight the data component process improvement initiatives and then the next steps after you achieve your accreditation what to expect moving forward. So let's get going. We'll just start off and I'd like to know from the panel here what really is accreditation? Maybe why would a facility want to pursue accreditation and what are some of the benefits? I will take that one from you. So accreditation really it demonstrates a higher quality of care to a community by a hospital. It also brings an accountability and a visibility to a program and to its teams as well as a quality mindset when addressing patient care. It also gives you a structure and a consistency to help you improve your efficiencies and reducing your waste. Interesting. And I will even go into it a little bit further. If you're interested those that are not current accredited facilities you can email accreditationinfo at acc.org and a member of our team will contact you. Or if you are one of our accredited facilities and interested in another service line you can also email that same address and speak with one of the team members about the process. But while you're here at Quality Summit go by the booth it's over there with the vendors talk to one of the team members you can find out more information about all the accreditations we offer and all the certifications we offer. So I'm going to take it one step further. You're told to get this done. You're told to define the process. Well first I'm going to ask you to define what your value is. The value of accreditation. Is it a return on investment? Is it more a weakness definition? Look at that metric point to say where do we want to improve. Once that's done create your team. Select your champions that includes medical director, staff, coordinator as it may be and more importantly it's the senior administration that you can go to for help and assistance. Once step A is done and you work with step B look at C which is to define your strategic plan. Look at this to say this is our expected process and how long it should take and further supporting the value of accreditation. So how you know with accreditation you know are how long does it take if my facility decided to start today how long will it take till I can get that certification in hand? Oh your mic isn't working. There it goes. Yeah. No no. You got a mic? Sorry about the technical difficulties. One of the things we always joke about is one of the biggest challenges you'll have with accreditation is IT. So just building your reports and doing other things such as that that's one of the biggest challenges and hurdles that you might have to face. So once the facility is assigned that facility has one year to complete that application. You'll be assigned to an accreditation review specialist. Now we will conduct monthly meetings. We'll go through your guidance statements. We'll go through the essential components and we will review right out of the gate. We'll be looking at your NCDR, cath PCI data or whichever one would apply and and talk really about the your goals your process of how long it's going to take to complete your application. Now however if the facility should experience any type of unforeseen event that should happen within their team maybe within their facility then as we near your due date we'll start discussing do you need an extension and but again we'll we'll talk about that as we near the due date. But it takes about one year and and many of the sites do complete early so but you do have that year. And I would like to add one thing to that for Leila. So there's a quicker option that I wasn't aware we just went through our version 7 reaccreditation and it was like birthday present. With being an NCDR chest pain MI center that we participate in that and we are sold on a platinum award so any award level so gold to silver or a platinum level it does come an abbreviated version so it decreases your number of essential components that are required. It took it from 140 down to 69 which was a great present and it made it a lot easier for the reaccreditation but it's also for new sites accrediting that same applies. Okay that sounds a wonderful program. Now I heard that all of our accreditations are going to be transitioning to a continuous model. Can anybody speak to that process and how it might speed up the accreditation itself? I'll take a little bit of that especially with the procedural tools. During I'm gonna back up just a little bit bear with me. During your site visit we'll actually have a discussion of the program maintenance ongoing expectations and as long as you maintain that and then go for a reaccreditation there's an attestation there's a button you click everything's automated now we all know that but it's been just a matter of we'll be able to pull some of the documentation from one version to the next. It's tough to say how much time that's going to alleviate on your end of it but I will tell you this right now it saves a lot. It really does so that's the ongoing expectation especially for procedural tools. So the procedural tools we mentioned electrophysiology cardiac cath lab transcatheter valve. Jamie you mentioned the chest pain MI award recipient expedited process for our chest pain center accreditations. We really haven't talked much about the heart failure accreditation and I would like to learn I'm a little curious is does the heart failure accreditation really make a difference with this challenging population. We all know the heart failure patients a very challenging population to manage. So Lisa I bet you can answer this since this is your specialty. Tell me about that. Absolutely so I always joke and tease wouldn't it be nice if your heart failure patients presented with a sign around their neck right. I'm your next heart failure patient. It's not that easy but accreditation for the heart failure patient we do kind of help make it easy. One of the things that we like to do is help take those heart failure guidelines and assist you in optimizing your care and your treatment plan for those patients. We know that with the heart failure patient it's really important that early recognition that it's your heart failure patient early stabilization as well as following the trajectory of their care and reevaluating and what needs to be done next for them. The really important thing with this heart failure patient of course first and foremost is to alleviate those symptoms when they first arrive and then their eventual outcomes. And so a big piece of that is you're going to be looking at your length of stay for those patients, your readmission rates, the mortality, and the main thing is is that you're following your transitions of care for those patients. So what does that look like? Are you able to refer them for appropriate advanced referrals, therapies, and treatments? Is that a patient that might need palliative care or hospice care? And the main thing is just kind of following your goals making sure that you've optimized your treatment plans and your cares for those patients. And heart failure accreditation kind of helps make that a little easier. So the heart failure patients I know sometimes there's not a large volume of them but this can be true for your transcatheter valve patient. Yes. So Leila, if a facility has a lower volume of transcatheter valve patients can they still achieve accreditation or certification? Great question. Yes absolutely they can. So let's define a low-volume facility. That would be 50 or less TAVRs in one year or 30 or less SAVRs, your surgical open aortic valves, in one year. I've you know there I've had many discussions post certification for transcatheter valve that going through that program, that process, it really brings a lot of structure and accountability to that team and and really it is a form of external peer review process for transcatheter valve. So yes low-volume absolutely. Very nice. So has anybody here worked with a smaller hospital that's seeking chest pain accreditation? Me. Yeah that's so amazing. I think we get caught so caught up thinking that chest pain accreditation is for your large PCI facilities and I'm happy to say one size does not fit all. I've recently worked with a critical access hospital who decided to do the chest pain accreditation and they were absolutely amazing. They knocked it out of the park. Thing is working hand-in-hand with your accreditation review specialist. Again looking at those guidelines, optimizing the care for those patients, identifying those that need the optimized care. How do you do that? How do you make that work especially for a smaller facility? You may not have all the resources that a larger facility has. So what do you do in that instance? Are you able to work with one of your PCI facilities that you refer your patients to? Can you send your patients to that cardiology group? Do you have a sister facility that you can transfer your patients to? Also I think it's important to keep in mind that you're doing your serial strategy testing, your risk stratification. Those patients, are you able to refer them to another facility or another place for stress testing? And first and foremost as that small facility, paramount importance is that early recognition of that STEMI patient. And do you have that process in place to get them transferred out in 30 minutes or less? So one size does not fit all. We work with your team. We help you tailor the needs to your facility. It's just not cookie cutter. We work with you to make sure that it makes sense for the size of your facility. Thank you for that Lisa. So you know one of you mentioned earlier about building a team to prepare for the starting point of accreditation. So do we have any coordinators out in the audience today? Okay so you know this is something that I like to ask. How many of you coordinators actually that's your only job at your hospital? One. All right. Thank the lucky stars for you all that said yes because unfortunately the coordinator typically gets to wear multiple hats to support the needs of their organization. So you know I think that's the biggest thing and for those of you who do not know intimately what a coordinator does, I'd like Jamie to share what she does on a day-to-day basis being a coordinator herself. This is a fun question because I think all of us can agree you can't really put it into a little little word of what a coordinator does. It all depends on maturity of the program first off. If it's a new program and maintaining accreditation or going for re-accreditation, it also depends on the facility size, the resources to the coordinator, as well as the leadership support. But for me my main drive is facilitating and overseeing the program while using a multidisciplinary team. So and I'm a list person so for me first and foremost is always establishing that relationship with my review specialist. Making sure I have regular meetings with them when we're going through the accreditation process and also reaching out and keeping that communication fluid to where anytime I have questions or concerns I reach right out to them and get the answers right away. The other thing is also understanding your current workflows and your current processes and the supporting documentation for those and being able to pull those together quickly. You will have to submit that documentation as well into the tool. Also having data. Data drives everything. So facilitating data, overseeing it, reviewing it, analyzing it, and also giving that back out to the teams to kind of go over with everything. And then that kind of drives your PI projects as well. You're overseeing the PI projects. Also education. Education to your team within the hospital. EMS. Also overseeing community outreach. That becomes a big part of my job. And the final piece was in the beginning and it stayed that way and I think this is why our program is so successful is we started with our multidisciplinary team establishing our chest pain committee and we meet monthly. It's you know the tool does so you can do it quarterly. We chose to do it monthly only because it brings us all to the table and we know that we're going to be there in the next month. We have same thing to where it gives us consistency within our program ensuring the multidisciplinary team is at the table every month. So the list you gave was quite lengthy. So you know I'm assuming that you have to have some dedicated time to that role. Very much. All right. So on that note if you do have a coordinator are they able to cover more than one hospital at a time. I know some of us have to work remotely and we might be spending some time at a sister hospital and then the main campus something of that nature. I'd love to take this one Carolyn for one sole reason I see a coordinator of mine that has filled this role very well but I'm going to throw out a comment to you and see if you agree or disagree. Do more with less. That sounded by right especially in days and today's age. Yes you can definitely cover more than one hospital. I will say as long as there's active engagement from that defined coordinator for all of those hospitals and what I mean by that is this. Do you go and stop and see them. Will you have conference calls with them. Will you communicate them on a regular basis as to their needs is it EMS relationship etc. that that specific hospital is working with. Definitely engage yourself throw yourself out there to them and we will work with you on that. Now can it be done virtually. Absolutely. As David this morning mentioned with the NCD our team a lot of their roles have pivoted to the at home or virtual process. We've done the same thing. We've solidified that. OK. So we understand what you guys are going through knowing that you are doing more with less. OK. So thank you. Thank you. And Carolyn I'd like to piggyback on Kevin's talk. Not only can you cover multiple areas you can also do multiple service lines at the same time. And I think this is a wonderful opportunity. So just for instance a combo of chest pain and cath lab you could do both service line accreditations at the same time. The thing that you've got to make sure is that you have the needed committee members for both accreditations. You also want to make sure that you've got the required resources for both accreditations. But again you can work together. You can complete flow charts together you can do education together and you can have your committee meetings together. So again accomplishing both accreditations at the same time using the resources that you have. The other thing I would like to mention is how many are in a system multiple hospitals. All right. That's great. We do system accreditations we call them cohorts and you can actually come together and go through accreditation as a system. I love this aspect because again you can work together have monthly system calls with your assigned accreditation review specialists work as a team to develop these flow charts these process system order sets really make it a team approach and achieve your accreditation. So what if a coordinator changes. How many of you are in the same role you were three years ago. Very very few times. We deal with this all the time. We deal with it all the time. Things happen. Everybody gets promoted hopefully gets promoted or you do other career changes etc. So how do we work through that. A couple of things. Work with your review specialist to know what has to be done and that's as follows. Make sure there is a signed job description and your resume correlates the role of the process of that said coordinator. OK. That's very important. In addition to that on the left hand side of the tool you'll see the contact bar. Make sure that is updated to the current and expected information. OK. Please following up with all that information. It's key to work with your review specialist as I've stated several times before to know the tool to work through the tool and the process because we have changed quite a bit over the last three to six years. We really have. So and to piggyback on that to Kevin which I think is one of these most important. Have any of you ever missed emails like I didn't get that email. So if your coordinator changes also make sure to click on that contact us button that's down at the bottom of the tool and send an email and let them know that the coordinators change so that again we can change you in the system and make sure you get those important emails. So the coordinator is such a crucial role as we all really highlighted here today and ACC has worked diligently to provide those coordinators or any new person on your committee with tools to not only not reinvent the wheel but also to teach and educate about certain topic areas. So I know that there's workshops for each of the school boards workshops for each of the service lines. Lila can you talk about the workshops now. So don't it is the chair once you lean over and talk. Bridget we're all nurses. You know how to adapt. So one thing that the team wants to do is with your workshops is in within the tool there is on your left hand side under additional resources. There is a switch out testing. There we go. OK testing me today. So workshop videos very important along with and David Bonner brought this up this morning during the NCDR summit or discussion. The Q I learning center is an amazing resource within the tool you get CE credits CME is whatever the case may be. But your workshop videos are very important even though your court your accreditation review specialist will schedule a kickoff meeting with the team. There's a lot of information that is covered during that time and some of it you know sometimes goes right over your head and I completely understand. So those workshop videos are there to watch. I highly recommend that perhaps you know the coordinator and whoever is going to be working in the tool to a brown bag lunch come together watch these videos. They're not very long and they're very very resourceful for this team. So yes absolutely. Tons of education. The Q I learning center is amazing. Laila I'd like to point out I have been doing this a long time and I kind of think I'm an expert sometimes and to cycle or two versions ago I actually sat down and watched some of those videos. She was the last time you're my reviewer and actually learn a few things so it was quite when even though you think you know what you're doing they did became very helpful and it's nice because it is in a controlled setting you can listen and learn something. And as a new coordinator or someone that's working on a new essential component you know is there help with documentation. Yes actually I'll take that. So when you are preparing to upload your documents because the tool you're obviously going to upload your your evidence here your documents into the tool name your document exactly what it is. For example if you're uploading your medical director's job description name it just that don't name it to the corresponding essential component because as new guidelines come out as the tool is updated they're not always going to line up. So again name your document to what best describes that document. So as available resources are expanded the ACC has done a wonderful job in kicking up their game as well. We have developed an ACC approved app called our cardio smart heart Explorer app. Correct. And it's basically a user friendly type of application that allows you to truthfully dive deep. There's education in there. There's information about how to develop the community education and e-hack program. There's information on how to support CPR and hands only events. There's also information about something called the shared decision model approach and education of which I'd like to note that if you look in all of your tools we are actively pushing that out to every one of our tools. That is important to know for all practitioners and staff. We all do it. We all talk about it and truthfully I love it how it is involved in the process. OK. To summarize briefly that cardio smart heart Explorer app is built for you. I actively encourage you guys to use it. Kevin actually if I can tag on several of my transcatheter valve sites right now use cardio smart for the shared decision making. It's an excellent module education for the physicians which is mandatory if you go through trans catheter valve certification. Excellent resource. So has everybody learned a lot so far. We're halfway done because we forgot about the other half. And one of the reasons why we're all celebrating this quality summit and that's the data you know we have to collect the data to measure how we're doing. So we mentioned earlier A.C.D. and the N.C.D.R. registries. So what are all these different data platforms for accreditation. I can answer that for my facility. So for chest pain we use the N.C.D.R. and the A.C.D. and those who don't know what A.C.D. I think we kind of touched on a little bit but it's the action performance database within the tool. Both of them give us plenty of metrics to measure not only our patient outcomes but also our facility outcomes. Thank you. You know in looking at the second question there what data metrics are important. So who are all out here abstract data. Don't you think all the metrics that you have to track are important. Absolutely. All right. Are you wouldn't want to abstract them. All right. So all of your metrics at your hospital are very very important. It tells your story. It tells you if you're doing good or if you need to work on something. And so what we like to say with the N.C.D.R. is look at any metric below that 50th percentile and if it's below then you need to be developing a P.I. or an action plan. Now with the A.C.D. you don't have those you know metrics or those comparisons to look at. So what we say is to look at your benchmarks. What are your internal benchmarks that you're monitoring and what are external benchmarks that you're monitoring. And again if you're not meeting those develop P.I. or action plans. But I will tell you that the most important thing is not just to abstract the data but you've got to get it in front of your team and not just those on your committee. You've got to get it to the frontline staff. So review it quarterly with your team. Review it with your staff. Let them know if they're meeting those those metrics and if not what can you do to improve it. So do you really need like a data dedicated data abstractor for your organization. So I'm going to speak from experience so previously when I worked at my previous position as a coordinator for chest pain and heart failure I actually stepped in the role as the abstractor as well. So who here only does abstraction. That's all you do. OK. A few. OK. All right. So the answer to that question is no you don't have to have a dedicated person but you do need to have a person that is named as such as the abstractor. Really the important thing is is that you have dedicated time set aside for whoever is doing that. And I would say weekly. I think David even said what fast and often like as far as the day like something like that. Yeah. In his sleep. But absolutely. Make sure that you have dedicated time to do that. So no you don't have to have a dedicated person but you do need a person named to that role. So with the ACD and the NCDR I know you highlighted that you aren't a might not be able to compare outcomes with the ACD with other facilities. Kevin talk to me a little bit about the calf PCI registry that you may be using for your calf lab accreditation not a problem. We get this question all the time. How does my hospital compare to other sites going through this process or other sites that are similar to my size. The rolling four quarter information allows you to do that. It looks at that information and we're going to cover the importance of the 50th percentile here in a little bit but we will actively compare it. You can also then drill down on each individual quarter four quarters as it may be for whatever quarter you're looking for. I look personally at the trend. Are you trending up or are you trending down or what's the issue. That's the biggest thing. When you look at the ACD however we do not have that ability to compare your hospital metrics to other other hospitals going through the process. Not as of yet because it's not built functionality wise. And Carolyn I'll ping in on that as well. You know one of the big things that we get asked because maybe you switch from chest pain in my back to the ACD or from the ACD to chest pain in my during the accreditation or during your maintenance time. Unfortunately the data doesn't transfer. So if you have data in the ACD it will not transfer over to the chest pain in my and vice versa chest pain in my will not transfer over into the ACD. And I know the ACD has something special called a dot CSV file. So what could possibly go wrong if a facility is using that. Absolutely nothing. Where's my CSV file uploaders. Where are you. Really. That's it. OK. You've never gotten the red screen of death where it scrolls up and says OK. It happens. OK. Previously I lied. I said it never happens. It used to happen to me too. The really amazing thing is it's simple fixes. I know it's frustrating when you see that. It seems like the end of the world but it can be something as simple as the way that your column headers are labeled. It could be something as simple as a decimal point in the wrong place with your ICD 10 codes. It could be date and time issues that might not be entered in just correctly. So they're all simple fixes. I will say that the ACD resources section does have and I'm very visual. So I truly appreciate this that it's step by step directions on how to develop that CSV file how to upload it with pictures. And there's also a template that you can use. So please if you've not used the template please go in and use the template. It's a game changer. After that if you're still having issues because we all know right it happens. Reach out to our team because we are here to help you guys. We will troubleshoot with you. And before the end of the day we'll help you come up with a solution on how to fix that. OK. So not a big deal. So you guys may be thinking how much data is needed for accreditation that crossed your mind. It's crossed a lot of minds because they ask me all the time how much data do I need. Two quarters or six months. We need to see that to kind of carry on the process of a recommendation. Now the question is can we use published or non-published. Yes to both. We can definitely use the published because that's again that's a comparison of your hospital and to other hospitals your size. We can also look at the non-published. However it is important to know one thing. You do not compare yourselves with this data because it isn't published so therefore it will not be comparable. However it will give you a gosh darn good idea of where you stand when those things are published. OK. So all the time I will use non-published data as well as my colleagues. And then when you get your data back I'm assuming you want to grow and improve your program. So that's where the word process improvement project comes into place. So who wants to speak about that process improvement and I would love to feel that one. So who in here has ever sat there and scratched your head and wondered what is my next project. Like I see one of my coordinators over here she just raised her hand right. I always say listen bad data in equals what a bad plan right. Like bad data bad plan. So that's the number one thing is make sure that you have accurate current data. OK. That's the number one. That's that's the foundation block for your project. Once you've done that you're going to review it. What are you looking at. What are the things that are important to you. Typically you're going to look at patient safety. You're going to look at ways to safety ways to reduce patients morbidity mortality. Those are of utmost importance. Then you're also going to make sure that you're able to take that information and you're going to look at safety again your patient outcomes. How are those tied to return on investment for your facility. Is there is there a way that you can turn that patient safety and save your facility money in the long run as well with that. Once you've achieved your goals, you're going to look at your trajectory. Like, what does your trend line look like? Are you heading in the right direction? Are you where you want to be? I always say never retire a PI. Like, you can get there and reach your goal and get happy with it, but don't retire it. Who here has like killed a process, your data looks good, you've met your benchmarks, and you retire that, and a year later, you turn around and just kind of do a pulse check, and you're like, what happened? When did you all quit doing the process? Show of hands, has anybody ever been surprised or disappointed by that, right? So, put it on the back burner, but PI, your PI is a constant, fluid, moving process. So you're always going to continue to reevaluate your data and look and see what's next, what can I do next? If you're stumped, if you don't know, reach out to your accreditation review specialist. We will go through your data with you and help you pick out your next PI project. Actually, Lisa, that's what we do with procedures, and I'm sure with chest pain. Basically, after your kickoff call, the first month, the second month, I like to go through their cath PCI, for example, data. And we look at each and every metric. We look at composite meds, AKI, radiation, cardiac rehab, and we see, are you in the 90th, 75th, or 50th, or 25th? So, on that second call, I like to review with my team, all right, let's start talking about your PI projects. You know, of course you're gonna target anything that's at the 50th percentile. And then we start working on your PI project right there. And we identify, where do you need to focus? Excellent point, thanks, Leila. Absolutely. So, your PI is kind of a revolving door. It never stops. Your accreditation really should be as well. It's a long time ago when I first started. We used to say, it's not a project, it's a program, which is very different. Projects have beginnings and ends, and programs do not have that end date. So, once you complete those mandatory items within the accreditation tool, and you've got your minimum of six months of data with the appropriate registry or the ACD, you know, there is a site visit. So, Kevin, can you tell us what a typical site visit would look like? Absolutely, and I use the word typical with quotes around it. I've been doing this job for 16 years. I have never done the same site visit twice, never. There's always different topics. There's always different agenda items. There's always different metrics to talk about. And I love it. About eight months ago, we were asked to totally redo the agenda for the site visit, both virtually and in person, and it has really restored my faith in the process because I've had a blast doing them, either virtually or in person. First of all, we'll set the mutually agreed upon date with your coordinators and your team. All right, we will work with you. We'll send you the agenda. We will go over the agenda with the caveat of saying it may and probably will change. That's a fact, okay? We'll start the day off usually with a quick presentation by the review staff. We'll cover five or six slides, discuss about what's gonna happen, the agenda, et cetera. We'll then hand it to you and say you present us with this PowerPoint information based upon what's written in the charter. That will lead us to a metric-driven discussion focusing on return on investment, length of stay, adverse outcomes, readmission criteria, et cetera. There's just a multitude of information that we talk about. We'll do that with your team. We'll do that with everybody present. Now, full transparency, I've been doing this new process now for several months, and again, I love it, but prior to doing this, the first people out of the room were who? Physicians, administration, they wanted to leave. Ever since doing this, I have not had an administrator or physician leave. They sit there, they talk to me, they're like, oh my gosh, Kevin, this is incredible. Our service line specialists have given us more tools to show you the return on investment and what's available for you guys. It's phenomenal to me, and you can just see the room entirely change from, well, tell me about how you activate the STEMI. No, give me your metrics, let's look at this information. Give me real-time data based upon the return on investment, all focused, again, on outcomes, how you guys are doing. From there, we'll transition over to the program maintenance. We've covered that several times here. Ongoing accreditation requirements, et cetera. That is the biggest challenge for hospitals out there. I don't care what size you are, I don't care where you're located, it doesn't matter. The ongoing expectations. We have built in the tool those requirements, time-dependent requirements that are there. It is important to maintain those because I have colleagues up here on the stage and in the audience who actually look at that on an ongoing basis. We'll cover that here in a little bit. But the biggest thing here is this, ongoing maintenance. During that issue, I'll throw out one general topic, or we all will, it is what next? Where do you want to go? What are the opportunities that you see it? And truthfully, I have not discussed reduction in door-to-balloon time in a while, I haven't. That's been pretty astounding to me due to the fact of my background being a cath lab junkie that I am, okay? After that, we'll do a little chart review or data discussion ongoing. That happens all the time, to be very honest with you. I do it virtually, I do it in person, I do it real time and I love it. We'll do a tour, at the end of the day we'll do a summation and we'll give a recommendation, okay? And let me tell you this, that we can all sit here and attest to this. We can be very flexible, fluid as to how the day goes. We may do the tour at the beginning or on the way out, et cetera. You will work with us and we will work with you, all right? I kind of want to tag on to what Kevin said here. It kind of touched me that accreditation is not a means to an end, it's not a race. You're not checking off boxes. I mean, I know it feels that way, right? When you're going through the tool, but it is about changing the culture of your facility and what is that culture? What do you want that to look like? And through this whole process, it's amazing what you can achieve for your facility. So there are accreditations and there are certifications. Leela, I understand the certifications are always a virtual site visit. Yes. And COVID did a lot of things, good and bad, for our whole country, the whole world in general. But for accreditation, it really let us flip the switch and be very competent with the virtual site review. So how does that look moving forward? So again, transcatheter valve and the freestanding ED, that is a certification and that is a virtual site visit. Now your accreditations are an onsite visit. They will rotate every other accreditation. But if the facility identifies a need or if the reviewer identifies a need that we need to come onsite, we will come onsite for that review. Or if the facility, again, requests that we come onsite, we will do that. But again, it would be an every other onsite review during your accreditation review phase. All right, so Jamie, did you guys have a virtual this last time? No, it was onsite. You had an onsite. So after your onsite visit, did you run up to the roof of your hospital and scream that we're done, we've got our accreditation? How did you market? Well, first we waited for the official words that we got the letter in the mail and then a welcome kit. And within that welcome kit had the marketing seal and also the marketing suggestions. And we always use those marketing suggestions because it kind of helps guide us and give us ideas of how to do it differently this time. Just fun little stuff too. We got a little plaque to put on my desk and a frameable certificate as well. For my hospital, this time we just updated our website with the new marketing seal, of course, in my email as well. And then we took out a billboard this time because we thought it'd be fun. We kind of put it down the street a little ways, but as people drove by, they knew that their community hospital was a chest pain accredited center again. Okay, sounds fun. I bet there's a ton of creative ways you can market and get that message out. Actually, Carolyn, I was at a site review probably about three months ago. And as I was walking up to the facility in the morning, there was a banner that was outside of their facility on the right hand side. I can see it exactly. And it had all of the different seals going down in a line, including that they were a magnet facility. And I thought how impressive for a patient or a family member to be walking into that facility and just see that line of seals. I mean, as a patient or as a family member, I would be impressed. I know that their hospital is committed to quality and that is very important to me. So it was an interesting way to market that, their seals. Absolutely, I mean, you're already raising the bar to provide this higher level of care to your community by going through the accreditation process. So why not let everybody know? And on that note, why should we maintain our accreditation? I will take that one on. So for all my coordinators out there, have any of y'all received that maintenance of accreditation email yet? I'm starting to see some. I know Jamie has. Actually sent it to her. All right, so you've worked so hard to obtain your accreditation. And I've said this before, don't put it up on the shelf and not do anything for the next three years. You need to maintain. Make sure that you're continuously updating your data, you're keeping it current. Don't stop your committee meetings. Keep those going. Make sure you've got the required members there. We just implemented a new program, which is what I was talking about with the emails. And so six months post your site review, you will receive an email. And what we're doing is we're looking at your data. Is it current? We're looking at your committee meetings. Are you having them? And did the required team members attend? And so you will get that email at the six month mark. Then we are doing a conference call with you at the one year mark. We want to keep you engaged in accreditation. And then at 18 months, we'll do another review and send you another email. Then at that two year mark, it's time to start that reaccreditation process. And so keeping you engaged is gonna be so important. What research has shown us and what time has showed us is the facilities that stay engaged, their reaccreditation process goes smoother and faster. So it's so important. Stay engaged, stay dedicated to your accreditation, stay dedicated to your committee meetings, keep that data current, keep those process improvement initiatives going. So I just want to thank everybody on the stage here today. And I'm sure all of your questions about accreditation and the data components of accreditation have been addressed. Everything's clear as mud, but we do have about 10 minutes left. And I do want to ask Michelle if there's any questions from the audience that we can address. I can, but I don't think they can. If you say it, I can repeat it. Okay. Okay. Can you tell us the basics of accreditation for chest pain and procedural emergency in such a case? Okay, so the question was, what are the basics of the accreditation? So what comprises the tool? And I can go ahead and answer that. We really look at your governance structure. So your program model, your education for your staff, looking at charters, things of that. The roles and responsibilities. We want to make sure that those people are in the right positions so that you are geared up for success. And then we also then look at your community structure. How are we getting the word out? If you build it, they will come. Well, if you don't teach your community members to contact 911, they're not gonna have that knowledge base. So getting out into your community. We have a section on EMS, which really looks at how do we collaborate with our EMS partners, which can be very exciting in itself. And then we break that down into your emergency department, your observation area, your acute care section. We have a whole section designated to your data. So like I said, even though the tool is one half, the data's the other half, we still pull that data, which is ultimately important into the accreditation tool. And then we also have a designation. So with that being said, we talked about small centers. They can be a base chest pain center, meaning they're transferring their STEMI patients out. And then we have a chest pain center with PCI. So you have the cath lab, you're taking care of that STEMI patient in your own cath lab 24-7. And then we have a process for chest pain with resuscitation. So not only we take care of our STEMI patients, but we have a defined process for when we gain ROSC back on our code patients and we can take care of them. And all of the tools are pretty much set up to mimic each other. So those sections are addressed in every single service line. So if you do one, it kind of looks like all the other ones, even though the contents might be slightly different. I'm gonna clarify. She is correct for chest pain. However, for the transcatheter valve, there's two essential components. For the structural heart, I should say, for the EP and the cath, there's six. So as you look at it, we look at the quality, we look at the governance section, just like Caroline was mentioning. Everything is built the same. In full transparency, we tell you who has to be at the meetings, we tell you how many people have to be there and what percentage of time. For the procedural tools, then we break it into the pre, peri, and post, back it up with the quality on the end. So again, it's a little bit different. There's different versions of it based upon the age of the tool. Chest pain, for example, Tracy, correct me if I'm wrong, but right now we're looking at rebuilding version eight, streamlining it. Bobby's working on updating information. Heart failure is on version three or four? Four. Four? Version four. It's the same thing, it's the same theory. So to me, that's the basics of accreditation. Everybody's different, just a little bit. By all means, ask us, please. Okay, thank you. We're working now. You mentioned something about the ACD and the NCDR registry specific for chest pain. Why would you use both if you have the NCDR chest pain in my registry? Good question. I can take that one. And I think this is just gonna be my opinion of that, but historically, the chest pain center accreditation tool had the ACD that really looked at the low-risk patient all the way up to that STEMI patient, whereas historically, many years ago, the chest pain MI registry looked at your AMI population. So when we merged years ago, accreditation and ACC, we really wanted to make sure that we would eventually get to the platform where you can choose one or the other and you can enter all of those patient population into either option. We're there now, but as you all know, it takes baby steps and it takes a lot of time to build that. So you do have the option of either using just solely the chest pain MI registry for all your patient populations, you get the same metrics back, or you can use the ACD and you get the same metrics back. But some people still use a combo and I'm not sure the answer to that. It might just be a level of comfort. And that's, in nursing, we do this because we've always done it this way, might be the rationale behind that. You want me to answer that? Sure. That's me. Okay. Yeah, I did start with the ACD for my low-risk and then I have always done the NCD or chest pain MI. The reason why I've stuck with the ACD for my low-risk is I get those monthly information. I don't have to wait for quarterly. And so I like, and again, we meet monthly. So I like having that and it gives me a lot of ED stuff directly to where, for example, door to EKG and door to physician. If I see that metric movement a little bit, I know something's happened at the triage portion or with the EMS so I can correct it quickly. So for me, it's that real-time information for my chest pain. Personal preference or facility preference may be the answer too. Just in comfort level. I'm used to it, so. I think we have time for maybe one or two more questions, Michelle. Actually, we're out of time because it's intermittent. Oh, we started later because of the, okay. All right. I would like to clarify just one thing about that last question and the statement of real-time, the ACD versus the chest pain MI registry. You can get a real-time chest pain MI registry as well as long as you're putting it in. If you wait until the end of the quarter to put it in, then you can't. But if you're putting it in weekly or something like that, then you can get that. Just a point of clarification that it is available both ways. Thank you, Michelle, for clarifying. There are a ton of questions and I will attempt to answer as many as possible in the app, but we are open. Okay, all right. Well, thank you, everybody, and I hope you enjoy the rest of the Quality Summit. Thank you.

accreditation

chest pain accreditation

procedural emergency accreditation

governance structure

data collection and analysis

process improvement initiatives

ongoing engagement

data management

improving patient outcomes