Welcome to Lesson 1 of ACC's Cardiac Cath Lab Accreditation Overview, covering essential components. I am Bobby Bunny, and I will be narrating this presentation. The purpose for this module is to provide an overview of how to navigate the Cardiac Cath Lab Accreditation Tool. As a reminder, there are detailed guides which can be found under the Additional Resources tab. The objectives are to identify the resources available to facilities within the Accreditation Tool, and demonstrate how to utilize the essential component functional tabs. Every essential component line item is assigned to a specific category or section. By doing this, the facility will be able to better identify individuals responsible for each essential component line item. There are six essential component sections that must be achieved for all facilities, and there is one special essential component section dedicated for those facilities seeking a specific designation. The essential components within the governance section provides guidance on the leadership, infrastructure, and oversight of the Cardiac Cath Lab program. It establishes a multidisciplinary team and expectations of the Cath Lab-specific staff education. The Quality section outlines how the organization must evaluate their Cardiac Cath Lab performance metrics, create Cath Lab-specific performance improvement initiatives, and how that relates to the overall organization's Quality Assurance Performance Improvement Plan. The Pre-Procedure section includes multidisciplinary screening for patient risk and readiness. Peri-Procedure refers to the procedural processes for sedation, infection control, and radiation safety. Post-Procedure covers patient handoff, communication, patient and family education, and discharge instructions. The Clinical Quality section outlines the Cardiac Cath Lab data and metrics the facility will track and monitor. And lastly, the Designation section covers those facilities choosing to add on external peer review. Within each of the essential component sections, every essential component will be identified as mandatory or recommended. The mandatory items are those that are required. All mandatory items must be met to achieve accreditation. Recommended requirements are those items that are typically seen in more robust programs, and all facilities are highly encouraged to review these items and implement the recommended processes. Recommended items often move to mandatory in future versions. Once successfully logged into the Cardiac Cath Lab online accreditation tool, the first page shown is the home page. Zooming in on the left navigation bar, you can see all of the tabs available. To review and access the essential components, click on the essential components on the left navigation bar. This will allow access to review each of the essential component sections in each individual essential component line item. For example, by selecting the Governance option, this provides access to the Governance section. Now that we have opened up the Governance section, we will demonstrate how to access the functional tabs within each essential component. We will use EC1M1A as our example. Here is a zoomed in view of EC1M1A line item that we selected in the previous slide. Selecting the black caret to the left of the EC identifier, the functional tabs for each EC will now be displayed. This provides a drill down option for each essential component. As shown, within each EC there are helpful resources, such as a detailed explanation guide of the requirement, a guidance statement, and references. Most importantly, each specific essential component allows the opportunity to ask questions and communicate directly with the accreditation review specialist assigned to the facility. The References tab will list the documents that support the rationale for the requirement. The title of the documents are listed as shown on the blue hyperlink. Once selected, it will open up that document in a separate window. A more comprehensive list of all references is available in a document which is located under the References Resources tab within the Additional Resources option on the main home page. The Guidance Statement tab is a very useful tab option. The information within this tab will provide clarification for the requirement and what type of supporting documents qualify to meet the essential component requirement. Therefore, this should be the first resource for questions regarding the intent of the essential component. If there are further questions, as needed, please consult with the assigned accreditation review specialist for assistance. Supporting documents are uploaded after the baseline phase. After the baseline gap analysis has been completed, the facility will be able to upload any supporting documents that are required to demonstrate compliance with the essential component line item. The accreditation review specialist will review the documents to verify the documents meet the requirements, advise if further adjustments need to be made, or consult with the facility if additional information is required. All supporting documents should be in PDF format and named appropriately to easily identify what the document represents. To submit a supporting document, click on the Supporting Documents tab. Click on Upload New Supporting Document. This will then generate a pop-up window to select and upload the appropriate document file into the Cardiac Cath Lab Accreditation Tool. Of note, if a document covers more than one essential component, it is not required to be uploaded several times. The document can be selected under the Add Existing Document feature as an alternative. This will allow access to documents previously uploaded. This option is especially helpful for a document with various components that span several essential components. There may also be examples of other facility supporting documents, known as Shared Practices, which are available for reference. These can be found under the Shared Practices tab. Facilities may utilize these templates. However, all submitted documents must accurately represent and reflect the individual and specific facility. While the Cath Lab Accreditation Tool offers Shared Practice documents, they are provided as guidance only. These examples provide a framework on which to construct processes. Each facility is responsible to ensure all submitted documents meet the intent of the essential component and line item. The Facility Notes tab is available, which allows the opportunity to record any notes to provide any added comments. For example, many sites use this to make internal assignments for who is responsible for a particular line item. Also, to add support or clarification to an uploaded document, some sites will add a few sentences or a narrative to further explain the process or provide a timeframe for completion. The Communication tab provides a feature that allows the facility and the assigned accreditation review specialist to send messages to each other concerning specific essential component and line items. Simply type the message directly into the communication box. When finished, submit the message by clicking the Submit button. After the submission, a table will appear tracking all correspondence. The user who submitted the question is listed in the first column. Next is the message entered, and the last column is the date the question or response was sent. For details on how to use this section, refer to the Messaging Center How-To Guide under the Additional Resources tab. This concludes Lesson 1 of 2. Thank you for your participation. For more information, visit www.fema.gov

ACC's Cardiac Cath Lab Accreditation Tool

essential components

mandatory requirements

recommended requirements

accreditation review specialist