Welcome to Module 7, Session 3 of the Cardiovascular Program Coordinator Course. This module is Improving Facilitation with content provided by Deb Kepin, Christy Chambers, and Michelle Wood. In Part 3 of the Facilitation Module, you will learn how to prepare for, achieve, and maintain your accreditation. Each of these three stages are instrumental in presenting your cardiovascular program as an ongoing effort to continually improve cardiac care at your facility. Rather than seeing the achievement of accreditation as a final goal, part of your role will be to educate your committee members, stakeholders, and leadership as to the importance and need of ongoing program management. This will ensure the efforts made and goals reached during the accreditation process will be maintained and continually improved. The kickoff meeting is your chance to set expectations for the accreditation committee and will require considerable preparation on your part. Managing and facilitating a project as large as accreditation, along with maintaining an ongoing program, will require everyone to participate. The kickoff meeting is the time to have that discussion. Accreditation is a team sport and should be seen as such. If you do not make this clear from the beginning, you may find yourself without the help you need to successfully run the program. In addition, it is always helpful to have these types of discussions with leadership before accepting the coordinator position so that everyone agrees. You will want to thoroughly prepare in advance to ensure the meeting goes smoothly. Your preparation should include review of the following so that you may introduce the scope of the project and be ready for discussions. Accreditation Tool and Gap Analysis, Tool Resources, Shared Practices and Guidance Statements, and Data Sources. In this initial meeting, you will want to provide an overview of the accreditation project, goals, objectives, and timeline for project completion. The agenda should be sent to the committee prior to the initial meeting. Include a copy of the gap analysis. This is their opportunity to review the gap analysis with respect to their specific area to determine if a document, process, etc. currently exists. Completion of the gap analysis will give everyone a picture of where they are, where they need to go, and how to best close the gap. Completion of this document is the first step in the accreditation process. You may find it helpful to have the gap analysis completed by committee members prior to this first meeting so that it can be returned to you, collated, and presented at the kickoff meeting. Expect this initial meeting to last longer than those to follow as it will include introductions, review and completion of the gap analysis, and the exploration of ideas related to the development of your committee charter. The necessary components of the charter are included in your accreditation tool. There are also samples you can use under the Shared Practice tab. You may wish to provide an example of the sample charter to start that discussion. Discuss the method of collecting data including the Accreditation Conformance Database and or NCDR Registry metric. Following the project kickoff, send a follow-up email with minutes, task responsibilities, and a reminder regarding the next meeting. It is advisable to schedule each meeting on a regular day and at the same time, but a reinforcing reminder is always helpful. Although the accreditation process allows for quarterly meetings, you may find it beneficial while going through the accreditation process to schedule those meetings monthly with a reminder that they must participate in at least 50% of those meetings. Lastly, be thankful and enthusiastic. Let everyone know you are grateful to have them on board with this important initiative. All people want to know that they and their opinions matter. As discussed previously, the kickoff meeting is the time to set expectations from the beginning and have conversations regarding delegated duties. Be clear as to why you are delegating the work. Explain your thought process for selecting the individual, the reason for delegating the work itself, and the benefits to the person. This will help to ensure that they will be engaged in completing the task or project. Also be clear that these individuals provide an update at each meeting. Agendas should be provided prior to each meeting and should clearly denote the item, person in charge, duration of discussion, and the expected outcome. Again, meetings should occur at the same time and day of the week so that the committee members are able to plan ahead. Agendas should include the allotted time to address each topic. It is important to provide minutes following each meeting with delegated assignments and timeline to completion. Focus initially on areas in the gap analysis that were not met and may take more time to implement changes. Requirements such as revising order sets and discharge instructions may take considerable time to complete. Starting early will ensure these revisions are accomplished within the accreditation timeline. Identify performance improvement project requirements early. As part of the accreditation process, you will be called upon to present at least one area where change has resulted in a process improvement. Invite others on the committee to participate in this presentation, particularly if their department was the source of the improvement. Try to find PI projects that you can tie to financial gain or savings. Try to make the PI projects meaningful to the team and leadership. The accreditation review specialist assigned to you and your facility acts in the capacity of a navigator. It is important to fully disclose barriers and challenges you may be experiencing so that they can assist you with these issues. The ARS will meet with you monthly by conference call, share best practice examples, and help you keep the accreditation initiative on track. Prepare questions you may have in advance of these calls. Your data will be reviewed during monthly calls and recommendations made for improvements when established goals are stalled. Upload documents as soon as possible. This gives the ARS an opportunity to review the document and provide feedback if the intent is not met. In the interim between scheduled calls, the accreditation tool has a communication function built into the platform that will enable you to message back and forth when questions arise. Remember, the ARS are the experts that are dedicated to seeing your program be successful. They have extensive clinical and leadership experience, leading other hospitals successfully through the accreditation process and beyond. There are certain items within the accreditation tool that need to be maintained throughout the three-year accreditation cycle. For annual education requirements, regular committee meetings demonstrating 50% attendance and data abstraction must continue. It is important that the team and leadership understand this commitment upon embarking on the accreditation initiative. You should have prepared the committee members from the onset that achieving accreditation is only one goal and the process of improving cardiac patient care does not end with a certificate. Your accreditation review specialist will follow the site visit with a report that will make recommendations regarding opportunities that you and your team can implement in the path forward. Share this report with senior leaders, committee members, and stakeholders as soon as it is received. This supports the sustainability of the program and identifies other goals to pursue. Continue to be visible outside of meetings by further engaging stakeholders, providing updates at staff meetings and huddles. Continue to update leadership as before. Stay visible. We don't celebrate our successes often enough. Make sure you recognize your team and their accomplishments. As a quality professional, you should also consider sharing your secrets of success with others by applying to present your PI through poster or podium presentations at local and national conferences. This is a great way to continue to develop yourself and provide insight and help others as they may be on the same journey. Your success and the success of your cardiovascular program is indeed the goal of your accreditation review specialist and ACC accreditation services. What we provide is a sustainable partnership that offers support and encouragement throughout the accreditation journey and beyond. Let's turn our attention back to Alex in the case study. Alex has successfully led the hospital to achieving accreditation. Following this achievement, many in the committee have moved on to other initiatives and attendance at meetings has declined. How could Alex have prevented this from happening? What can he do at this point? To continue the momentum, preparing committee members for participation in a program that does not end with accreditation sets the expectation up front that the program is ongoing and will require a continued oversight to ensure the ongoing requirements are met. Sharing the final report provides a framework for the program moving forward and establishes responsibilities throughout the three-year accreditation term, encouraging momentum if the program should stall. This concludes Module 7, Session 3 of the Cardiovascular Program Coordinator course.

accreditation process

kickoff meeting

gap analysis

committee charter

cardiac care