Welcome to the Training Module 3 for ACC's Chest Pain Accreditation. This training module is designed for healthcare professionals who will take their facility through the chest pain accreditation process and review the data submission options, requirements for data submission, then finish with specific ACD and calculated measure training. If you are not using the ACD and using only the NCDR Chest Pain MI Registry, you may still benefit from slides 14 through 21, but this module is not required for NCDR Chest Pain MI Registry participants using only the registry for data submission requirements for the chest pain accreditation tool. The workshop modules are explicitly designed for any facility that is in the process of completing chest pain center accreditation. Any information regarding accreditation is highlighted in the workshop modules. The modules are subject to change at any time as we are continually updating the accreditation products to enhance the functionality of the tool for our customers. However, the facility's registered users of the online accreditation tool will have access to the most current workshop modules as needed. Anything shared in this training workshop module is confidential and privileged and only meant for the facility currently pursuing chest pain center accreditation. In addition, the modules and any information embedded cannot be published, distributed or shared with any third party. The objectives for this module is to first demonstrate how to utilize and operate the Accreditation Conformance Database, also known as the ACD. We will describe the ACD randomization program option for those that will continue to use the ACD as their data collection option through the application phase of the accreditation process. We will then review the calculated measures and their functionalities when using the ACD and lastly highlight all resources that are available to support these online chest pain center accreditation tool functions. Let's now review the ACD randomization process. For facilities pursuing chest pain accreditation, you have three options for data submission. You can utilize only the ACD for all patient records. You can utilize the NCDR Chest Pain MI Registry for all patient records or you can utilize our hybrid model, which would be a combination of both the ACD and the NCDR Chest Pain MI Registry. For facilities utilizing the NCDR Chest Pain MI Registry, your accreditation review specialist will have read-only access to your dashboard reports, so no additional actions would be needed by the facility other than completion of the abstraction patient volume. For additional information, go to the Additional Resources tab and review the Chest Pain MI Registry fact document. If you have questions after reviewing the material, please consult your accreditation review specialist. For re-accrediting facilities that choose to utilize only the ACD data submission option, if you have kept your ACD current and up-to-date in the previous accreditation tool, you are not required to complete the baseline submission. Your accreditation review specialist will override this requirement. If your facility did not remain current with data abstraction, you will follow the instructions for the new facility. For the baseline phase submission requirements for new accreditation facilities or facilities that did not remain current with their ACD data abstraction, your facility would pull the most recently coded discharges, utilizing the primary ICD-10 codes from the Patient Selection Criteria Guide, then enter those patients into the ACD working from the most recently coded backwards until the required number of patients are submitted, or you have gone back six months from the currently coded date. For re-accrediting facilities, you would go back either six months or to where you left off in your previous tool. For option two, facilities utilizing the NCDR Chest Pain MI Registry for all patient types, you would review and follow the inclusion and exclusion criteria and all corresponding registry user guides. Your accreditation review specialist will have read-only access to your NCDR dashboards to review your data. Option three is our hybrid model for data submission. Facilities can utilize both the NCDR Chest Pain MI Registry and the ACD for data abstraction. Your facility can opt to put any patient types in either location. Follow the Patient Selection Criteria Guide under the Additional Resources tab and all corresponding registry user guides. There are three phases to the accreditation process. In the first phase, all facilities that are utilizing the ACD must enter the exact number of patient encounters listed on the Patient Selection Criteria Guide to comply with the baseline gap analysis phase. This must be completed within the first 60 days after initial access is granted to the tool. For existing customers, if the ACD is up-to-date in your previous tool, the baseline submission is not required. For NCDR Chest Pain MI Registry customers, the ARS will assess your data submission to ensure your facility is up-to-date with data abstraction based on the defined data submission deadlines. If up-to-date, the baseline submission is not required. If you are a brand-new NCDR Chest Pain MI Registry customer and have yet to submit any patient data, work with your assigned Accreditation Review Specialist as you may need to utilize the ACD for your baseline submission only to ensure completion within the first 60 days. In the next two phases, facilities will then have various options to continue to report their performance measures utilizing any of the three baseline submission opportunities. The Patient Selection Criteria Guide will list the baseline phase requirements for each patient type along with the primary ICD-10 codes and the required volume for each patient type. Resuscitation patients are only required for facilities pursuing PCI with resuscitation accreditation. For facilities utilizing the ACD, the Patient Selection Criteria will remain the same in both phases, the application phase and the accreditation phase. Facilities will declare the randomization strategy in their Chest Pain Center Charter and ensure that the correct number of patients are abstracted monthly following the Patient Selection Criteria Guide using primary ICD-10 discharge codes for each patient type. For example, if you run a report for your monthly primary ICD-10 low-risk discharge codes and 500 patients appear on that report for that month, your facility would randomize those 500 patients based on your declared strategy and enter only the 30 of those patients required into the ACD based on the Patient Selection Criteria Guide. A randomization strategy, for example, could be to select three patients per day starting with the first day of every month until your patient quota is met. If you are an NCDR Chest Pain and My Registry customer, you will follow the NCDR Registry inclusion and exclusion requirements and reference guides. The randomization option allows for flexibility to accommodate small and large healthcare organizations and promote any chest pain data collection processes that a facility may already have in place. For ACD customers, the facility must define and declare its randomization strategy for the monthly sampling submission requirements. This randomization strategy should be defined and entered into the Chest Pain Center Charter document for reference. The facility will then pull a primary discharge code report for all encounters for that specific month. Based on your randomization strategy, you would select the appropriate number of patients and enter them into the ACD. If the facility volume is under 30 records, for example, for low-risk patients, all will be entered.

Chest Pain Center

Accreditation Training

Healthcare Professionals

Facility Profile

Confidentiality

chest pain accreditation

data submission models

Patient Selection Criteria Guide

randomization strategy