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. Our final focus in this module is reviewing the calculated measures. Let's get started. Calculated measures are reporting measures which are automatically calculated from the abstracted ACD data fields. Compliance within the measures is provided in a monthly report with a convenient drill down feature. It is formatted to match all items within the clinical quality EC-8 which supports measuring process improvement line items within the tool. This slide lists the summary of calculated measures within each grouping for the clinical quality tab in your tool. To access the calculated measures function, select it on the left menu bar of the chest pain accreditation homepage. This will open up the calculated measures homepage. Within the calculated measures function, the user can easily access the ACD directly from there if needed. To review the facility monthly calculated measures report, click on the measures year to date report hyperlink on the calculated measures homepage. During the accreditation process, the measure year to date report will likely be referenced often to validate the data entry. If the data reflects erroneous information such as negative numbers or results well outside of range, changes can be made to the patient record as needed. The changes will then be updated and reflected in the report by the next day. On this homepage, the mandatory calculated measures are listed by grouping headers and will require no supporting documentation under the clinical quality essential component. The ARS will pull over any specific data needed into the clinical quality essential components from either the ACD year to date report or the NCDR chest pain in my registry dashboard. If utilizing the hybrid data submission model, both resources will be utilized by your ARS. Similar to the function of the essential components, to access more detailed information regarding the calculated measure, click on the caret to the left of the calculated measure identifier. This will allow access to the measure definition and the different components related to the measure. The measure definition references the inclusion exclusion criteria for the denominator and how the calculation occurs. This section will also provide you with the mandatory EC items that this calculated measure supports in the accreditation tool. This is a sample of the measure year to date report. The initial screen reflects the monthly data per calculated measure. In the header of the year to date calculated measure box, the date and time of when the report was last updated will be displayed. To drill down on the patient episodes of care that qualified for the measure, click on details under the calculated measure identifier. A table will then display with detailed information. Users may now analyze and validate the cases that were included in the measure and determine how the calculated measure value was computed. If the user would like to review the patient record of any outliers or make any changes to a patient record, then the user simply needs to click on the view hyperlink on the right-hand column to view the patient's ACD record. Your facility can also export the report into Excel, which will allow you to filter your data if needed. W. Edward Stemming is renowned as the father of quality and was quoted to say, you can't manage what you don't measure. By utilizing the ACD or the NCDR chest pain MI registry, the data obtained should serve as fuel to review compliance with quality and process metrics to drive improvement initiatives. We look forward to our partnership with you and the journey together of achieving chest pain center accreditation to be the vehicle towards attaining our shared strategic goal of delivering excellent patient care to the community and the chest pain center population that you serve. If you are interested in pursuing our Heart Care Center National Distinction of Excellence recognition, the link is provided here to explore the requirements. For chest pain accreditation questions or concerns, please reach out to your assigned accreditation review specialist, who is your navigation consultant for this process from start to completion. If you have not yet been assigned an ARS, please utilize the contact us feature for assistance.

Chest Pain Accreditation

Accreditation Conformance Database

data submission

healthcare training

compliance monitoring

Quality Metrics

Patient Care Improvement