Welcome to Module 2 for ACC Chest Pain Accreditation, where we will review the essential components. This training module is designed for healthcare professionals who will take their facility through the chest pain accreditation process. Our goal is to communicate all of the resources available to you in the chest pain accreditation tool and to provide an understanding of how to utilize the tool so that your path to accreditation is both successful and beneficial. Let's get started. 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. Our objectives for this module is to provide an overview of how to navigate the chest pain center accreditation tool. As a reminder, there are detailed guides which can be found under the Additional Resources tab. The objectives are to identify essential components, demonstrate how to access and utilize essential component functional tabs, define essential component criteria and rationale, and discuss resuscitation designation. The goal of the chest pain center accreditation is to ensure that each facility has a comprehensive chest pain center program. 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 and those that should actively participate within the CPC multidisciplinary team. There are nine essential component sections that must be achieved for all facilities. The essential components within the governance section provides guidance on the leadership and infrastructure and oversight of the chest pain center program. It establishes a CPC multidisciplinary team and expectations of that team's specific staff education and how to provide policies and direction for facility wayfinding. Quality section outlines how the organization must evaluate their chest pain center performance metrics, create PI or QI initiatives, and how that relates to the overall organization's quality assurance performance improvement plan. The community outreach section includes education and the resources offered to the community. Pre-hospital section refers to the facility's partnership and relationship with EMS providers and agencies. ACS patient care management focuses on the front-end emergency department processes, flow charts, and order sets, non-invasive ischemia testing, and the appropriate use review of stress testing. Observation management will evaluate the management and standardization of ACS observation care The transitions of care section includes communication, discharge planning, patient and family education, and follow-up care. The clinical quality section outlines the CPC data and metrics the facility will abstract, track, and monitor. Lastly, the designation section will be completed in accordance with your facility's applying designation, either CPC without PCI, CPC with PCI. The CPC with PCI facilities also have the option to add on the resuscitation designation to address the out-of-hospital cardiac arrest patients. Each of the essential component sections, every EC 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 updates. Successfully logged into the Chest Pain Center online accreditation tool, the first page shown is the home page. To review and access the essential components, click on essential components on the left navigation bar. This will now allow access to review each of the essential component sections and each individual EC line item. We will demonstrate how to easily navigate by using the governance EC for an example. To demonstrate how to access the functional tabs within each EC, we will use EC1-M1A as our example. If we move 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 EC. As shown, within each EC, there are helpful resources such as a detailed explanation of the requirement, guidance statements, and references. Most importantly, each specific EC allows the opportunity to ask questions and communicate directly with the accreditation review specialist assigned to the facility through the communication tab. This tab will list supporting 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 that document in a separate window. A more comprehensive list of all references is available on the left menu, References tab. The 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 EC line item. The ARS 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 a PDF format and named appropriately to easily identify what the document actually represents. 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 file into the Chest Pain Center Accreditation Tool. Of note, if a document covers more than one EC item, 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 EC items. For example, if the facility has a lengthy outcomes report with a variety of metrics and performance indicators, upload that document once and provide the page numbers within the document, which meet that key individual-specific requirement. The Chest Pain Center 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 EC line item. Here are 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. The Facility Notes tab is available, which allows the opportunity to record any notes or provide any added comments to communicate to the ARS to provide further clarification. For example, if the supporting documentation uploaded is pending additional information, you can use the Facility Notes to add another 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 ARS to send messages to each other concerning specific EC line items. Simply type the message directly in 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. Let's get started with a brief EC review. First section of the Essential Components is Governance and sets the foundation for the Chest Pain Center Program. It provides the infrastructure for a successful and optimized CPC program. The intent of this section is to remove barriers, aligning people and services more effectively while enabling transparency and enhanced decision-making processes. The Governance section is composed of three tabs. The primary model focuses on your Chest Pain Center charter, your multidisciplinary committees, and your meetings and attendance grids, for compliance. Staff Education focuses on your facility policy for staff education and compliance for completion. All ACS mandatory education items will now be housed under the Staff Education tab. Facility Wayfinding will focus on your facility's policy for signage inspections and reporting, along with emergency signage photos for entrance points. Essential Component No. 2 focuses on Quality. This is one of the main pillars of achieving Chest Pain Center accreditation and requires integrating continuous improvement in all aspects of care through monitoring and evaluating the Chest Pain Center Program's processes. This is a cornerstone requirement and integrates continuous improvement in all aspects of care, including quality monitoring and evaluation of processes in the care of the Chest Pain Center population. Essential Component No. 3 is Community Outreach. This focuses on public awareness activities through selected community interactions. The overall goal will be to educate the public on prevention, intervention, and care of cardiovascular diseases. Facilities should partner with local businesses, employers, and health care providers within the community to accomplish these requirements. A Community Health Needs Assessment is also required every three years and should be utilized to assess and plan community education and screening events to reduce the overall ACS risk of your patient population. Essential Component No. 4 is Pre-Hospital Care. It requires a formalized relationship with community health care providers and, in particular, a strong focus on coordinator efforts with first responders in all EMS agencies. Essential Component No. 5 is ACS Patient Care Management, and this focuses on the front-end emergency department or initial treatment that may be provided to the chest pain center patient. The goals within this section is to quickly assess, diagnose, treat, and reassess chest pain signs and symptoms. In addition, these initial care settings should ensure appropriate patient disposition and discharge to make certain there are smooth transitions of care. It is important to differentiate this population to decrease the length of stay. By creating specific care pathways for these potential ACS patients, facilities can maximize efficiencies and ensure the program is performing at an optimal level. ACS flowcharts and order sets will be required to ensure your facility provides evidence-based guideline therapy. You will also provide documentation to support your non-invasive ischemia evaluation testing modalities as well as your appropriate use criteria review process. EC-6 will look at your ACS observation management processes. Your facility should have protocols and processes in place for the treatment and management of ACS patients placed into observation surveys and services. For ACC chest pain accreditation, your assigned ARS will also have access to our new return on investment calculators to provide feedback to the facility utilizing your specific patient volumes and length of stay for process improvement discussions, both for ED throughput and ACS observation. EC-7 will evaluate your facility's policies, protocols, patient education, and instructions for transitions of care touchpoints from admission to discharge. The EC-8 clinical quality tab will not require any documentation to be uploaded. Your assigned ARS will populate this EC with your facility-specific data. ACC chest pain accreditation offers three distinct designations. Chest pain center is for referral facilities that do not perform 24-7 primary PCI or only perform primary PCI during limited hours. Chest pain center with PCI is for facilities who perform 24-7 primary PCI services with no diversion. Our third option for designation is chest pain center with PCI and resuscitation. This option is only available for PCI facilities who offer 24-7 primary PCI. We have updated our resuscitation designation requirements with the latest guidelines focusing on the out-of-hospital cardiac arrest patient and the transitions from the pre-hospital setting to the facility. Initial post-resuscitation care protocols, risk reduction prior to discharge, and performance evaluation and improvement requirements for a holistic approach to the out-of-hospital cardiac arrest patient to improve patient outcomes. If your facility utilizes targeted temperature management for fever reduction, maintenance of normal thermia, or cooling, your protocol and order sets will need to be provided. Our new option for our resuscitation customers for facilities that participate in the CARES registry, we will accept quarterly CARES reports in lieu of additional abstraction requirements. Our additional ACC accreditation products are listed here and you can find information on our CV Quality website.

ACC Chest Pain Accreditation

healthcare professionals

comprehensive program

mandatory requirements

direct communication