Welcome to the training module for ACC's Chest Pain Center Accreditation. Training module is designed for healthcare professionals who will take their facility through the Chest Pain Center Accreditation process. Our goal is to communicate all of the resources available to you in the Chest Pain Center Accreditation tool and to provide an understanding of how to utilize the tool so that your path to accreditation is both successful and beneficial. 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 facilities 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 first demonstrate how to navigate the online Chest Pain Center Accreditation tool, identify essential information that must be entered in the facility profile, and review the three phases of the accreditation process. Let's review the specific phases of the accreditation journey. The baseline gap analysis phase is defined as the first stage of the accreditation process. Baseline gap analysis occurs within the first 60 days once initial access is granted into the online Chest Pain Center Accreditation tool. During the application phase, monthly data submission via the chosen plan is required. You will meet at least monthly with your assigned ARS to discuss progress, data submission, potential process improvement topics, and an overall summary of progress, next steps to assist your facility with the on-time completion of your accreditation tool requirements. Lastly, the accreditation phase is defined from the period of accreditation granted until expiration. During this phase, data submission is still required and the ARS will provide additional information related to the ongoing additional accreditation requirements. The first step of the accreditation journey begins with an introduction to your Assigned Accreditation Review Specialist, or ARS. With an assigned ARS, the journey towards accreditation is attainable. The ACC's ARS has the expertise to provide tailored guidance, recommendations, and note any opportunities to achieve your accreditation status. The ARS will contact the Chest Pain Center Coordinator as noted in the key contacts of the facility profile and will have frequent communication and track your progress towards achieving Chest Pain Center accreditation. The Baseline Assessment is composed of three components. The first component is the Facility Information Analysis. This includes the facility information and key contact information as reviewed earlier in the presentation. Once all areas are confirmed and completed, a green checkbox will appear on the left navigation bar. Baseline Gap Analysis is the second component. Only answer yes if the intent of the item is met at the time of the Baseline Gap Analysis. Supporting documents are not needed at this time. However, the Chest Pain Center Coordinator should be aware that the documents are currently up to date and readily available to select yes. When conducting the Baseline Gap Analysis, it will behoove the organization to be honest and truthful with the current realities and operation of their existing Chest Pain Center program. By doing so, this will allow the ARS to identify any shortfalls and partner to build upon current processes and focus on specific quality and process improvement initiatives that would strengthen the program and result in the most beneficial outcomes for the patients and community. For facilities utilizing the ACD for data abstraction, follow the Patient Selection Criteria Guide to enter the required amount of patients to complete the Baseline Gap Analysis phase. For reaccrediting facilities, if your previous ACD is current and up to date with data submission, you will not be required to complete the Baseline Gap Analysis data component and your ARS will override this requirement. If you are a reaccrediting facility and did not maintain your data during the accreditation phase, you will follow the same steps as a new facility to complete the baseline data component. For facilities utilizing the NCDR Chest Pain in My Registry, if your facility is up to date and aligns with the current abstraction deadlines, you will not be required to complete the data portion of the Baseline Gap Analysis. Your assigned ARS will complete an override for this requirement. If you are a new NCDR Chest Pain in My Registry customer and have yet to enter patients into the registry, please work with your assigned ARS as you may need to utilize the ACD to complete the baseline data component requirements more timely to achieve completion within the first 60 days. Once all components of the Baseline Gap Analysis are completed, the facility will go to the Accreditation Tool homepage and select Submit Baseline. Once baseline submission is complete, the Submit Baseline selection on the left navigation bar will now change to Submit Application to indicate that the facility has completed the first phase of the accreditation process. Now the facility is at the beginning of the second phase of the accreditation process, the application phase. During the application phase, requirements of the facility will be ongoing ACD encounter or data via the chosen data entry pathway, ensure all mandatory tool items be met with supporting documentation. The application must be submitted within 12 months of initial access or prior to the product purchase date. The process is ongoing and provides guidance and direction with review of supporting documentation and metrics. When the facility is ready and in coordination with the ARS, the site review is then scheduled within 90 days from the point of application submission. Of note, there are no blackout dates permitted. Once the date for the site review has been determined, the ARS will provide the agenda along with the attendee requirements. A final review of all EC line items, supporting documentation, metrics and data results will take place prior to your site review. On the day of the visit, the visit takes place from morning to early to mid-afternoon. There will be a defined arrival and departure time. The ARS will provide a PowerPoint presentation and the facility will need to provide their process improvement project and outcomes. There will be a program discussion with the entire team to review the synergy of the overall chest pain program. In addition, a tour of the units and areas caring for ACS patients will take place. Once these agenda items are complete, the ARS will conduct the site review summation and answer any additional questions you may have. Depending on the time frame of the agenda, lunch may need to be provided. Following the site review, an executive summary or finalized report with detailed observation and opportunities is provided. Accreditation awards and certificates will then be forwarded to the key contact following the formal approval from the Accreditation Review Committee. The facility will continue with the required data submissions and chosen data pathway options. For any changes, update the foundational information, data pathway options section and inform the assigned ARS. Ongoing accreditation requirements. Please complete the EHAC summary volumes. Your facility will continue to have access to the accreditation tool for references, shared practices, tool resources, and to upload ongoing requirement documents. Data collection and review must be maintained. Your assigned ARS will continue to be your resource if you need assistance.

Chest Pain Center

Accreditation

Healthcare

Facility Processes

Patient Outcomes

Chest Pain Center Accreditation

Baseline Gap Analysis

Accreditation Review Specialist

data submission

site review