Welcome to Lesson 2 of ACC's Heart Failure Accreditation Tool Orientation Course. This learning activity was developed by myself. I am Liza St. Clair, and I will also be narrating this presentation. The objectives are to identify essential components that your team must complete to achieve heart failure accreditation, and demonstrate how to access and utilize the essential component functional tabs. The goal of heart failure accreditation is to ensure that each facility has a comprehensive heart failure program. Each 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 heart failure multidisciplinary team. There are eight essential component sections that must be achieved for all facilities, and there is one special essential component section dedicated for those facilities seeking a specific designation. Currently, the Heart Failure Version 4 Accreditation Tool is offering an outpatient services designation. The criteria for meeting this designation is outlined within this section. The essential components within the governance section provides guidance on the leadership and infrastructure and oversight of the heart failure program. It establishes a heart failure multidisciplinary team and expectations of heart failure-specific staff education. The quality section outlines how the organization must evaluate their heart failure performance metrics, create heart failure PI or QI initiatives, and how that relates to overall organization's quality assurance performance improvement plan. The community outreach section includes education and the resources offered to community members. Pre-hospital refers to the facility's partnership and relationship with EMS providers. Early stabilization focuses on the emergency department and observation services process. Acute care will evaluate the inpatient management and standardization of the heart failure care provided. The transitions of care section includes communication, discharge planning, patient and family education, and follow-up care. And lastly, the clinical quality section outlines the heart failure data and metrics the facility will track and monitor. Within each of the essential components sections, every EC will be identified as mandatory, recommended, or innovative. 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 versions. There are also innovative strategies which could apply. Once successfully logged into the Heart Failure Online Accreditation Tool, the first page shown is the home page. Review and access the essential components, click on the essential components on the left navigation bar. This will give you direct access to review each of the essential component sections and each individual EC line item. For example, by selecting the Transitions of Care option, this provides access to the Transitions of Care section. To demonstrate how to access the functional tabs within each EC, we will use EC7.M5 as our example. Selecting the black caret to the left of the EC identifier, 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 guidance statements and references. Most importantly, each specific EC allows the opportunity to ask questions and communicate directly with Accreditation Review Specialists or your ARS assigned to your facility. The References tab will list up to three supporting documents that support the rationale for the requirement. 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 in a document which is located under the References resource tab and the Additional Resources option on the main home page. The Guidance Statement tab is a very useful tab option. Information within the tab will provide clarification for the requirement and the type of supporting documents that qualify to meet the EC requirement. Therefore, this should be the first resource for questions regarding the intent of the essential component. If there are further questions, as needed, please consult with the assigned ARS for assistance. Supporting 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. ARS will review the documents to verify that 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. To submit a supporting document, click on the Supporting Tabs document. Click on Upload New Supporting Document to generate a pop-up window to select and upload the appropriate file into the Heart Failure Accreditation Tool. Note, if a document covers more than one EC, 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 ECs. 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 meets the key individual specific requirements. There may also be 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 Heart Failure Accreditation Tool offers Shared Practice documents that are provided as guidance only. These examples provide a framework on which to construct processes, and the facility is responsible to ensure all submitted documents meet the intent of the EC line item. The Comments 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 missing additional information, add another few sentences or a narrative to further explain the process or provide a time frame 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 a message directly into 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. This concludes Lesson 2 of 4. Thank you for your participation.

Heart Failure Accreditation Tool

essential components

accreditation

governance

clinical quality