Welcome to lesson 3 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. Our objectives for this module is to review the three phases of the accreditation process. Your Baseline Gap Analysis, Application Phase, and finally the Accreditation Phase. 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 Heart Failure Accreditation Tool. During the Application Phase, monthly data submission via the chosen plan is required. And lastly, the Accreditation Phase is defined from the period of the accreditation granted until expiration. During this phase, data submission is still required and the ARS will provide additional information related to the ongoing accreditation requirements. The first step of the accreditation process 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 Heart Failure Coordinator as noted in the key contacts of the facility profile and will have frequent communication and track your progress towards achieving Heart Failure Version 4 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. The Tool 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. Reporting documents are not needed at this time. However, the Heart Failure Coordinator should be aware that the documents are currently up to date and readily available. 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 heart failure 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 will strengthen the program and result in the most beneficial outcomes for the patients and community. The last component is the Accreditation Conformance Database, Baseline Gap Analysis. The database will be required to enter the last 30 patient encounters, the primary discharge diagnosis of heart failure into the ACD. This must be completed within the first 60 days after initial access is granted into the tool. At a minimum, all mandatory fields with a red asterisk and highlighted in yellow must be captured if applicable to the patient episode of care. 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 and ensure all mandatory tool line items be met with supporting documentation. The application must be submitted within 12 months of initial access or prior to the anniversary date. The role of the assigned ARS 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 for between 30 to 90 days from the point of the application submission. Of note, there are no blackout dates permitted. The application phase is the most vital component during their accreditation process. This is where the focus on key areas is maximized with the goal of making change through the quality and performance initiatives led by the Heart Failure multidisciplinary team and senior leadership. This happens by a deep dive in evaluating metrics and resulting data, ensuring compliance with the essential components, working within the community, both internal and external, reinforcing smooth transitions of care to realize the impact across the entire care continuum of heart failure patients. Following accreditation, the facility will continue to maintain and monitor these processes for continued optimal performance. Once the dates for the site review have been determined, the ARS will provide an agenda along with the attendee requirements. As needed, the ARS can make any adjustments to the agenda. The ARS will also review the list of required attendees for the roundtable discussion. A final review of all EC line items supporting documentation, metrics, and data results will take place prior. On the day of the site review, the visit takes place from morning to early to mid-afternoon. There will be a defined arrival and departure time, and the ARS will provide a PowerPoint presentation and the facility will need to provide their process improvement project and outcomes. There will be a roundtable discussion with the entire team to review the synergy of the overall heart failure program. In addition, a tour of the unit and areas caring for heart failure patients will take place. The site review will also include a chart review. This is a review and not an audit and is designed to identify strengths and areas of opportunity. The ARS will require a list of current or recent heart failure patients. A random selection of patients from the list will then be reviewed to ensure key data points are properly documented. This provides an opportunity to validate documentation of supporting documents and offers opportunities for further process improvement. It is important to involve a staff member knowledgeable to assist to guide the ARS and team members through the chart more efficiently. Lastly, there is a summation session. This is a casual discussion of the observations and opportunities for the facility. The ARS will provide a final recommendation relative to the accreditation status. Following the site review, an executive summary or finalized report with detailed observations and opportunities is provided. Certification awards and certificates will then be forwarded to the key contacts following the formal approval from the Accreditation Review Committee. After the facility accreditation is formally approved and granted, the facility will continue to measure and sustain the gains or improved processes. Data collection, performance metrics, required staff education, and other essential component items will continue at the frequency noted within the tool. The facility will continue to utilize the tool and the ARS will be available as a resource when needed. Through the achievement and maintenance of ACC Heart Failure Accreditation, your organization will certainly instill and foster a culture of continuous process improvement. We look forward to our partnership to strategically enhance the delivery of cardiovascular care to ultimately improve heart health and patient outcomes for the community and heart failure population that you serve. This concludes Lesson 3 of 4. Thank you for your participation.

ACC's Heart Failure Accreditation Tool Orientation Course

accreditation process

Baseline Gap Analysis

Application Phase

Accreditation Phase