Hi, I'm Liza St. Clair. I'm one of the accreditation clinical product managers for the American College of Cardiology. I handle and manage the heart failure accreditation, as well as the transcatheter valve certification program. Joined with me here today is Robert Bunney. Hello, my name is Robert Bunney, and I'm one of the accreditation clinical product managers for the American College of Cardiology. My service lines are the cardiac cath lab accreditation and the electrophysiology accreditation. Good day, everyone, and thank you for joining us here today for the economics of accreditation session within the Quality Summit 2021. We're very excited to have you here with us, and more excited about having our keynote speaker, Kathy Carrito, from Lawrence General Hospital, to share her experiences with accreditation services and how it has benefited their hospital programs. So the objectives of today's session will be to show how accreditation can optimize management and treatment options for cardiac care patients. And also, while going through the accreditation process, how can you identify cost-saving opportunities? And before we begin and hand it off to Kathy, we'd like to share with you and provide some background information as to what your hospital leadership is actually dealing with as of today and the challenges they must face. Not only must they maintain their current programs and cardiac services that they provide to their community, but they need to look at how to grow that revenue and increase that profit margin. How do they even look at diversifying their portfolio and in creating new revenue streams, which may include creating a transcatheter valve program and expanding those services and providing quality care to your patients? So adopting new technologies is one way to actually create a new revenue stream. But also, one of the things that hospitals are actually looking at is looking beyond their four walls of a hospital and getting into the outpatient arena. We've seen that for PCIs especially, that ambulatory surgical sites are taking on and conducting PCIs within that setting if their state does allow, as the supply and demand actually has increased, especially with this baby boom generation. And in addition to that, not only are they doing surgical procedures outside the hospital walls, but they're also taking care of patients as follow-up care and going into the outpatient care setting and setting up clinics. So they are doing follow-up with their heart failure patients that have been discharged from the hospital to ensure that they have the follow-up appointments, ensuring that they have the support to maintain their diet, their activity level, and are adhering to their medication regimen and ensuring that they are titrated to the guideline-directed medical therapies if possible. And all this just to avoid possible readmissions, which could cut into and make reimbursement penalties less. So not only are they doing, again, sustaining the current programs that they have, but they're looking, again, making sure that they have a reasonable profit margin and also looking to see if these programs are going to benefit them in the long term. And in addition to that, as we've seen within the past year, they also now need to address health care equity and address social determinants of care, which can actually deter the health care that is needed for certain patient populations, which does include maybe patients who are homeless or have some type of food insecurity or even can't even afford or have the means for transport to a follow-up appointment or a diagnostic test they need. So having to balance all of that really is a struggle, again, for our hospital leaders of today. So health care leaders today might try to look at labor as a solution and reducing their labor as a solution to reduce their overall expenses and increase their profit margins. However, that is actually counterintuitive. 60% of our hospital budgets are actually attributed to labor. However, given the fact that we have an aging population and a larger growing aging population at that with the baby boomer generation, we have already experienced staffing and nursing shortages pre-pandemic. And going forward post-pandemic and currently today, we don't see that as a solution in the near future. So we really need to focus on strategies outside of the labor box, per se, and really focus on the periphery of items that we may be able to control costs, such as supplies, pharmaceuticals, purchase services, and investments maybe into outpatient services. So looking at that type of infrastructure, that's going to support the labor force in caring for this population in the future. So as we avoid trying to reduce the labor force, what we should be actually concentrating is how to invest in that labor force that we currently have. Looking at your HART team and everyone else and your staff, you actually want to ensure that you are investing in them. You want to ensure that they feel valued. And so we can reduce staff turnover. You want to ensure that they are engaged in your heart failure programs, your chest pain programs, and or any other programs and services that you do provide. You want to ensure that they have a stake at the table when decisions do have to be made. And in doing so, you've not only valued that staff member, but you've also allowed for possibly easy adoption of new ideas and improvements that need to be made going forward. So contribution of your staff is critical, and prioritizing them in engagement, again, should be our priority. As we look through accreditation, we do ask that you identify who those employees are, who should be at the table and contribute to those decisions. So I would be amiss if we didn't actually address the current COVID pandemic and the financial challenges that our hospitals and hospital leaders are dealing with today. Last summer, we saw that many of the staff were furloughed due to decreased volumes in maybe procedural areas that had to close down. Executives, clinicians, and staff were even taking pay cuts to ensure that they could even keep some of their staff. And some of those units that may have been dedicated to chest pain or heart failure, we had a site that was recently shared with us that their observation unit who took care of their heart failure and chest pain patients actually had to close and convert that unit into a COVID unit. So again, having to pivot very quickly to meet the needs of your community is vital. Not that your program will actually end, but actually pivoting to make sure that you meet the needs, again, of your community. And in some dire circumstances, there were some hospitals that did have to close. And as we go forward, we do know that the patient volumes are probably expected to remain a little bit lower than what our baseline levels were. So how do we go into more of a survival mode while keeping our staff engaged in the process? In addition to the specific challenges presented by COVID, hospitals face many other challenges on a day-to-day basis. Partnering with the American College of Cardiology on the Pathway to Accreditation can help address some of these challenges. With hospitals' limited resources, our role at the American College of Cardiology is to share and assist you in implementing the latest guidelines. As you work in our tools, the guidelines are embedded into the essential components. When we talk to our customers, they believe they are using evidence-based practice until we evaluate their processes and see that they are not in compliance with the standards. ACC is committed to partnering with you to take that evidence-based, guideline-driven care to the bedside. Another way of stating that point is operationalizing the science. The best care delivery model requires a symbiotic relationship between the patient and the operations and science. The accreditation framework can help to develop that process. This framework consists of governance, community outreach, pre-hospital care, early stabilization, acute care, transitions of care, and clinical quality in the disease state tools such as chest pain or heart failure. And it consists of governance, quality, pre-procedure, peri-procedure, and post-procedure, in addition to clinical quality for the procedural tools such as cath lab or EP. One way the accreditation framework can help is to re-engineer your workflow to reduce variation. This occurs through standardized processes, realigning care, utilizing the existing resources, and supporting clinician practice patterns. This lends itself to improved performance as demonstrated through evidence-driven compliance, transparency, accountability, sustainable change, and return on investment. The data is used to validate the improved performance and outcomes. Other examples of return on investment include inventory management for the procedural tools, reducing the cost of wasted or expired supplies, room utilization, tracking case start times and efficiency, improved room utilization and staffing guidelines can greatly impact the bottom line of some of these labs. Tracking of complications. In the cath lab, an acute kidney injury event or bleeding event not only lends itself to worse outcomes, but increased costs during that hospitalization, including treatment and length of stay. Cost avoidance is another form of return on investment. Performance improvement projects on deficient metrics such as risk-adjusted acute kidney injury or bleeding can help to identify issues and develop processes to reduce those events. Identifying patients at risk, implementing proactive interventions to avoid those complications and monitoring post-procedurally are some of the ways accreditation can help to reduce those events and avoid the added cost associated with those events. Same-day discharge, developing and implementing criteria to determine which patients are eligible for to be safely discharged home the same day. So when it comes to return on investment and quality care, accreditation can give you the edge. So what is the end result if you implement and go through the accreditation process? It actually provides you a culture that you can implement into your program. And it provides an efficient operational model that supports the advancement of patient care, investing in your staff and allowing for possible research and delivery of the high-valued products, as well as looking at data within your programs and utilizing that data to really make the best decisions for your program. And now I'd like to introduce Kathy Carrito from Lawrence General Hospital. She serves as the cardiac director for their cardiac service line. She will give us a real perspective of how they've implemented accreditation programs and how that has been really a part of their culture in providing the best care to their patients. She has served as the cardiac service line director for the last 10 years. And during that whole time, she has actually maintained accreditations for many other programs that they do provide. She has actually been with Lawrence General for 37 years. So she is a very senior member and very knowledgeable about their organization and started out as a CCU floor nurse. She then was promoted as a coordinator in the cardiac cath lab and then a director of the cardiac cath lab. So let's give it off and I will hand you off to Kathy Carrito, who will again share her perspectives in how accreditation has served their organization. Well, thank you very much for having me. So Lawrence General Hospital is a community hospital. We're situated about 26 miles north of Boston and five miles north of New Hampshire. We are a level three trauma center and we hold many accreditations, particularly in the cardiovascular realm. And we have a number of different programs that we provide. So I'm going to start with a little bit about what we do here at Lawrence General Hospital. We are a level three trauma center in the cardiovascular realm. Our emergency room is the fifth busiest emergency room in the state of Massachusetts, seeing close to 70,000 visits per year. As I said before, we hold many accreditations. One's I'm most proud of, of the American College of Cardiology, because I'm the director of cardiovascular services at the hospital. Accreditation, American College of Cardiology, American College of Surgeons, and radiology as well. Lawrence General likes to offer advanced care close to home. As I said before, we have one of the state's busiest emergency department. We are a level three trauma center. Our heart and vascular program is accredited through the American College of Cardiology. We have a thoracic surgery program in partnership with Leahy Hospital, and we have an outstanding orthopedic surgery and orthopedic traumatology. We have a 24-7 hospitalist pediatric center, and we are partnered with a family medicine residency through the Greater Lawrence Family Health Center here in Lawrence. During the height of COVID, Lawrence was at the epicenter. We were impacted extremely hard with COVID. We became a testing center and a vaccination center for our community. As I said before, Lawrence is located 26 miles north of Boston, five miles south of New Hampshire. And the city of Lawrence is the second poorest city in the state with a poverty rate of 21.4% and a median household income of just over $32,000. Our population mostly is Latino. It is an extreme hardship for our patients to travel to Boston, so we have to make sure that they receive the same high-quality care at Lawrence General as they would at the tertiary hospitals in Boston, such as Mass General, Brigham and Women's, Beth Israel, and Tufts. So we did this through turning to quality, and we turned to look for our cardiovascular services line. In 2013, we looked for a cath lab accreditation program. Unfortunately, at that time, the American College of Cardiology did not have cath lab accreditation. So we turned to ACE accreditation, and in 2013 and 2015, we were accredited through ACE. We were the only community hospital in the U.S. at that time without surgery on site to attain this accreditation, and we're the only hospital in New England to have this accreditation as well. But of course, wanting to be part of your governing body, which is the American College of Cardiology, they did offer cath lab accreditation. I'm not quite sure when, but we did apply for that in 2018, and in 2021, we were just reaccredited with PCI accreditation through American College of Cardiology. Expanding on that, we decided we would try chest pain accreditation, and we've received chest pain accreditation in 2015, and we were reaccredited in 2018 and most recently in 2021. Making it a full service line, we decided that we would go to heart failure, and in 2017, we applied for and received heart failure accreditation through the American College of Cardiology, and in October of 2020, we did our reaccreditation. I'm very proud to say that we have also received the Heart Care Center of Excellence four years in a row now. We just received it for 2021, so we're very proud of our accreditations through the American College of Cardiology. This shows here all our accreditations. It makes us feel proud here at the hospital that we can offer these services to our patients and we can offer these services to our community so they do not have to travel into Boston. As I said before, it is a hardship for our Latino population to travel. Some of the quality improvement initiatives that we've done through our accreditation for heart failure, we looked at our readmission rates, specifically our Medicare 30-day heart failure readmission rate trend. And as you can see, we've been steadily going down on our rates, but if you notice in quarter two of FY20 and quarter one of FY21, we had an uptick, and this both coincided with the two COVID surges that we had. So as you can see, we've steadily decreased and we continue to decrease our heart failure readmission rates. And this is just some more data showing how we've trended down over the years. That's a little bit older data, but we are down to about 20% on our readmission rates, less than that, actually. And we did this through patient education, doing ticket to discharge, making sure that patients had the right education at the right time. We use the standardized order set. So physicians had to use best practices. They could not order one-off medications. It had to be used through the order set. We made follow-up appointments for our patients prior to discharge. So when they went home, they had the appointment in hand and they fully knew when their appointment was so that there was no confusion and they were seen by their PCP or cardiologist. Currently, right now, we're working on a home diuretic protocol with our partners in VNA. This is to help some of our patients that are a little bit fluid overloaded based on a protocol to prevent them to coming to the emergency room unnecessarily and then hopefully prevent readmission. That should be starting sometime in September for us. For the cath lab, our quality initiatives, we reduced kidney injury or AKI. We did this by using a maximum allowable contrast calculator. This is part of our timeout. It is announced with our timeout, so our physicians and our team members know exactly how much contrast we should be using. Another important thing that we use is the contrast-induced nthropathy calculator. This is also done pre and post procedure, so we know the SIN score. We also have a pre and post hydration order set and use that for our patients with elevated creatinines and elevated SIN scores. And we have maintained for the cath PCI registry, we have a AKI of 3.83, and that was for quarter four of 2020. Also for the cath lab, we're working on metric number three of the NCDR, which is median time to PCI, which is 60 minutes. We all know that the gold standard is to make sure that it is less than 90 minutes, but the faster you have that artery open, the less damage it will do to your left ventricle. And currently we are running at about 64 minutes. So we're looking to reduce that to get it down to 60 minutes. This slide here also shows the quarterly metrics that are rolled into that 64 minutes, because it is a roll in four quarters for the NCDR. And as you can see over the last four quarters of 2020, we have steadily decreased by quarter our door-to-balloon time. We've done that by doing a STEMI report card. This shows the artery prior to angioplasty and after angioplasty, the diagnostic EKG, as well as all the metrics and a little story of the patient and it is all HIPAA compliant. And it is sent to everyone that touches the STEMI patient. So that is our EMS partners, everybody in the emergency room, interventional cardiology, the cath lab, our telemetry unit, as well as our critical care unit. And our EMS uses this for their teaching rounds as well. When we looked at the NCDR metric number three, we had a breakdown of where the 90 minutes came from, but in order to get to the 60 minutes, we had to try to shave off some time. So what we did is try to have a goal of door to EKG read less than seven minutes, EKG read to STEMI page less than three minutes, getting that patient into the cath lab in less than 27 minutes and opening up that artery in less than 23 minutes. So that gives us our 60 minutes. For chest pain, we did a chest pain observation unit trial. This trial was done on our telemetry unit because we didn't really have any dedicated space. We found that using the hospital, we've used this with the hospitalist, but we found that this really kind of increased our length of stay because I don't think they were really as invested as our emergency room physicians are as far as trying to get these patients out on a timely manner, not disparaging the hospitalist, but they have a lot going on as well. So we moved it to the emergency center. We have six beds in the emergency center that make up our EDU. We're trying to expand it right now, but we found that having the emergency room physicians and dedicated personnel in the EDOU really drove patients' time in the emergency center down. It also helped us with our door to EKG times and our door to EKGs went from 18 minutes to 10 minutes. We still struggle with this right now, as I guess every hospital does, is trying to make sure that every patient comes in and gets their EKG and have it read by a provider within the 10 minutes. So I don't think this is just germane to Lawrence General. We're also trying to improve our troponin turnaround times. I'll talk about that in a little bit and by utilizing our advanced life support partners for drawing the bloods. And we just recently instituted a high sensitivity troponin protocols. All this quality initiatives has helped us improve our quality and our throughput. So we're very proud about that. So quality improvement project that we did for chest pain, for our recent chest pain accreditation, we did it around improving troponin turnaround times. We all know that the diagnosis of MI involves the evaluation of clinical signs and symptoms and EKG and cardiac biomarkers. Current American College of Cardiology and American Heart Association guidelines state that troponin is the preferred biomarker of diagnosing MI. And we all know it's important to understand that the positive troponin does not diagnose myocardioschemia or infarction. A positive troponin risk stratifies patient into an increased likelihood of ischemia or infarction, but it is not diagnostic. So prior to 2020, Lawrence General utilized troponin I and our positive value was 0.046. Our levels were drawn at zero, three and six hours of the patient arriving to the hospital. Some of our times are medium time for arrival to initial troponin results. As you can see, we're well over 90 minutes for years 2017, 18 and 19. Our goal is to have that less than 60 minutes. Our percentage of patients with initial troponin results within 60 minutes of arrival, again, from 17 to 19 was less than 15%. Our goal at Lawrence General is to try to get it to 50%. So you can see that we're far below our goal. We found that we had limitations of that EMR. At the time we were using a Paragon system and we also had problems with workflow. In May of 2019, we implemented a new EMR system and that has been Meditech. But we also found that it did not improve our goal of achieving at least 50%. So we got together and began discussions in June of 2019 with our EMS partners, specifically Lawrence General Advanced Life Support for drawing troponins on all chest pain calls coming to the hospital. So we had a timeline. We had a goal of the first trial to start in October of 2019, it was October 14th. Unfortunately, we had a launch failure. We set another date of November 19th of 2019. And I'm sad to say that we also had a launch failure on that as well. But not wanting to give up, we tried again in December of 2019 for having our ALS draw the troponins on all our patients coming into the emergency room via EMS. And we had to launch off. So it took us three tries, but we were able to do it. And in January of 2020, our lab announced that they were going to be getting a new analyzer and that would be able to do high sensitivity troponins. So at some point in time, we were gonna have to change our troponins. Three months into our trial, we analyzed our data, but we found that we did not really improve any of the turnaround times. We found that there was a delay getting the labs ordered and the patient must be registered prior to ordering a lab. So those are the two barriers that we found out from our trial. So then we turned on to doing the timeline of implementation to our high sensitivity troponins. And in August of 2020, we had an initial meeting with a work group and we set the goal of developing an algorithm utilizing the high sensitivity troponins in the heart score. We are trying to agree on a testing interval, agree on a delta, and discuss how we're gonna roll this out for hospital-wide education, because it is a huge undertaking implementing these high sensitivity troponins. We presented our plan to the cardiovascular steering committee in September. We developed a inpatient chest pain protocol. There were eight versions of this, and we also developed a emergency center chest pain protocol, and there were seven versions of that. Once we got all the versions settled, we presented it to our medical executive committee where it went to approval. And then we provide hospital-wide education by the end of September. And we started our high sensitivity troponins in October of 2020. That's when we had our goal live. This here is our protocol. It utilizes both the heart score and the troponins with the deltas, and it basically puts patients in a bucket on how we're going to be utilizing the troponin draws. And we settled for our troponin draws of zero and two, but after doing a little bit of review, we decided that we would do zero and one with an option to do a three-hour troponin as well. And that was our inpatient one as well. Again, both versions had several versions of that until we settled on the final version. So here are some of our times. Our median time for arrival to troponin draw, we're running about anywhere from 31 minutes to 29 minutes in 2021. And initial draw to results, 55 minutes and 50 minutes. But overall, we are still struggling with meeting our 90 minute under the 60 minutes. Some of the issues that we've had because of this is because of COVID. We've had two surges of COVID. As I said prior, our community has been really hit hard with our COVID. Again, now we're starting to see an uptick in COVID with the Delta variant as well. We've had to pull some lab personnel to do our testing. So like most other hospitals, we are struggling to get new employees into the hospital. So right now we're in the process of regrouping, looking at the data. We did add a dedicated EMS registration area. So when the EMS comes in, they are registered right away. This has helped us with getting the patient a visit ID quickly so that we can order the labs and any type of imaging. So we're gonna wait and see if this has helped with our improvement and go from there and we'll analyze the data and see where we go from there if any other improvements that we need to do. We are an accredited hospital. We have four accreditations with the American College of Cardiology and it helps us with our marketing. We have it on our website. The ACC is very, very nice and they have a very excellent website where you can go in and find out what hospitals are accredited. It also helps us with our media and our fundraising to have these accreditations. The value of accreditation I think was said best by the American College of Cardiology. It's saving lives and preventing irreparable heart damage and improving the cardiovascular patient's quality of life are the absolute fundamentals of accreditation. The net improved cardiovascular outcomes means your facility can also measure success and in terms of improved patient satisfaction and outcomes, a multidisciplinary team approach to treatment and precise cardiovascular care strategy, a reduced risk of liability and maximized reimbursement for cardiac treatment and procedures. I thank you for your time and attention. So Kathy, thank you for that excellent, excellent presentation. Obviously your commitment to our cardiovascular patients is very apparent with your diversified portfolio of accreditations and how that's really translated into patient outcomes and improved processes and really persistence in trying to make better patient outcomes for your patients and your commitment there, not only meeting the benchmark, but also surpassing it. One question I have for you, Kathy, is the return on investment piece. It is obviously seems like a lot of work that you've invested within the past 10 years doing your accreditations, but how do you comprise your teams or conduct your meetings to ensure that you are meeting the accreditation standards? How many people do you have involved in your team and or are there multiple teams that you have to assign? Well, thank you very much for having me and excellent question. So with heart failure and chest pain accreditation, we have one team. It is a cardiovascular steering committee. So that is made up of team members of both nursing and physicians, case managers from the emergency room, telemetry, ICU, anybody that touches that cardiovascular patient. And we hold our meetings monthly. And again, it's emergency room physician, interventional cardiology, diagnostic cardiologist, nursing, pharmacy, nurses at the bedside as well. Thank you, Kathy. One of the things that jumped out to me during your presentation was that every cath lab struggles with and is mindful of acute kidney injury. Now your data shows that you're in between the 75th and 90th percentile when it comes to acute kidney injury, which is a fantastic number. You had mentioned that you calculate the max contrast dose and include that in your timeout. I know from experience and many cath labs deal with this, there is a cost to having an acute kidney injury with prolonged length of stays for patients in addition to any kidney damage that may be permanent, hopefully not. In addition to that calculating max contrast dose, are there any measures besides the hydration protocol? I know in between your diagnostic and your PCI, do you have a timeout where you discuss where you are or a huddle where you discuss where you are with the contrast so far? And also from that standpoint, do you have a call out when you're approaching that threshold? Great question. Yes, some of the stuff that we do, you know, with our patient population here in Lawrence, we have a lot of patients that have a lot of comorbidities such as diabetes and hypertension. So obviously we need to pay attention to acute kidney injury. So yes, we do look at our contrast and as we're approaching the maximum contrast, we do let the physicians know, the team know that is doing the procedure that we are reaching that. We also monitor the creatinine both pre and post procedure. And if we're doing a stage procedure, we're obviously looking at the creatinine and make sure it's safe for us to do so as well. Great. And thank you for sharing your data regarding heart fail readmissions. I know that trying to care for this population is particularly difficult during this COVID pandemic and doing outreach really, and ensuring that they are staying on their medications, adhering to their diet, exercise, doing their follow-up appointments, and given that we are still going through the pandemic, have you had any lessons learned? Anything new that maybe that you've had to pivot or implement to kind of meet the needs of your community? Yeah, we are instituting a home diuretic protocol. It is a quite lengthy protocol as far as partnering with the VNA that we have here in Lawrence. And they see the patient and the patient is able to, if they gain a few pounds within the week or whatnot, they have this protocol that they follow in conjunction with their physician where they're administered some Lasix. It could be PO, it could be IV, and that is in conjunction with our VNA. And we'll be starting that in September. So we're looking forward to seeing the data on that. Thank you. That's great information to share. Kathy, you had mentioned that within your cath lab, you're shooting for a benchmark of a door-to-balloon of 60 minutes, which we know the national standard is 90 minutes. And in addition to the chest pain accreditation you said you have, which kind of shifted its focus to a first medical contact-to-balloon of 90 minutes. And so that internal benchmark of 60 minutes is definitely in line with the chest pain accreditation. And we know that the time, the sooner we can open that artery, the better it is for preventing any further muscle damage. Do you partner with the EMS side to allow them to call and activate the STEMI team at your hospital in order to meet that benchmark? Yes, absolutely. Since the inception of our STEMI program, our EMS partners are able to activate from the field, which is a great help to us. We're a small community hospital. So we don't have a team here 24 seven. So some of our nurses are within 20 minutes of the hospital. So every second that we can gain on that, that is, it's just a great benefit to us. But yes, our EMS partners are allowed to activate out in the field. Okay, I think that's all the questions we have at this time. Again, Kathy, thank you again for a wonderful presentation, sharing your experience with accreditation and your continued commitment again towards accreditation and your commitment to your patients and community. Thank you so much for having me. I really appreciate it. It's been a great journey with the American College of Cardiology.

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