Welcome to Lesson 2 of ACC's Transcatheter Valve Certification Tool Orientation Course. This learning activity was developed by myself. I am Liza St. Clair and I will also be narrating this presentation. The overall objective of this lesson is to provide an overview of how to navigate the Transcatheter Valve Certification online tool. As a reminder, there are detailed guides which can be found under the Additional Resources tab. The specific objectives for this lesson are to define an essential component and demonstrate how to access, navigate, and utilize EC functional tabs. The goal of Transcatheter Valve Certification is to ensure that each facility has the foundational elements to build a successful Transcatheter Valve 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 Transcatheter Valve multidisciplinary team. There are two 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 Transcatheter Valve program. It establishes a Transcatheter Valve multidisciplinary team and expectations of a Transcatheter Valve specific staff education. The Quality section outlines how the organization must evaluate their Transcatheter Valve performance metrics, create Transcatheter Valve PI and QI initiatives, and how that relates to the overall organization's Quality Assurance Performance Improvement Plan. Within 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 certification. 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. Once logged into the Transcatheter Valve version 1.1 online certification tool, the first page shown is the homepage. To review and access the essential components, click on the Essential Components on the left navigation bar. This will now allow you access to review each of the EC sections in each individual EC line item. For example, by selecting the Quality option, this provides access to the Quality section. To demonstrate how to access the functional tabs within each EC, we will access the Program Model tab and use EC1-M2D as our example. Selecting 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. The References tab will list resource documents that support the rationale for the requirement. Title of the documents are listed as shown with a 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 Resources tab within the Additional Resources option on the main home page. The Guidance Statement tab is a very useful tab option. The information within this tab will provide clarification for the requirement and what type of supporting documents 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. The ARS will review the documents to verify the documents meet the requirements, advise if further adjustments need to be made, and 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 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 TransCatheter Valve Certification Tool. Of 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 the document once and provide the page numbers within the document which meet that key individual specific requirement. There may also be examples of acceptable supporting documents, known as Shared Practices, which are available for your 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. While the TransCatheter Valve Certification 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. The Comments tab is available which allows the opportunity to record any notes or provide any added comments to communicate to the ARS and assist with further clarification. For example, if the supporting documentation uploaded is pending additional information, add another few sentences or a narrative to 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 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. This concludes Lesson 2 of 4. Thank you for your participation.

Transcatheter Valve Certification Tool

Liza St. Clair

facility program

governance

quality requirements