Welcome to Lesson 3 of ACC's Transcatheter Valve Certification Tool Orientation Course. This learning activity was developed by myself, and I am Liza St. Clair, and I will also be narrating this presentation. Our objectives for this lesson is to review the three phases of the certification process. Baseline Gap Analysis, Application Phase, and the Certification Phase. The Baseline Gap Analysis phase is defined as the first stage of the certification process. Baseline Gap Analysis occurs within the first 60 days once initial access is granted into the online Transcatheter Valve Certification Tool. During the Application Phase, submission of supporting documents and action plans, if appropriate, are required. And lastly, the Certification Phase is defined from the period of the certification granted until expiration. During this phase, your ARS will provide additional information related to the ongoing certification requirements, which will include continued uploads of annual, semi-annual, quarterly supporting documents for mandatory essential components. The first step of the certification process begins with an introduction to your assigned Accreditation Review Specialist, or ARS. With an assigned ARS, the journey towards certification is attainable. The ACC's ARS has the expertise to provide tailored guidance, recommendations, and note any opportunities to achieve your certification status. ARS will contact the Transcatheter Valve Administrative Coordinator or Program Navigator, as noted in the key context of the facility profile, and will have frequent communication and track your progress towards achieving certification. 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. Supporting documents are not needed at this time. However, the Transcatheter Valve 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 Transcatheter Valve 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 will result in the most beneficial outcomes for the patients and community. Once all components of the Baseline Gap Analysis are completed, the facility will go to the Certification 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 certification process. During the application phase, requirements of the facility will be ongoing data submission to the STS-ACC TBT Registry and Surgical Database. Ensure all mandatory tool line items be met with supporting documentation, and 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 application submission. Of note, there are no blackout dates permitted. The application phase is the most vital component during the certification process. This is where the focus on key areas is maximized with the goal of making change throughout the quality performance initiatives led by the transcatheter valve multidisciplinary heart team and senior leadership. This happens by a deep dive in evaluating metrics and resulting data, ensuring compliance with the essential components, and working with staff and other departments to reinforce a shared decision-making process that incorporates the patient's values and goals that result in the realization of how it impacts across the entire continuum of care for patients. Following the achievement of certification, 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. The virtual site review takes place from either morning to early to mid-afternoon. There will be a defined start and end time. The ARS will provide a PowerPoint presentation, and if applicable, the facility will provide their process improvement project and outcomes. There will be roundtable discussions and the entire team to review the synergy of the overall transcatheter valve program. Lastly, there is a summation session. This is a casual discussion of the observation and opportunities for the facility. The ARS will provide a final recommendation relative to the certification status. Following the site review, an executive summary or finalized report with detailed observations and opportunity is provided. Certification awards and certificates will then be forwarded to the key contact following the formal approval from the review committee. And lastly, the facility will also continue with the required data submissions. After the facility certification is formally approved and granted, the facility will continue to measure and sustain the gains or improve 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 transcatheter valve certification, your organization will certainly instill and foster a culture of continuous process improvement. We look forward to your partnership to strategically enhance the delivery of cardiovascular care to ultimately improve heart health and patient outcomes for the community that you serve. This concludes Lesson 3 of 4. Thank you for your participation.

Transcatheter Valve Certification Tool Orientation Course

Baseline Gap Analysis

Application Phase

Certification Phase

ARS