A Journey Toward Better Patient Care: The Accreditation for Cardiovascular Excellence (ACE) Accreditation Process

Meet the Cardiac Catheterization Lab team at Forbes Regional Hospital in Monroeville, Pennsylvania.  Formed from a blend of diverse community labs in the Pittsburgh area in 2008, the team soon learned the necessity of collaboration as the new facility transformed patient services from diagnostics only to a comprehensive heart and vascular center; essentially moving from community-based to tertiary care. With everyone pitching in and learning as circumstance demanded, the team coalesced around a strong belief in accreditation to drive best practice.  

“Accreditation puts us on a path to drive best practices in our institution,” says Dan Oslowski, Manager of the Cardiac Catheterization Lab. “We chose Accreditation for Cardiovascular Excellence (ACE) because of their collaborative nature; we felt their program was appropriate for us,” he continues. “Other accreditation bodies take a global look. ACE is singularly focused on the quality of the cath lab and PCI, legitimizing your cath lab processes.”

How ACE Accreditation Works

Step 1: Preparation for Online Application

After acquiring three other accreditations (Stroke Certification, Heart Failure Certification, and Chest Pain Center Certification), the cath lab at Forbes Regional Hospital decided to obtain ACE accreditation in April 2012. They first reviewed requirements and processes from the ACE website, then secured administration’s approval, noting that the price of service was never an issue. Dr. Paul Kleist, Quality Director for the cath lab, said, “Our market is very competitive. We can advertise our accreditation credentials which other hospitals nearby cannot. We feel this gives us a competitive edge.”

Carolyn (Carrie) O’Leary, Clinical Research Coordinator, printed off the requirements and noted that the summary was quite thick. “When I first looked through, I thought, ‘Oh my goodness’; it just seems a little overwhelming at first, but as you go through it, you realize it’s not. Most of the requirements are processes we’re already doing and we only needed to tweak some of them. We felt it was something we could do.” Forbes Regional agreed that the process would be a multi-disciplinary approach and the effort had to pool from different departments such as Biomed, Medical Records and Admissions. “You definitely need physician approval and buy-in, because some modifications and changes will affect them,” states Ms. O’Leary. “We had the backing of Dr. Aashish Dua and Dr. Kleist, our medical and quality directors, because they realized we were working to do the best thing for the patient.”

Once buy-in from the team was secured, the ACE accreditation process began. Responsibilities were assigned and everyone met once a week to report progress, verify criteria and determine next steps: whether to work with an existing protocol or develop a new process. “Everyone gave their knowledge and special skill set to support the accreditation process,” confirmed Ms. O’Leary. “It couldn’t have been achieved without the team approach. Our collaboration with ACE accreditation was the catalyst that created a cohesive, blended culture that focused on key quality indicators. We used the process as a springboard to make ourselves better before receiving accreditation.”   

For example, the cath lab realized that the existing radiation exposure tracking plan needed to be adjusted to conform to current quality protocols. “Prior to our accreditation process, we would measure and record fluorodose exposure by time only. ACE requires a total dose to be recorded in mGy as well as DAP measured in microGym2.  We changed our policy to include more stringent warning levels and follow-up procedure. It’s a team effort that requires the attention of the physician, scrub, circulator and person on the monitor. This change drives increased awareness and improved patient safety,” said Ms. O’Leary.  

“Another procedural change we took dealt with the contrast-induced nephropathy (CIN) score,” notes Mr. Oslowski.  “We did the standard things that most cath labs do: we hydrated our patients before the procedure and if they had an elevated creatinine, we might start them on a bicarb. But we didn’t have a policy for that and that was one of the ACE requirements. The medical director of our cath lab, Dr. Dua, created a process to evaluate every patient admitted to the lab to get a CIN score. Depending on this number, we would call a physician and start the patient on bicarbs sooner; we would implement this an hour before starting the procedure. Now every patient gets a CIN score to determine optimal care. Our pre-procedural pause now includes the CIN score, maximum dye load that the patient should receive, and their serum creatinine clearance. The result is greater attention to issues and concerns, and makes the procedure safer for patients.” This amended practice “is based on an integrated team approach of highly skilled care delivery, and ensures the safety and comfort of our patients,” confirms Dr. Dua.

In July, once the team considered the process complete, information was assembled and placed in a binder for organization and review. Digital information was transferred to a memory stick for the online submission process, which was an 11-page application that included cath lab policies, procedures and volumes. “It took us a few months to compile the necessary information,” notes Ms. O’Leary. “If there had been a devoted FTE, it would have taken a few weeks. And whenever we had a question, we always consulted with someone at ACE; there was definitely good rapport. The website is helpful, too, you can find a lot of information there.” Once the application was submitted online, within a few weeks, Forbes Regional Hospital was contacted by ACE and a date for the site visit was set.

Step 2: The Site Visit

The ACE expert clinician team arrived at Forbes Regional Hospital in July. The team was comprised of three cath lab nurses who inspected the cath lab for two-and-a-half days.  The inspection included:

• Randomly reviewed cases: charts and angiograms within an ACE-selected timeframe;
• Personal inspection and verification of equipment and maintenance programs;
• Observation of a cath lab procedure;
• Assessment of the informed consent process prior to procedure;
• Verification of abstracted data from approximately 100 charts.

ACE clinicians also interviewed hospital staff: Dan Oslowski, Cath Lab Manager; Dr. Paul Kleist, Quality Director; Dr. Aashish Dua, Medical Director; Carrie Kuzmen, NCDR Data Analyst; Peggy Blackwood, Radiation Physicist; Michele Flatt, Cardiovascular Service Line Administrator; Laura Burkhart, Cath Lab Nurse Practitioner. Prior to the conclusion of the site visit and based on the information gathered, the ACE team provided a de-briefing of observations and suggested improvements that could be immediately implemented. “An unexpected benefit was that we had a positive exchange, not a punitive one,” states Mr. Oslowski. “We didn’t expect the process to be enjoyable, but the ACE clinicians are people who have worked in the cath lab. They have aspired to help even more people by working to accredit cath labs to provide better care for the cardiac patient. It was a committed experience and we had an instant bond. They understood our challenges and provided guidance for best practice.”

Step 3: Data Review and Report

After the site visit, the cath lab uploaded a collection of 84 angiograms, coronary interventions, physician reports, and case reviews to the ACE website. The reports were randomly selected from a list by the ACE clinicians. These reports were distributed to independent physicians to review online, remotely, via a HIPAA-compliant server. “We were told that the data review and final report compilation would take approximately 45 days,” noted Mr. Oslowski. “In the meantime, the cath lab worked on policy and procedure improvements that the ACE clinicians had suggested. “We all realized the changes would require extra steps, whether by checking a patient in or providing extra documentation and charting,” said Ms. O’Leary. “But ACE had brought our lab together and boosted our morale. We all knew the process was for the betterment of the patient, so it inspired everyone. Every day we work as a team toward a common goal of providing quality patient care.”

When the 10-page ACE report arrived within six weeks, the cath lab staff learned that they had achieved provisional accreditation status. “The report was a comprehensive action plan with specific suggestions toward attaining a perfect cath lab,” said Mr. Oslowski. “We saw it was an honest look at our lab and ACE provided a map for us to do better.” Details from the report advocated:

• More specificity in physician reports to close the loop on readmission rates.
• Development of a monitoring process for 30-day readmission rates for all PCI and angioplasties.
• Consider participation in the action registry, Mission: Lifeline, through the American Heart Association.

Mr. Oslowski, with assistance from Clinical Coordinators, Medical Records and Admissions, persisted in determining the best methodologies to remediate the action plan. ACE’s continued support at each juncture sustains the cath lab at Forbes Regional Hospital on their journey toward better patient care.  “ACE accreditation gave us the opportunity to step back and reflect on our current practices,” notes Ms. O’Leary. “We are able to validate our processes by looking at best practice through the guidance of a third party.” As a result, “our cath lab is a unique mix of experienced individuals with a primary goal of delivering the highest quality of care. We pride ourselves in maintaining maximum satisfaction levels amongst our patients and their families,” confirms Dr. Dua. 

ACE accreditation is valid for two years, during which time ACE provides ongoing consultation and updates on industry guidelines and Appropriate Use Criteria (AUC). “We still have work to do,” said Dr. Kleist. “We continue to improve by looking at our procedures and standardizing care. ACE emphasizes protocols to reduce risk, costs and variability. The result is improved outcomes and quality.”  

ACE Accreditation Lessons 

The collaborative spirit of the cath lab at Forbes Regional Hospital provided the impetus to take the accreditation journey with ACE. “We expected that the accreditation process would measure up to best practice,” said Mr. Oslowski, “and we knew the work would be very useful toward improving our acute coronary care. The unexpected benefit was the camaraderie we found with ACE. Their experts are cut from the same cloth and are equally as passionate about the cath lab as our team. Improvement is a continuous effort and the whole cath lab is engaged with ACE. I would tell everyone: ‘don’t be intimidated; ACE is there to help you.’” Ms. O’Leary agrees, “It was a learning process for me and the rest of our staff. It was definitely a positive. It can seem like it’s overwhelming, but just go through each point of the accreditation criteria one at a time; it’s doable and it’s for a good reason. Don’t get discouraged; it’s a great process to go through to get an outside perspective. Just stay organized and get everyone involved.”  

The desire to change patient outcomes for the better and create a more transparent process ensuring the alignment of policy, procedure and data can be approached in many ways. “The ACE process is better,” declares Mr. Oslowski. “ACE drives best practices with experts who have the same interest as you. There is mutual understanding and respect, because they’ve been in the cath lab and PCI trenches,” he continues. “ACE experts are singularly focused on quality for the cath lab segment and have gone through what you’ve gone through. The partnership with expert colleagues is gratifying.” 

Forbes Regional Hospital has been providing quality care since 1978. A 350-bed facility with 15,000 inpatient admissions, 12,000 surgeries and nearly 50,000 emergency department visits annually, the hospital provides an advanced level of care to patients. To learn more about Forbes Regional Hospital, please visit https://www.wpahs.org/frh.

ACE, an independent organization sponsored by the Society for Cardiovascular Angiography and Interventions (SCAI) and the American College of Cardiology Foundation (ACCF), offers independent evaluation and monitoring of facilities that provide cardiovascular care. By reviewing facility and operator performance and comparing clinical decision-making to nationally accepted best practices, ACE peer review and accreditation services plays a critical role in continuous quality improvement programs. Learn more at https://www.cvexcel.org.