Lessons from David & Goliath: Promoting Quality Care in Community Hospitals - Lawrence General Hospital advances quality processes with Accreditation for Cardiovascular Excellence (ACE)

Proper perspective: visibility & options

What would you do if you found yourself to be David in the Goliathian world of Healthcare? If you were Lawrence General Hospital, Lawrence, Massachusetts, you would look to innovative and quality initiatives to hold your ground on the slippery slope of accountable care. As the first hospital in New England to achieve ACE accreditation, not only does Lawrence General Hospital hold distinction amongst its peers, but this hospital is also the first nationally to voluntarily validate and offer transparency of quality processes within a community hospital setting. Lawrence General Hospital performs diagnostic cardiac cath, ST-elevation myocardial infarction (STEMI) cases, and percutaneous coronary intervention (PCI) procedures without on-site surgery. “It’s the reality of the low-margin hospital environment,” said Kathy Caredeo, RN, BSN, MM, Director of Cardiovascular Services at Lawrence General Hospital. “With revenue declines and increasing costs, you position yourself to be the best to capture revenue streams.” 

Adjacent to nationally-recognized hospitals and research centers in Boston and Cambridge, Massachusetts, “Lawrence General wanted to show that patients can get quality care right at home,” said Sharon Coram, RN, Operations Manager, Cardiac Cath Lab. With Massachusetts fully engaged in the accountable care environment and these healthcare processes currently being adopted on the federal level, public reporting scrutiny is undeniable: medical facilities are closely monitored with substantial oversight to best practice adherence. 

“The outstanding healthcare options available in eastern Massachusetts afford New England a highly educated patient base that expects excellent care,” said Seth Bilazarian, MD, FACC, FAHA, FSCAI, FASNC, RPVI, Medical Director at Lawrence General Hospital. “We wanted to validate that patients can get quality care in the community and to use available means to show that the lower cost of local care does not jeopardize quality outcomes, that, in fact, the community hospital is a high value validation.” And being the first hospital in New England to achieve ACE accreditation “indicates a spirit of commitment to quality that is pervasive amongst the nursing, physician and technical staff at Lawrence General,” said Dr. Bilazarian. “This is a valuable message to the greater community.”  

Proactive response: leveraging available tools 

To validate and promote their quality programs, the cardiac cath lab (CCL) at Lawrence General Hospital decided to seek out confirmation with Accreditation for Cardiovascular Excellence (ACE). “We were looking for third-party validation and a means to benchmark against others utilizing Appropriate Use Criteria (AUC),” said Ms. Caredeo. “We know that ACE is the only provider of Cardiac Cath/PCI accreditation, that they judge quality core measurements of the CCL by aggregating data to NCDR definitions and that their affiliation with nationally-recognized professional organizations, the American College of Cardiology Foundation (ACCF) and the Society for Cardiovascular Angiography and Interventions (SCAI), could put us on the map.” 

Once administration support for accreditation was secured in April 2012, the CCL at Lawrence General began to strategize how they would begin their quality journey with ACE. Fears were expressed: how would the staff find time; what if labor costs became too burdensome; what if the CCL failed to achieve accreditation; what if the review revealed issues in tangential quality areas? Thus began the ten-month self-examination phase. “We pushed ahead because this administration continues to establish Lawrence General Hospital as the best community hospital in the area,” said Ms. Caredeo. “We wanted to validate our mission to provide great care and services close to home for our community, and be recognized in the cardiac cath lab clinical area of expertise; that’s why we applied for ACE accreditation.” What the CCL staff discovered was that their review of operation procedures and policies as compared to the current ACE Cath/PCI standards wasn’t so difficult, but it was time-consuming. “The process was systematic and thoughtful; it required getting input and buy-in from the staff on how to address challenging issues,” said Ms. Coram.  “Ultimately, it encouraged physician collaboration to build consensus on acceptable policies and procedures, particularly with PCI. We shared the goal of accreditation and were all very proud to be a part of it; the ACE process enhanced our teamwork.”

With Lawrence General Hospital’s comprehensive procedure and policy guidelines uploaded to the ACE website, the ACE site visit was scheduled within the next two weeks. On February 12, 2013, two experienced ACE review nurses arrived to evaluate and review cath records, procedural reports and physician reports. The evaluation lasted two days, culminating in interviews with all interventionalists, the CCL staff, manager and director. “The process was not daunting and the reviewers couldn’t have been nicer,” said Ms. Caredeo. “The evaluation was not punitive and the ACE reviewers worked with us to achieve accreditation; everyone wanted us to do well.” On March 27, 2013, Lawrence General Hospital learned that they had achieved provisional accreditation. Before full accreditation status could be obtained, the CCL revised procedures, including the following changes:

• Engage in comprehensive follow-up with patients after the utilization of contrast to evaluate patients for contrast-induced nephropathy (CIN).
• Provide a standardized and more descriptive physician reporting structure.
• Review all physician reports to ensure completion.

“ACE continued to advise us on quality processes and outcomes; it was collaborative,” said Dr. Bilazarian. “The concurrent expert review of angiograms by practicing cardiologists gave us confidence and sustains our enthusiasm for process improvements and better quality initiatives.” The CCL at Lawrence General Hospital achieved full accreditation on June 14, 2013.

Vanquishing the challenge: continuing the quality journey 

Employing ACE accreditation as a springboard, Lawrence General Hospital maintains a leadership role in best practice implementation; there exists a hospital-wide willingness to find innovative solutions to challenging situations. Partnering with ACE, Lawrence General Hospital is advancing a solid foundation for continuous quality initiatives (CQI) through: 

• Anti-coagulation policy — created the same guidelines and protocol for diagnostic cardiologists and interventional cardiologists regarding antiplatelet and antithrombin agents for patients undergoing a cardiac cath. 
• All patients stay on aspirin during an invasive procedure and are loaded with clopidogrel or another antiplatelet agent prior to PCI. 
• Avoiding radial artery occlusion — began a pilot study on January 1, 2013 to minimize radial artery occlusion, which occurs in 2-10% of the population. 
• Currently utilizing the radial artery technique in 75% of cases and working to realize 85%; one of the first hospitals in the United States to implement a “radial artery first” lab due to evidence of patient benefit¹ (2010).
• Through active prescreening of viable candidates, the research has allowed reduction of pressure and amount of time the compression band stays in place. 
• A Barbeau² evaluation is instituted pre-and post-procedure, once the compression band is removed, to determine patency of blood flow to the patient’s hand.
• If occlusion of the radial artery is apparent, intervention begins by applying pressure to the ulnar artery to improve radial artery flow.³ Accomplished zero radial artery occlusion following the ulnar artery intervention technique from a sampling of 200 cases. 
• Collaboration with ACE for policy finalization once the pilot study is concluded. A more formal study will then be initiated so that data can be presented to peers.

Accreditation with ACE has afforded the CCL at Lawrence General Hospital a reputable distinction within the hospital, the community and the greater New England area. Their process transparency and innovative evidence-based care, validated by ACE, underscores a commitment to quality. By achieving and exceeding national guidelines, Lawrence General Hospital maintains confidence that they are providing excellent patient care and ensuring reputational operators. “We are excited to share our achievement of ACE accreditation with our consumers,” said Ms. Caredeo. “The hospital marketing team has initiated a multi-faceted public relations campaign advertising the accreditation. Our promotion has been comprehensive: digital billboards and ads, social media and print including a newsletter lead story, press releases and full-color magazine ads. We even have a new badge that features our accreditation achievement displayed prominently on the hospital’s home page.”

Finally, it comes down to pride of service and best practice: “Accreditation with ACE was worth doing,” said Ms. Coram. “ACE affirmed that we were doing a good job, but also helped us look further into areas we could improve upon. The validation makes us feel confident. We are doing as good a job as any major medical center. I encourage this process for other cardiac cath labs.” Ms. Caredeo agrees: “It was money well spent. ACE validated that patients can get quality care right at home. If you’re serious about quality, initiate the ACE process. When it comes to patient care, you want to be sure you are doing the right thing. Look to ACE for ongoing expertise and CQI; they provide perspective from the current available science.”

The authors can be contacted via Kathy A. Caredeo, RN, BSN, MM, Director of Cardiovascular Services, at kathy.a.caredeo@lawrencegeneral.org

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 ACE's website.

References 

1. Caputo RP, Tremmel JA, Rao S, Gilchrist IC, Pyne C, Pancholy S, Frasier D, Gulati R, Skelding K, Bertrand O, Patel T. Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheter Cardiovasc Interv. 2011 Nov 15; 78(6): 823-839.
2. Barbeau GR, Arsenault F, Dugas L, Simard S, Larivière MM. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the Allen’s test in 1010 patients. Am Heart J. 2004 Mar; 147(3): 489-493.
3. Bernat I, Bertrand OF, Rokyta R, Kacer M, Pesek J, Koza J, et al. Efficacy and safety of transient ulnar artery compression to recanalize acute radial artery occlusion after transradial catheterization. Am J Cardiol. 2011 Jun 1; 107(11): 1698-1701.