First-Ever Cardiac Catheterization Lab Accreditation Program for a Hospital System

Jeffrey S. Carstens, MD, Cardiovascular Executive Medical Director, Dan Whelan, Cardiovascular Division Director, Christopher Pineda, MSN, RN, CCRN, RCIS, Director, Cardiovascular Services, Justin Rousek, Senior Industrial Engineer, CHI Health, Omaha, Nebraska

Jeffrey S. Carstens, MD, Cardiovascular Executive Medical Director, Dan Whelan, Cardiovascular Division Director, Christopher Pineda, MSN, RN, CCRN, RCIS, Director, Cardiovascular Services, Justin Rousek, Senior Industrial Engineer, CHI Health, Omaha, Nebraska

Catholic Health Initiatives (CHI), a national nonprofit health system comprising 105 hospitals in 19 states, sought national accreditation for its cardiac catheterization laboratories. The decision to seek accreditation was made by the National Cardiovascular Service Line Senior Leadership Team, which aimed to demonstrate to the community (including consumers, referring physicians, and regulators) that CHI cardiac catheterization laboratories meet or exceed nationally recognized standards in heart care. 


Selecting an accrediting body

The CHI search team, operating on a national level, evaluated multiple accrediting bodies based on services identified as most relevant and beneficial to CHI. The search criteria included identifying accrediting bodies with expertise on conditions such as heart failure, acute myocardial infarction (AMI), and ST segment elevation myocardial infarction (STEMI). The search team chose Accreditation for Cardiovascular Excellence (ACE) as the accreditor for its catheterization laboratories, concluding that ACE would provide the broadest, most comprehensive evaluation of CHI’s catheterization laboratory operations and procedures. The search team also characterized ACE’s approach as “holistic” because of its emphasis on standardizing policies, procedures and equipment across multi-hospital health systems, as opposed to offering accreditation programs on a hospital-by-hospital basis. 

ACE accreditation includes physician-to-physician guidance, with the goal of ensuring compliance with nationally recognized standards to maintain the integrity of each individual CHI cath lab. Additionally, while the ACE accreditation process would identify best practices as well as shortcomings at individual CHI hospitals, the report itself would encompass all CHI cath lab facilities. ACE’s approach lined up well with the integrated cardiovascular service line and quality structure within CHI Health’s Omaha market. 

Accreditation process

CHI Health-Omaha was the first CHI market-based organization (MBO) to complete the ACE application and to undergo accreditation review. MBO is a term defined by CHI to reference a CHI-affiliated provider of health and health care in a specific market. A local team was formed by the Omaha MBO to address the application process: a gap analysis focusing on policies, standard operating procedures, and documentation of compliance with standards and best practices. In parallel with the gap analysis, ACE initiated a dialog with our local team to share information about the specific criteria for accreditation and to answer questions. This dialog helped our team prepare for the ACE survey, an intensive site visit that took place over 5 days to review all 5 facilities. The site visit came at a particularly challenging time for CHI Health-Omaha, as the MBO had recently implemented a new electronic health record (EHR) system, a difficult process for any healthcare organization. Nevertheless, the feedback provided by ACE, both during the site visit and through the dialog that preceded it, challenged our team to examine specific processes and procedures, such as refining standard reporting tools and mechanisms, and helped our catheterization laboratories achieve or exceed the level of quality expected within the ACE standards.

Once the gap analysis was complete, the team created a Gantt chart to set objectives, categorize the ACE standards, and divide them into “manageable pieces,” designating specific points of contact within the service line. We instituted a series of weekly meetings to assess our progress and to assign specific standards and follow-up tasks to individual team members, including the compilation of documents that were required for accreditation. The team members had to report to the larger group with evidence of compliance in their respective standards. At the beginning of the process, some team members assumed their individual facilities were fully compliant with the standards. However, investigation sometimes revealed a lack of the evidence required to meet specific standards. This information was used to determine how and where to allocate resources and to produce the required information to demonstrate compliance.

Protocols assessed to eliminate variations

For example, our catheterization laboratories had established a protocol that would trigger email communications if a patient reached a certain threshold for radiation exposure. The email would be sent by the catheterization laboratory manager to the treating physician, the patient’s primary cardiologist, and the catheterization laboratory scheduler. This communication reported the amount of radiation the patient was exposed to, and that a follow-up appointment had been made for a skin check and re-evaluation. Additionally, the information in the email needed to appear in the patient’s EHR. However, we found that emails were not always issued when indicated and appointments were not always kept. As a result, we designated specific team members to ensure that these tasks were completed and that the protocol was followed in every case. 

Short-term experience and impact

ACE was very specific in terms of defining the criteria for accreditation, and the ACE accreditors were helpful in answering our questions and coaching us through the process. We feel this collaborative process was driven by a shared motivation to succeed and the creation by ACE of a learning environment. For example, we learned from the process that there were some opportunities within the CHI system to further standardize care standards and best practices, and to eliminate any variations. ACE has also been a valuable resource in validating a high level of integration within our laboratory facilities.

The National Cardiovascular Data Registry (NCDR) metrics measure quality improvement and are an important part of the ACE accreditation process. All CHI facilities participate in the registry. An ACE review of system-wide data from CHI use of NCDR metrics has spurred development of a contrast-induced nephropathy (acute kidney injury) prevention protocol. The protocol was recently approved and is ready for implementation at all CHI catheterization laboratories. 

The ACE accreditation process validated our belief that the CHI Health Omaha market catheterization laboratories constitute a single program operating at multiple sites. While this is a long-held belief within CHI, it was gratifying to have it validated by a credible outside entity. 

Improved reporting systems

On the other hand, the ACE accreditation process highlighted the need for a more refined and standardized approach to catheterization laboratory reporting. We found that the reporting system did not consistently provide information about how patients were treated in an easily discernable way and how coordinating ongoing care was documented. For example, for patients receiving one or more stents, our reports did not always indicate whether it was a drug-eluting stent or a bare-metal stent, or if single or multiple vessels were involved. Additionally, even though we were adopting a new EHR system, we found we had multiple electronic reporting tools that did not consistently communicate with the patients’ EHRs. While we continue to improve our standardized reporting mechanisms, ACE accreditation has been helpful in providing guidance.

Conclusion and next steps

Pilot program: the coach for the entire CHI system

Since we completed the ACE accreditation process, 24 additional (as of September 1, 2015) CHI catheterization laboratories have initiated the accreditation process or have announced their intent to do so. We have had a series of calls with some of the other MBOs pursuing ACE accreditation, and we have shared our Gantt chart and other relevant documents with them. Just as ACE coached us through the accreditation process, we are now coaching our sister facilities, in keeping with CHI’s goal to have all of its catheterization laboratories accredited by ACE. 

A continued quest to identify quality improvement opportunities

The coaching sessions have yielded a better understanding of how the different CHI catheterization laboratories operate, prompting us to look inward to identify areas for improvement. Moreover, communication with the other MBOs reminds us that other CHI catheterization laboratories face the same challenges as we do, and that our facilities can work together to standardize procedures and processes in the continuing quest for quality improvement. Perhaps most importantly, ACE accreditation has made us more conscientious about optimizing the patient experience through ongoing monitoring of processes and policies that we have implemented to comply with ACE standards, particularly those that are directly relevant to cardiac catheterization and percutaneous coronary intervention. 

Jeffrey S. Carstens, MD, Cardiovascular Executive Medical Director, CHI Health, Omaha, Nebraska, practices general cardiology that includes office- and hospital-based consultations and performs diagnostic tests such as echocardiography, stress testing, coronary angiography, and coronary intervention including stent placement. He is board certified in both cardiovascular diseases and interventional cardiology. He has completed additional training and certification in CT coronary angiography. Dr. Carstens has participated in numerous clinical research trials over the years including trials for lipid management, hypertension, heart failure, and trials of newer types of stents. Dr. Carstens is a Fellow of the American College of Cardiology, and has membership in the Nebraska Medical Association and the Metro Omaha Medical Society.