Lab Accreditation

Perspectives on ACE Reaccreditation: The Cath Lab Director’s View

An interview with Lynn Smith RN, MSN, Director of Heart and Vascular Services, Bon Secours St. Francis Health System, Greenville, South Carolina. 

An interview with Lynn Smith RN, MSN, Director of Heart and Vascular Services, Bon Secours St. Francis Health System, Greenville, South Carolina. 

In 2011, Bon Secours St. Francis Health System in Greenville, South Carolina, was the first hospital to be nationally recognized with Accreditation for Cardiovascular Excellence (ACE) accreditation. They followed that accomplishment in February 2014 by becoming the first hospital ever to receive reaccreditation for its CathPCI program from ACE. 

By comparing information collected against national data and best practices as defined by experts in the field of interventional cardiology, ACE accreditation brings a strategic, long-term approach to quality improvement. Bon Secours St. Francis Health System achieved full accreditation with ACE for two years in 2011. To achieve ACE reaccreditation, the staff and physicians at Bon Secours St. Francis Health System worked side by side with ACE’s expert cardiology professionals to implement appropriate use criteria (AUC), engage providers in the quality outcomes process, and validate compliance with current published guidelines and national standards. ACE reaccreditation recognizes the hard work and commitment of all members of the Bon Secours St. Francis Health System cardiac catheterization team.

Perspectives on ACE Reaccreditation is a series that explores the ACE reaccreditation process from inside the cath lab. In the current article, Lynn Smith provides her viewpoint on the ACE reaccreditation process as a cardiac cath lab director with Bon Secours St. Francis Health System. Prior articles explored the ACE reaccreditation process from the perspectives of the healthcare executive1 and the interventional cardiologist2.

After gaining your first accreditation with ACE, why did Bon Secours St. Francis Health System pursue reaccreditation?

Lynn Smith, RN, MSN: We wanted to be sure that our quality system was well implemented and had improved beyond our first accreditation. We knew we were at the top of our game, as compared to national standards. The ACE reviewers did a deeper dive this time; they knew our areas of opportunity for improvement and worked with us to step up our game to a new level.

What did this level of physician engagement do for your cath lab team?

L. Smith: First, our physicians were highly engaged, and that was exciting for the entire team. The ACE reviewers are experts in interventional cardiology with an excellent grasp of all aspects of cardiac care. Getting physicians to standardize reporting is not an easy accomplishment. They are accustomed to their own way of dictating reports. However, our physicians considered the ACE reviewers as peers, and that made it easier for them to accept their recommendations to follow national standards. 

Our medical director, Dr. Siachos, stated to me that that the ACE reviewers gave him a more highly relevant recommendation for improving the quality and process of care than any other review committee. We have had reviewers from a range of organizations in our cath lab, including Joint Commission and the Department of Health and Environmental Control (DHEC). We monitor our quality data through multiple registries, including the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR), CathPCI and the ACTION-GWTG registry, but the ACE experience was completely different.

How was the ACE review experience different? What was the response of the cath lab team?

L. Smith: Change is always a challenge, and no one ever wants to be the first to change. But, once we could point out how the physicians were embracing national standards, and changing and adjusting their documentation, the cath lab team began to understand that it was necessary for everyone on the team to change. For example, the cath lab team, supported by ACE recommendations, decided to expand chart audits so that the whole team participated. This allowed the team to learn areas of opportunity within their own documentation and that of their peers, improving the overall quality and accuracy of the case event log. The documentation from the case event log flows over to the standardized report system and is what generates the foundation of the physician report. The physician then reviews the report, adds case-specific data, and then finalizes the report to be sent to the medical record. It was imperative that the cath lab team’s documentation “paint the picture” of the case events, both to improve the quality of the reports and to ensure standardization of records.  

The positive reinforcement and continued focus on improvement, quality, and patient and staff satisfaction has improved the overall morale for the cath lab team and we attribute a lot of that to ACE. Since our first accreditation, we have had minimal staff turnover and no use of travelers. Since the first accreditation, our Gallup scores (a measure of employee satisfaction) have continued to go up. 

What is it about external review that is so helpful?

L. Smith: External review reinforces to the cath lab team that our level of performance is nationally recognized as best practice. It is an ongoing process and is a core component of our long-term commitment to quality. We have learned that self-monitoring is limited in its ability to be effective.  External review is critical for identifying areas of improvement. We also knew we would get feedback on what we are doing right, which gave the team confidence that we are doing a great job for our patients.

After our first ACE accreditation in 2011, we knew we could rely on ACE external reviewers to provide recommendations on areas where we could improve the quality of care in our cath lab. For example, one physician was identified as needing to improve his image quality (to engage the coronary artery longer to improve visualization). The fact that this feedback came from an ACE reviewer, a highly credible source, caused the physician to changes his practice. ACE focused not only on the cath lab team but also on the physician’s clinical practice, which made a very positive impact on the staff. 

What were some of the changes you implemented as a result of the ACE review?

L. Smith: We instituted monthly case reviews to discuss challenging patient cases and the rationale of the physician for handling that case in that particular way. Previously, we had monthly morbidity and mortality reviews with physicians and leadership, but no case reviews with the actual cath lab team. These case review sessions have become very interesting and thorough, and the entire staff increases their knowledge and engagement.  

Did the review influence your approach to documentation? What changes did you see in the cath lab team?

L. Smith: The staff is highly engaged. It is great to be recognized for a job well done by local and national standards. For example, we weren’t routinely and fully documenting the patient’s symptoms prior to each procedure (so this was not flowing into the case report). This means that the hospital and the physicians were at risk for not meeting the Appropriate Use Criteria and potentially at risk for reduced reimbursement.  

A good example of this relates to the correct documentation of renal insufficiency versus renal failure following catheter-based procedures. Because of ACE, we became aware of the impact of lacking or incorrect documentation, and how improper coding of the same event can affect quality metrics and reimbursement. From a safety perspective, the Centers for Medicare and Medicaid Services (CMS) considers renal failure to be a complication of cardiovascular procedures. If we incorrectly document an episode of renal failure, it contributes to the complication rate for the facility. It is critically important that if renal failure is documented, that it meets a well-defined metric of clinical severity. 

Given your experience with accreditation and now reaccreditation, would you recommend ACE accreditation for other cath labs?

L. Smith: Oh, yes, I think every cath lab should consider accreditation. So much of the feedback is positive — it is important to understand which aspects of your process already meet the standards of care. The ACE review process allowed us to monitor our success, but also identify areas to improve the delivery of care. We pursued ACE accreditation and reaccreditation because we believe it ultimately benefits our patients.  

Facilities seeking ACE accreditation or reaccreditation can obtain more information and complete the application process at


  1. ACE. Perspectives on ACE Reaccreditation: the Healthcare Executive’s View. An Interview with Johnna Reed, RN, BSN. Available online at Accessed July 20, 2015.
  2. Perspectives on ACE Reaccreditation: The Interventional Cardiologist’s View. An interview with Thomas Siachos, MD. Cath Lab Digest. 2015 July; 23(7). Available online at Accessed July 20, 2015.