Accreditation

Chest Pain Center Accreditation

Wayne W. Ruppert, CVT, CCCC, NRP, Cardiovascular Coordinator,

Cardiac Cath Lab, Bayfront Health Seven Rivers, Crystal River, Florida

Wayne W. Ruppert, CVT, CCCC, NRP, Cardiovascular Coordinator,

Cardiac Cath Lab, Bayfront Health Seven Rivers, Crystal River, Florida

What is Chest Pain Center (CPC) Accreditation All About?

If you ask the CEO, you could hear, “It attests to the fact that our facility exceeds rigorous industry standards in caring for cardiac patients.” The CFO may tell you, “Overall, it’s a program that delivers a positive return on investment and reduces our readmission rates.” Here’s what other roles in the hospital might say:

  • Marketing Director: “Chest Pain Center accreditation is a PR and marketing windfall, and we love to feature the badges and icons!”
  • Cardiology Medical Director: “It helps our facility achieve a level of cardiac care that is consistent with current evidence-based practices.”
  • Cath Lab Team: “It helps us stay on top of our game in responding to ST-elevation myocardial infarction (STEMI) alerts.”
  • Nurses and EMS: “Chest Pain Center accreditation brought us a ton of valuable cardiac education.”
  • Emergency Department Medical Director: “It streamlined our workup for cardiac patients.”
  • Most importantly, patients: “They were awesome! When I said ‘chest pain’, they had me in an ER bed before my spouse could park the car. I was in the cath lab minutes later and they stopped my heart attack. They saved my life.”

If you ask the same question of me, a Cardiovascular Coordinator — the person who coordinates the accreditation process — my answer will vary. Sometimes I’ll say it promotes acid indigestion, hypertension, insomnia, and accelerates the graying of hair. But on most days, my personal answer will be, it is the best and perhaps most rewarding job I’ve ever had. However, every day, I will tell you that the Chest Pain Center accreditation process is an amazing, transformational journey that can convert a rural hospital that provides dismal cardiac care into an efficient, highly-tuned machine that provides a level of care on par with many large, urban, university-affiliated hospitals. I can make such an assertion because I have personally witnessed it, multiple times, and at multiple facilities.     

The primary benefit of the Chest Pain Center (CPC) accreditation process is that it improves cardiac patient outcomes and reduces variations in care. A secondary benefit is it improves efficiency and effectiveness of patient care processes. It does so by design, by assuring that the elements of patient care — patient evaluation, diagnostic testing and therapeutic interventions — are consistent with the latest evidence-based guidelines and best practices.    

The central components of CPC accreditation are physician order sets, nursing policies, procedures, and protocols; they are the instruments that drive every facet of patient care (Figure 1). While these items are far from glamorous, they comprise the structural framework of accreditation. How do you assure that the correct diagnostic tests, procedures, medications, and therapeutic interventions are ordered? The answer is, you provide a standardized physician order set that is consistent with the latest evidence-based guidelines or you implement an evidence-based nursing protocol, policy, or procedure that has been approved by your facility’s physicians. In a hospital, a nurse cannot give her own mother an aspirin without a physician order. Every action that occurs within a hospital is driven by a physician order or an approved nursing protocol, policy and/or procedure. Accreditation mandates that a hospital’s physician order sets, nursing protocols, policies and procedures, and hospital bylaws are consistent with the latest evidence-based guidelines and best practices. The American College of Cardiology (ACC) accreditation requirements mandate that safety considerations, such as medication contraindications and warnings, are built into order sets. The ACC provides sample order sets that hospitals can utilize.     

The peripheral components of CPC accreditation include anything outside the above items that has the potential to impact the outcome of patients with known or suspected acute coronary syndrome (ACS). These components extend beyond the walls of the hospital, starting with public recognition of heart attack symptoms and ending with the patient in cardiac rehab and follow-up care after their hospital discharge. In the ACC’s Cycle V Chest Pain Center with PCI and Resuscitation Accreditation, there are 352 components. The hospital must do everything within its power to reduce morbidity and mortality associated with heart disease within the community it serves. Many of these initiatives, such as the public education and community aid programs required for accreditation, have excellent PR and marketing benefits.   

To ensure that a hospital’s cardiovascular program structure and processes are effectively resulting in good outcomes, accreditation requires that a quality improvement (QI) program be utilized to continuously monitor and measure performance metrics. Examples of commonly used cardiovascular QI programs or data sources include the American Heart Association’s Mission: Lifeline, ACC’s QI Campaigns and Toolkits, the National Cardiovascular Data Registry (NCDR) Chest Pain - MI Registry, and ACC’s CPC Accreditation Conformance Database (ACD) that may be used in lieu of the Chest Pain - MI Registry.    

A key factor to providing consistent evidence-based care while streamlining hospital work processes is the Chest Pain Center Performance Improvement Committee. The ACC requires that the CPC Committee be comprised of C-suite executives, the emergency department (ED) and cath lab physician leaders, directors of quality, ED, cath lab, ICU, tele, med-surg, and laboratory, EMS, and frontline staff. By formal charter, the committee is tasked with evaluating all components of cardiac care such as physician order sets, protocols, policies, procedures, work processes, performance metrics, and outcomes. The committee utilizes industry-standard QI tools and forms specialized task forces to develop solutions to problems. As an example, during the gap analysis phase of our most recent accreditation process, our CPC Committee identified that our facility only had a 22% compliance rate for meeting the benchmark standard for “providing a troponin result within 60 minutes of patient arrival.” We formed a Troponin Turn-Around-Time (TAT) Improvement Task Force that consisted of ED and laboratory leadership, and focused on identifying and implementing solutions. An Ishikawa (fishbone) diagram (Figure 2) was used to dissect the original work process, and identify delays and inefficiencies. From this chart, we developed and implemented solutions (Figure 3 demonstrates the final result).      

The Chest Pain Center accreditation process provides hospitals with a structured template that converts the herculean endeavor of CPC accreditation into lists of manageable tasks. The ACC accreditation model provides hospitals with an Accreditation Review Specialist (ARS) to guide them through the entire process. The ACC’s “Cardiovascular Care Coordinator Certification (C4)” program prepares the hospital Cardiovascular Coordinator for this mission by providing the following education: team building, leadership, project management, data analysis, and application of quality improvement tools. It is a recipe for success.

The Accreditation Experience: A Transformational Journey

In 2012, I started a new job working as an interventional cardiovascular and electrophysiology (EP) lab technologist for Pasco Regional Medical Center, a 120-bed rural community hospital located in the small town of Dade City, Florida. In our single cath lab suite, we performed diagnostic cath, percutaneous coronary intervention (PCI), peripheral procedures, pacemaker/ICD implantations, and EP studies with limited, right-sided ablation therapies without onsite CVOR backup. Just a few months prior to my arrival at Pasco Regional, the Emergency STEMI program was launched. Our volumes were low, our reputation in the community needed improvement, and EMS typically encouraged patients to go to our competitor hospital, in the next town over.

Wanting to improve our overall cardiovascular service line performance (and hence our reputation and volumes), hospital administration decided to seek Chest Pain Center accreditation. Unbeknownst to me, I had been targeted for this assignment due to my prior background in the cath lab and EMS, my experience as a 12-lead ECG instructor, and my status as a Florida Nursing Continuing Education Provider. One morning I was summoned to the office of the CNO and after hearing her plan, I reluctantly accepted the role of Cardiovascular Coordinator. The CNO then produced an overstuffed, 4-inch-thick notebook (I’ll never forget the loud “thunk” it made when it hit the table in front of me). She said, “This is the accreditation manual. We have an empty office on 1-South. We’ll set you up in there. Now go get us accredited!” This event transpired in 2012 when the Accreditation Toolkit was only available in hardcopy. Today, this document — and the entire process of applying it — is totally electronic and is completed online, which is many times more user-friendly than it was back then.

I opened the binder, which was titled “Requirements for Chest Pain Center Accreditation” and was divided into the following sections:

  • Governance
  • Community Outreach
  • Pre-Hospital Care
  • Early Stabilization
  • Acute Care
  • Transitions of Care
  • Clinical Quality

Each section contained lists of numerous objectives known as “Essential Components (ECs),” and had descriptions of how each was to be carried out. All told, there were several hundred ECs that had to be addressed. As I reviewed many of the ECs, my heart sank; I suddenly had strong reservations about the new job I’d just accepted. To become accredited, we needed to have dedicated ED and Admission Order Sets for STEMI, NSTE-ACS and Low Risk Chest Pain. We needed about 25 different protocols for things like “ED Walk-In Chest Pain” and “Non-ED Patient STEMI Alert.” We needed multiple physician, nursing staff, EMS, and public education programs. None of these were in place. And this was the tip of the iceberg. I remember thinking to myself, I just bit off more than I could chew.    

I buried my head in the accreditation manual, in part because I’ve always been good at reading the instructions, but also to hide much like an ostrich does when frightened. I quickly discerned that we were obligated to form a Chest Pain Center Committee and I made a list of all key individuals who should participate.     

In a flash of inspiration, I decided to engage this group: we would share the responsibility of achieving CPC accreditation together. I would read the manual and determine which leader(s) “owned” each task, and prioritize items based on complexity and the estimated time needed to complete each. Prior to our first CPC Committee meeting, I met one on one with each leader to review their department’s role in the accreditation process and to perform a gap analysis. This would allow us to see where we currently stood and to generate a roadmap of things we needed to accomplish in order to achieve successful accreditation.      

I met with our two Fire Rescue agencies and learned our hospital had a dismal reputation with EMS providers. I invited the EMS chiefs to join our CPC Committee, welcomed their harshest criticisms, and promised we would work collaboratively to bring patient care to the level we’d want our own families to have should they become our patients.

By the time our first CPC Committee meeting rolled around, everyone was optimistic and eager to get started. By doing our departmental gap analyses in advance, everyone knew we had a long journey ahead. This would have been discouraging if not for our C-suite leaders, who made it clear they would support us every step of the way. If we made all of the improvements needed to achieve accreditation, it would spark a chain reaction: the care our facility would provide to cardiac patients would notably improve, along with patient outcomes. Our reputation in the community and with EMS would be restored, and that in turn would increase patient volume and revenue. But to me, the most remarkable benefit I observed was that this endeavor had become a unification factor. People who previously functioned independently of others, working in their own “silos”, started working collaboratively as a unified team with one common goal: successfully achieving Chest Pain Center accreditation. The results of this collaboration far exceeded the sum of what each person could have done alone.

In April 2013, I attended the “Cardiovascular Care Coordinator Boot Camp,” and was pleased to learn that our approach to coordinating our accreditation efforts was on target.   Also, I gained a healthy insight into the use of QI analytical tools.

Throughout the 12-month pre-accreditation process, we abstracted charts and manually tracked multiple performance metrics, including things like door-to-electrocardiogram (EKG), door-to-EKG read by provider, door-to-troponin turnaround time, and for STEMI patients, door-to-PCI. (Today, the ACC’s Accreditation Conformance Database [ACD] provides full Calculated Measures Reports for tracking these metrics). We formed task forces to address multiple deficiencies. We broke down and examined work processes, looked for ways to improve every piece of each process, and then constructed new techniques that worked. We incorporated all of these system improvements into a universal flowchart, which depicted our “new and improved way of doing things” (Figure 4). We engaged in joint training sessions with Fire Rescue EMS personnel. This included numerous 12-lead ECG in ACS courses, STEMI drills, and cath lab observation sessions with EMS. During the latter, we reviewed ECG abnormalities and correlated them with angiographic findings in the cath lab, and also reviewed things EMS could do to improve patient flow during STEMI alerts.

Over the next 8 months, our average door-to-PCI times dropped from 74 to 48 minutes. We also had two 13-minute and one 12-minute door-to-PCI, each the result of rapid STEMI Alert notification by EMS and early cath lab activation. About this time, I thought to myself, is it just me, or is EMS bringing us more patients? My answer came a few weeks later when I met with our local EMS chiefs. One chief smiled and said, “Our crews tell us they are now encouraging cardiac patients to come here. You guys have STEMI patients bypassing the ER and going straight to the cath lab. That doesn’t happen at the hospital down the road” (our competitor). Then his expression became serious. He looked me in the eye and said, “It’s amazing. Never thought I’d see it happen, but you guys have really turned this place around.”

As a way to celebrate our mutually achieved success, we sponsored a Lifesavers’ Award Banquet. We invited the EMS crews, along with the ED and cath lab teams who saved the lives of STEMI Alert patients. We also invited the patients and their families. Criteria for inclusion were that patients must have suffered cardiac arrest and survived. The first banquet was held in 2013, and has been repeated every year since. After eating a catered meal, each Lifesaver was presented with a framed “Citation of Meritorious Performance”. Over 80 people attended this poignant event, along with reporters from the local newspapers. The following day, the event made the front page of the Dade City News. The banquet was so successful it became a much-anticipated annual event (Figures 5-6 are from Bayfront Health Seven Rivers’ 2019 event).

To satisfy the several community service-related CPC accreditation requirements, we implemented a program called “Neighbors Saving Neighbors.” Together with EMS, the hospital provides Hand-Only CPR/AED training to members of a community. We also donated several AEDs. Community residents partner with ReadyAlert, a service that links to the county 911 dispatch center and automatically rings responders’ cell phones when anyone in the community calls 911 and reports someone is “unconscious and not breathing.” Responders are able to reach the victim’s home in less than 2 minutes to start CPR and provide an AED shock. In our first year, we trained 274 responders in 3 communities (Figure 7). Like the Lifesavers’ Banquet, this resulted in free media coverage for the hospital and EMS.

The Site Visit

After a year of intense work, the day arrived for our formal CPC site visit. In the two weeks preceding this day — December 18, 2013 — I had worked over 130 hours. When our Accreditation Review Specialist (ARS) arrived at 6:30 am, I’d been awake for over 20 hours. Pumped on adrenaline and caffeine, I gave our PowerPoint presentation to our ARS, the 70+ hospital team members, and EMS providers crowding the small auditorium. The presentation consisted of recapping the many accomplishments we had made over the past year, as well as some (HIPAA-compliant) slides of team members engaged in patient care activities, CPC Committee members during brainstorming sessions, and some photos from our Lifesaver’s Awards Banquet. When the photo of a STEMI cardiac arrest/therapeutic hypothermia survivor hugging the cath lab nurse who helped save her life was projected on the screen, I glanced at our ARS; she was dabbing her eyes with a Kleenex. Hours later, after the ARS conducted her full on-site review, we were called back into the auditorium. As the ARS started her summation of findings presentation, the fatigue had finally caught up with me; the next thing I knew, someone was shaking me and I heard clapping and shouting. It was Doug Clemson, our cath lab director, grinning ear-to-ear. “We did it, brother, we did it!” he exclaimed.     

After doing some of my own clapping and whooping, I was asked to address the group. My speech was short. As I approached the podium, a voice shouted, “Way to go — you got us accredited!” I picked up the microphone and responded, “Thank you, but no, I did not get us accredited; all of you in this room did. My job as CV coordinator is like being the conductor of a band, and each of you are the musicians.” I then made eye contact with the group as I pointed to everyone around the room. “Without each of you doing your jobs, I would just be a solitary man waving a little baton in an empty room — and there would be no music. The amazing improvements we’ve made to our hospital in the past year resulted from the dedication and hard work performed by each of you. And by all of us pulling our resources together. That’s what got us accredited. I thank and congratulate each of you, and I’m honored to have been your conductor.” The group gave a standing ovation, and I will never forget the intense vibe of positive energy emanating from that energized group.     

In the ensuing 7 years, I have coordinated five accreditation projects: three Chest Pain Center and two Atrial Fibrillation accreditations. At Bayfront Health Seven Rivers, we are working on our second (and my sixth) accreditation process:  Heart Failure Accreditation, Version 3, with the American College of Cardiology.

In Conclusion

CPC accreditation is a well-designed, multifaceted performance improvement program, and would benefit any hospital seeking it. Smaller community hospitals with minimal cardiovascular sophistication stand to gain the most. Hospitals with well-developed cardiovascular programs, such as large, urban, university-affiliated medical centers, would require less time and effort to meet accreditation standards. Even if a hospital’s patient care practices are state-of-the-art, every hospital stands to benefit from the enhanced internal communication, collaboration, and team-building aspects indigenous to the accreditation process, as well as system reviews that could improve patient throughput. And the community recognition and positive publicity associated with accreditation certainly will not hurt any hospital’s reputation.      

For hospitals interested in pursuing one or more cardiovascular accreditations, there are several credible entities offering various forms of accreditation (the following is not necessarily a complete list): Accreditation for Cardiovascular Excellence (ACE), The Joint Commission (TJC),  American Heart Association (AHA), and the American College of Cardiology (ACC). ACE (www.cvexcel.org) offers several accreditation products, and has a strong focus on radiological safety and excellence. TJC, the well-known CMS-affiliated accreditation agency (www.thejointcommission.org), and American Heart Association (www.heart.org) teamed up in January 2019 to offer multiple levels of hospital cardiac center certifications. The American College of Cardiology’s Accreditation Service (https://cvquality.acc.org/accreditation) currently offers several cardiovascular accreditation products: Chest Pain Center (3 Designations), Heart Failure, Cardiac Cath Lab, EP Lab, and Transcatheter Valve Certification.

The Bayfront Hospitals (including my facility) and our corporate parent chose the American College of Cardiology due to their academic expertise and clinical focus in cardiology. The ACC is an international leader in cardiovascular research which authors a majority of the evidence based cardiovascular Best Practices and Guidelines, and credentials all cardiologists to practice cardiology. Their academic resources, the clinical guidelines and academic white papers that I’ve use to author order sets, protocols, policies and procedures, are second to none. Our physicians respect the accreditation process, no doubt because many of them are board-certified through the ACC. I have completed five accreditations with the ACC.     

Can hospitals accomplish what we did without engaging in a formal accreditation program? Absolutely!   However, the beauty of “accreditation” is that everything comes in one neatly structured package, you get a professional “coach” (the ARS), and when it is all said and done, you get the recognition (you rightly deserve) by marketing your status as an accredited Chest Pain Center. Accreditation is one of those rare things where all involved parties benefit:  patients, hospitals, EMS, and the general public. It’s a true win-win experience, and for most hospitals, it’s a true game-changer. 

Email Wayne Ruppert, CVT, CCCC, NRP, Cardiovascular Coordinator, at wayneruppert@gmail.com.