Cardiovascular Rounds

Navigating the new CV accreditation landscape

by Megan Tooley Director

For years, CV service lines have pursued formal accreditation or certification to both improve clinical quality and distinguish their programs in a competitive marketplace. However, with the growing demands placed on CV programs to cut costs, many administrators are being forced to reevaluate which accreditation programs are right for them, and ensure they can gain the most value from them.

This process is complicated by the fact that the number of accreditation options is increasing. Furthermore, existing accrediting bodies are evolving the metrics of evaluation to align with value-based care, adding criteria like appropriate utilization, and patient-centered care delivery.

To navigate these complexities, the Cardiovascular Roundtable has developed a CV Accreditation Crosswalk and identified strategies programs are using to optimize their investment.

We’ve outlined below the three key challenges members face when pursuing CV accreditations paired with tools and best practice guidance to help tackle each. 

Challenge 1: Selecting the “best-fit” accreditation program


CV Accreditations Crosswalk

Get an “at-a-glance” view of the following characteristics:

  • Name of accreditation
  • Sponsoring organization
  • Key application requirements
  • Steps for accreditation
  • Cost
  • Potential benefits
  • Number of participating programs

GET THE CROSSWALK

The first step to a successful accreditation strategy is evaluating the available options to determine if they would be valuable for your program. However, this can be harder than it sounds: there are over twenty major CV-specific accreditations that institutions could pursue either to gain recognition for a strong CV program or to bolster a program in need of process improvement. Many of these overlap with one another, making it difficult to know which accreditation to choose. For example, there are five different options for Heart Failure accreditation alone. There are also fourteen different cardiovascular related diseases for which a program could pursue Joint Commission Disease Specific Certification—that’s more options than any other major service line.

To help members sort through and assess the multiple options, we’ve created the CV Accreditation Crosswalk. This tool summarizes the major accreditation and certification programs for CV services (including interventional cardiology, chest pain, heart failure, a-fib, diagnostics, and more), and outlines the key information you need to know to make a decision, such as requirements, steps of the accreditation process, costs, and potential benefits.

Use this resource to determine if there are accreditations that align best with your program’s strengths and strategic aims—we’ve even included the links to the supporting organizations so you can get further information on the application process if you decide there’s strategic value for you.

Challenge 2: Efficiently navigating the accreditation process

Having identified which accreditations are best for their organization, CV administrators will need to develop an efficient approach to manage the accreditation process itself. Each accrediting body has its own requirements, which involve significant data collection, documentation, and material submissions. This time-intensive task often falls on the shoulders of already time-strapped administrators or staff, which can be inefficient and ineffective.

In response to this challenge, Genesis HealthCare System, a 350-bed community hospital in Zanesville, Ohio, has streamlined the accreditation process for CV by creating a CV Accreditation Coordinator role. In 2011, CV leaders at Genesis decided to seek certification to bolster a new a-fib program. Administrators had realized that the lack of a strong EP program was resulting in significant volume leakage to a competitor. So when asked to be the beta site for the Society of CV Patient Care (formerly Society of Chest Pain Centers) atrial fibrillation accreditation, administrators realized the potential of the certification process to encourage organization and gain publicity.

Given the aforementioned complexity of the certification process, Genesis decided to dedicate a nurse accreditation coordinator to oversee the various ongoing projects required for certification. Having already led Genesis through heart failure and chest pain accreditation, her familiarity with the processes proved invaluable in helping them meet the necessary requirements for this new certification. As a result of her efforts, they became the first U.S. hospital to receive full SCPC atrial fibrillation certification, while maintaining their chest pain and heart failure accolades. The accreditation coordinator now acts as the key point person overseeing Genesis’s CV certifications, ensuring they are maintaining the required standards, centralizing data submission, and incorporating these accolades into outreach efforts.

Genesis credits the certification process with presenting an opportunity for thorough self-examination of the quality and effectiveness of their a-fib program, enabling them to identify areas for improvement and key goals for their program.

 

You can learn more about Genesis HealthCare’s a-fib program in our publication Blueprint for Atrial Fibrillation Centers.

Then, Download Genesis HealthCare’s CV Accreditation Coordinator job description.

Challenge 3: Optimizing the value of accreditation

Finally, CV leaders will need to ensure their program is capturing the most ROI from their accreditation.

While accreditation programs can drive improvements in a variety of ways, they do come at a cost in terms of financial investments, staff, and time. Therefore, before deciding to invest in pursuing accreditation, programs must ensure they clearly understand what they aim to achieve through the process beyond just the title, and how.

Commonly cited benefits and drawbacks to pursuing accreditation:

Benefits:

Drives process and quality improvement efforts
Supports adoption of evidence-based best practices
Reduces variation across sites as all working toward same standard, protocols
Market differentiation, in both physician and patient marketing
Evidence of commitment to quality

Drawbacks:

Cost of certification
Difficult to secure executive buy-in
Resource investments needed to meet standards
Time and staff investments necessary to oversee submission
Unclear ROI

For one example of how you can leverage accreditation for performance improvement, we’ll turn to Ochsner Health, a non-profit health system in Louisiana. CV leaders at Ochsner used the process of pursuing IAC (Intersocietal Accreditation Commission) Echocardiography Lab accreditation as an opportunity to standardize performance and QA standards across their vast CV imaging network.

When first evaluating accreditation, CV leaders recognized the resources needed to manually abstract data for all echo labs would be daunting as there was significant variation in data collection protocols and processes across sites. Therefore, administrators created a set of metrics—using IAC standards—that all echo labs would report on, and ensured they were calculated in a standardized manner. Then, the CV leaders engaged IT personnel to develop new queries and reporting in the cross-site CV information system, which allowed for easy data abstraction and near real-time analysis across the network.

By having all reporting elements within their CVIS, Ochsner administrators are able to seamlessly and more efficiently pull required IAC data for all accredited sites, while also eliminating errors previously experienced with the manual abstraction process. In sum, Ochsner has been able to capitalize on the requirements set forth by IAC as a forcing function to elevate performance reporting and protocols across sites.

Access Ochsner’s full case profile and more in our publication Reframing CV Imaging Growth Strategy.

Learn more

Ultimately, accreditation can be a powerful way to internally improve and distinguish your program in the market, as long as you carefully evaluate what options are best for your program, have a strategic approach for effectively obtaining and maintaining the certification, and leverage the process to achieve broader strategic goals. For more information, access the resources below.

Accreditation resources for Cardiovascular Roundtable members