Perspectives on ACE Reaccreditation: The Interventional Cardiologist’s View

In February 2014, Bon Secours St. Francis Health System in Greenville, South Carolina, was the first hospital to receive reaccreditation for its cardiac catheterization laboratory and CathPCI program from the Accreditation for Cardiovascular Excellence (ACE). Reaccreditation was another accomplishment for Bon Secours St. Francis Health System, which was the first hospital to be nationally recognized with ACE accreditation in 2011.

ACE accreditation is a strategic, long-term approach to quality improvement based on comparing information collected against national data and best practices as defined by experts in the field of interventional cardiology. Programs that achieve full accreditation are recognized by ACE for two years, at which time their facility must be reviewed again for continued recognition. To achieve ACE reaccreditation, the physicians and staff at Bon Secours St. Francis Health System worked hand-in-hand 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 consensus documents. Reaccreditation recognizes the hard work and commitment of all members of the catheterization team.

Perspectives on ACE Reaccreditation is a 2-part series that explores the ACE reaccreditation process from inside the cath lab. In August, Lynn Smith, Director of Heart and Vascular Services at Bon Secours St. Francis Health System, will offer her insight on the ACE reaccreditation process from the perspective of the cath lab director. Below, A. Thomas Siachos, MD, shares his viewpoint on the ACE reaccreditation process as an interventional cardiologist with Bon Secours St. Francis Health System.

Dr. Siachos, why did Bon Secours St. Francis Health System pursue reaccreditation with ACE?

Our hospital is somewhat unique in that the physicians and administration work very closely together to monitor quality and ensure that patients receive excellent care. But we know that self-monitoring is only so effective; external review is critical for identifying areas of improvement. Having gone through 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 the cath lab. We also knew to expect feedback on what we are doing right, which gives us confidence and peace of mind that we are doing a good job for our patients. As part of our long-term commitment to quality, we knew that external review would be an ongoing process. We wanted to develop continuity with the ACE review committee, so reaccreditation with ACE was an easy decision.

What was the ACE review experience like?

The ACE reviewers are clearly experts in interventional cardiology with an excellent grasp of all facets of cardiac care. Over time, we had an opportunity to interact with multiple ACE reviewers in our cath lab. They were easy to work with, respectful, and non-intrusive. For people who may be hesitant to allow that kind of access to your cath lab, it is important to understand that they are there to help, to make things better for your physicians, staff, and patients. When you are able to regard the reviewers as your partners in quality improvement, it is easier to embrace their recommendations. In fact, their recommendations were completely appropriate. None of our 18 physicians disagreed with anything the reviewers said. We have had reviewers from a range of organizations in our cath lab, including The Joint Commission, the American Heart Association Get with the Guidelines (AHA-GWTG) initiative, and the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR). The ACE reviewers gave us more directly relevant recommendations for improving the quality and process of care than any other review committee to date. 

What is it about external review that is so helpful?

It’s having another set of eyes review your performance. The ACE reviewers know what they are talking about; they know what’s being done around the country to provide the highest standards of care. As an example, after examining some of our imaging studies, the reviewers noticed suboptimal contrast opacification of the vessels in some cases where transradial access was used. This allowed us to tweak our process to ensure that we were providing the best care for every patient. There is also the psychological component of hearing an outside perspective. When an external expert tells you something needs to be fixed, the recommendation holds more weight than if your colleague were to make the same suggestion. The reviewers opened our eyes to deficiencies in our process, and they were able to make some suggestions that we had not considered on our own.

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

As a result of the review, we had multiple practical recommendations that we could implement immediately. One example of a simple change with a major potential impact on the quality of care was instituting monthly catheterization conferences to review notable patient cases and discuss the performance of the full cath lab team. Physicians routinely participate in cath conferences in the academic medical setting, but we tend to let go of this tradition in private practice. By starting our own monthly meetings with a standardized format to review our performance, we have reintroduced the rigorous peer-review culture of academic medicine into our small, non-academic private practice.

Did the review influence your approach to documentation?

Yes, absolutely. The ACE reviewers identified that we needed to standardize our cath lab reporting system at every step of patient care. Our practice had 11 interventional cardiologists with 11 different approaches to case dictation. In addition to the lack of standardization, we also had weak documentation to support AUC. For example, we weren’t routinely and fully documenting the patient’s symptoms prior to each procedure, or documenting the anatomy observed during the procedure. Our challenge was to shift from 11 different approaches to dictation to one standardized reporting format.  

We all know of facilities that have gotten into trouble with the Centers for Medicare and Medicaid Services (CMS) as a result of poor billing and coding practices. We all feel the increased scrutiny from outside sources. To avoid problems with inappropriate procedures, physicians have to be able to justify their clinical decisions. Documentation is everything; by putting a standardized documentation process in place, facilities can minimize their risk. Documentation prior to and during the procedure is what will mandate whether the procedure is appropriate. Getting cardiologists to think about how to maximize documentation to prevent inappropriate catheterizations takes a lot of training and a lot of work, but it is doable. We are now in the process of providing an extensive didactic review of best practices in documentation for all of the cardiologists in our practice. We are also developing a tool to streamline documentation. Our goal is to have a single handout that condenses the AUC requirements into an easily absorbable format for all of our cath lab members. Multiple resources are available to help cath labs to improve their documentation. In 2014, the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography (ACC/AHA/SCAI) issued a health policy statement that endorses new standards for structured reporting of clinical and operational data for cardiovascular procedures. As outlined in the health policy statement, structured reporting provides a framework for cath labs to document the appropriate level of clinical and administrative detail to meet the AUC for coronary revascularization.

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

Yes, I think every cath lab should consider accreditation. I know it’s not always fun to hear about things that need to be fixed. But it is so valuable to have another set of eyes — completely separate from your own insular community — to examine your process and provide recommendations to minimize complications and maximize safety for your patients. Much of the feedback is positive — it’s equally important to understand which aspects of your process already align with 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 will ultimately benefit our patients. 

Facilities seeking ACE accreditation or reaccreditation can obtain more information and complete the application process at:https://www.cvexcel.org