The document discusses accreditation for cardiovascular excellence (ACE) and provides information about the ACE accreditation process and its benefits. The 5 step ACE accreditation process involves: 1) reviewing ACE standards, 2) collecting data and preparing the application, 3) initial ACE review of the application, 4) an onsite review, and 5) ongoing reporting. The onsite review involves record reviews, policy reviews, facility tours, and interviews. Maintaining ACE accreditation requires ongoing data reporting and notifying ACE of any major program changes. While the accreditation process requires work, it is presented as the best tool to ensure hospitals are meeting quality standards for cardiovascular care.

1. Accreditation for Cardiovascular
Excellence (ACE)
Jane Kiah, M.S., R.N., Director, Invasive Services

2. Any new process fails or succeeds according to
the participants viewpoint….

3. • But despite the work involved in the process, we
would benefit from a review of the FACTS of ACE
Accreditation despite a warning from Rex W.
Huppke, the Chicago Tribune reporter who declared
several weeks ago that FACTS died at the age of
2372….
” To the shock of most sentient beings, Facts died
Wednesday, April 18, after a long battle for relevancy
with the 24-hour news cycle, blogs and the Internet
….Facts is survived by two brothers, Rumor and
Innuendo, and a sister, Emphatic Assertion.”

4.  Obviously quite a few
regulatory agencies have
not accepted this
paradigm shift…. Elvis is
still in the Healthcare
industry it seems since
we are increasingly
governed by factually
based criteria and not by
“emphatic assertion” of
appropriateness.

5. Administrative Benefits of
ACE Accreditation

6. Quality Measures Reporting
Now a Fact of Life in Healthcare

7. Data Registry Participation is Required
or at Least Expected
Hospital Level
Internal Decision
Support
Service Line Specific

8. Pay for Performance
Way Beyond Core Measures
ARRA and HITECH
Improper Payment
Elimination and Recovery Act
Comprehensive Error Rate Testing (IPERA)
(Cert) Program
www.cms.gov/CERT

9. What are these measures and
where did they come from…?
 RAC Program = $
 Comprehensive Error Rate Testing
(Cert) Program = $
 Efforts by the government to control
healthcare costs

10. Recovery Audit Contractor (RAC) Program
• Made permanent by the The Tax Relief and Health Care
Act of 2006 to identify improper Medicare payments -
both overpayments and underpayments-in all 50
states.
• RACs are paid on a contingency fee basis, receiving a
percentage of the improper overpayments and
underpayments they collect from providers
• RACs may review the last three years

11. RAC Program:
Major Causes of Improper Payments
 Physician orders missing
 Illegible/missing signatures
 National policy or Local policy requirements not met
 The medical record does not support medical necessity

12. Comprehensive Error Rate Testing
(Cert) Program
January -February, 2012- Cardiac
 DRG 247 Percutaneous Cardiovascular Procedure 30% review
w/ Drug Eluting Stent w/o MCC
 DRG 253 Other Vascular Procedures w/CC 30% review
 DRG 264 Other Circulatory System OR Procedures 30% review
 DRG 287 Circulatory Disorders Except 30% review
AMI w/Cardiac Cath w/o MCC
 DRG 251 Percutaneous Cardiovascular 30% review
Procedure w/o Coronary Artery Stent w/o MCC

13. Comprehensive Error Rate Testing
(Cert) Program
Amended the Improper Payments Information Act of 2002. Signed by
the President on July 20, 2010
• Designed to improve agency efforts to reduce and recover improper
payments
• Identification and estimation and risk of improper payments.
• Improper Payment: Any payment to the wrong provider for the
wrong services or in the wrong amount
• Overpayments and underpayments:
 Didn‟t meet the statutory coverage requests
 Didn‟t meet the Medical necessity requirements
 Incorrectly coded
 Didn‟t submit sufficient documentation

14. Hospitals and Physicians
all have skin in the game and need to
work it out together

15. ACE Accreditation
is the best tool
currently available
to make sure
you‟re rolling down
the right path.

16. The ACE Accreditation Process

17. The ACE Accreditation Process
5 Steps:
1. ACE Standards Review
2. Data Collection and Application Preparation
3. ACE Initial Review of Application
4. Onsite Review
5. Ongoing Reporting of Data, Lab or Operator
Changes, Significant Events

18. Step 1: ACE Standards Review
• Review applicable lab ACE Cath/PCI Standards –
(Full service, labs without on-site cardiac surgery, hospital based
diagnostic labs or free standing lab facilities)
• Perform a gap analysis of structure, process and outcome
standards to determine eligibility and readiness
• Develop a Process/Performance Improvement Plan for
outlier indicators to meet accreditation criteria

19. Domains
• Facility • Medical Records – Clinical
• Equipment documentation and
results reporting
• Leadership structure
• Procedure indications
• Fellows and physician and informed consent
extenders
• Procedure preparation
• Nursing personnel and conduct
• Technologists and other • Outcomes: Data
personnel collection
• QA Program and CQI
processes

20. Performance Metric Requirements
STEMI Process Metrics Requirement
STEMI patients receiving ASA on arrival (no contraindication to ASA) ≥ 95%
STEMI patients receiving ASA at discharge (no contraindication to ASA) ≥ 95%
Heart Attach Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction ≥ 90%
(LVSD) (no contraindication to ACE and ARBs)
Statin at discharge in patients with dyslipidemia (no contraindications to statin use) ≥ 95%
Heart Attach Patients Given Smoking Cessation Advice/Counseling ≥ 95%
Heart Attach Patients Given Beta Blocker at Discharge (no contraindication to beta-blocker ≥ 95%
use)
Heart Attach Patients Given PCI Within 90 Minutes Of Arrival ≥ 80%
Readmission within 30 days for an unanticipated problem related to the initial STEMI ≤ 20%
STEMI Outcome Metrics
In-hospital risk-adjusted mortality for STEMI patients receiving PCI ≤ 7.5%
Unadjusted in-hospital mortality for STEMI patients ≤ 10%
Transfusion of whole blood or RBCs post PCI (excluding CABG patients)* ≤ 7%
Major bleeding (excluding CABG patients)** ≤ 12%

21. Robust Quality Assurance and Improvement
Program
Credentialing and
Re-Credentialing
Clinical Outcome Peer Review of All
Indicators Operator
Performance
Accurate and Assessment of AUC,
informative angiographic quality,
completeness and
reports and accuracy, fluoro time
documentation and contrast

22. Step 2: Data Collection and
Application Preparation
Documentation to support standards compliance:
• Credentialing
• Education and training
• Policies
• Procedures and indications
• Equipment
• Quality Improvement Program
• Performance improvement project in process or
completed
• Peer Review Process
• Clinical Outcomes

23. Step 3: ACE Initial Review
• Electronic submission of application forms, data and
payment
• ACE conducts review of documents and notifies of
acceptance for accreditation consideration
• Telephone conference to review application questions
• Site visit scheduled
• Site visit requirements, surveyor needs and agenda
distributed

24. Step 4: Onsite Review
• 3 Experienced Nurse Reviewers and a 2 ½ day survey
• Require access to computer terminals and a navigator to
help
• Review of 10 records of each operator including
hemodynamic logs, and angiograms, non-invasive studies
• Policy and Procedure Manual review
• Tour of facility, labs, prep and recovery areas
• Review of equipment and PM logs
• Observation of procedures
• Personnel files and staff interviews

25. Step 4: Onsite Review
• Interviews with Medical Director, leadership team, data
coordinator Quality Assurance and Peer Review Coordinators
• Review of QA process and documentation
• Download studies and records to bring to Medical Review
Board
• Prepare summary report
• Medical Review Board review
• Final review and recommendation for full or provisional
accreditation in 2 to 3 months

26. Step 5: Ongoing Reporting to ACE
• Quarterly NCDR CathPCI Registry
Institutional Outcome Reports
• Major program changes-
 Medical Director
 Operators
 Equipment or procedures
 Sentinel event

27. Helpful Hints
• Address gaps in structure, process or outcomes early
(SCAI Quality Improvement Toolkit a great resource)
• Audit to ensure protocols and practices are consistently
followed
• Ensure HIM department has process to store outside
functional studies
• Structured reporting templates that include all
required data elements is vital
• „Do Not Use‟ abbreviations in dictation
PCI transcribed as “Post Coronal Irradiation”

28. Helpful Hints
• Implement an „Appropriate Use‟ process ASAP
• Transfer of medical records and images to ACE remote
server requires planning and dedicated personnel
• Schedule site visit when all key team members are
available
• ACE Reviewers give great advice!!

29. Is the process worth the
pain?
Here are some “Emphatic
Assertions”

30. Thank You!