comprehensive cardiac center certification...•providing direct care, or stabilizing and...

Comprehensive Cardiac Center

Certification

November 10th, 2018

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© 2018, The Joint Commission

The Joint Commission, in collaboration with the American Heart Association, will be offering a combined Comprehensive Cardiac Center Certification as of January 1, 2019, which merges the Joint Commission’s Comprehensive Cardiac Center Certification and the AHA’s Cardiovascular Center of Excellence accreditation

All revisions to the Comprehensive Cardiac Center Program reflect a collaborative review of existing requirements alongside the latest standards of practice and professional literature

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Objectives of this presentation

−It is our Mission to “Help Healthcare Organizations Help Patients”

−Today’s purpose:

• Highlight the value and benefits of Comprehensive Cardiac Center Certification program

• Provide an overview of the program, as well as revisions to requirements and standards

• Discuss Performance Measures

• Illustrate the pathway to becoming CCC certified

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Comprehensive Cardiac Center Certification: Values and BenefitsCraig Beam

PresidentPetra ICS

Former Chairman of the BoardAmerican Heart Association

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VALUE OF Comprehensive Cardiac Center Certification

•National networking

•Information and best practice sharing

•Collaboration

•Resources

•Mentorship

•National provider education and webinars

•Best practices to improve processes, quality indicator scores, patient care and outcomes

•Patient/Caregiver Education

•Toolbox of patient and caregiver resources

•Promotion of self-management

•Quality Improvement Consultants

•Collaboration on PI plan to improve patient care and outcomes

Online Community

Education Resources Consultation

•Promotion of systems of care

•Set public policy

•Develop legislative campaigns

•National presentation and showcase opportunities

•National promotions

•Marketing and communications toolkit

•Certified centers play an active role in setting national agenda, establishing key priorities

Advocacy Recognition Advisory Working Group

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Integrated Systems Approach

•Streamlines patterns of care across the Cardiovascular service line, identifies disparities in care, focuses on areas for quality improvement initiatives, and improves population health, community engagement and patient satisfaction

Staff

•Multidisciplinary collaborative care approach

•Allows for optimal delivery of high-quality patient centered care

•Staff engagement though working towards a common goal of certification connects staff to their work and can reduce turnover

Patients

•Increased patient satisfaction

•Confidence and trust in the providers meeting the highest quality of care

•Belief that staff is doing everything possible to promote best possible outcomes

•Quality cardiovascular care provided in the patient’s home community

Payors

•External validation that certified facility adheres to latest evidence-based medicine

•Demonstrates commitment to quality to patients, providers, payors and policymakers

•Improves quality, care coordination, and compliance with national care guidelines

VALUE OF Comprehensive Cardiac Center Certification

Comprehensive Cardiac Center Certification: Overview and RevisionsLisa Wilson, MBA, BSN, RN, CEN, NE-BC

Project Director-Clinical, Department of Standards and Survey MethodsThe Joint Commission

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What is Comprehensive Cardiac Center Certification with

The Joint Commission?

• The Comprehensive Cardiac Center (CCC) certification program is a

voluntary two year certification program that provides an

independent evaluation of an organization’s comprehensive cardiac

center services

• Biennial Onsite Reviews are two reviewers, two days

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TJC Standards for Disease Specific Care

Clinical Practice

GuidelinesPerformance

MeasuresPerformanceImprovement

What is Comprehensive Cardiac Center Certification with

The Joint Commission?

E-dition®

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Scope of the Comprehensive Cardiac Center

• Cardiovascular Risk Factor Identification and cardiac disease prevention

• Management, triage, and risk stratification of emergentcardiovascular conditions*

• Providing direct care, or stabilizing and transferring patients who require care beyond the scope of services provided*

• Providing for consultation, referral, and transfer arrangements*

• Planning for discharge, follow-up, and transitions of care*

*As of January 1st, 2019

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Scope of the Comprehensive Cardiac Center

• Management of Ischemic Heart Disease (AMI, STEMI, UA) through medical, interventional, and surgical care, including acute coronary syndrome treatments (CABG, ICD, PCI, Cath)

• Management of Cardiac Valve Disease (Replacement/Repair)

• Management of Dysrhythmias (electrophysiology services and outpatient device clinics)

• Management of Cardiac Arrest (prevention of in-house arrests, resuscitation, and targeted temperate management)

• Heart Failure management (including outpatient services)

• Cardiac Rehabilitation (either on site or by referral)

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Volume Requirements

• CABG: 125/year

• Valve replacement/repair: 50/year

• PCI: 200/year

• Primary PCI for STEMI: 36/year

• If volumes are not met, demonstration of risk adjusted outcomes reported to a nationally audited registry that meet or exceed the national average are required

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Revised Requirements

Certification Participation Requirements

−CPR 14 revised to include all hospitals compliant with federal laws, including Medicare conditions of Participation

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Revised Standards

CCCM Management

−CCCM.1: Program charter added with designated physician leader

−CCCM.2: Center executive leadership structure revised

−CCCM.3: Revised to span across the continuum of care

−CCCM.4 revised to clarify yearly review of order sets

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Revised Standards

CCCM Management (Continued)

−CCCM.5: Includes new and revised elements for a greater focus on system collaboration and safety

• EP2 (NEW) center has a process for receiving patients from other facilities and document care during transfer

• EP5 (NEW) center has evidence consistent involvement regional SOC at least every six months

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Revised Standards


−CCCM.6: Condensed and revised for clarity with a slight revision in education requirements

• EP 8 (NEW) ancillary staff require 2 hours CE

• EP 9 (REVISED) CV acute care RN’s 8 hours

• EP 10/EP 11 (REVISED) RN attending conference shares new knowledge with CV care delivery team

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Revised Standards


−CCCM.6: Condensed and revised for clarity with a slight revision in education requirements

• EP 12 condensed language and a new element ACLS for code blue responders

• EP 13 and EP 14 drills and debriefs

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Revised Standards


−CCCM 7 Physician and Interventional lab staff availability (REVISED)

• The intent of this requirement has not changed; requirements still assure availability of various disciplines

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Revised Standards


−CCCM.8: EP 4 (NEW) related to collaboration

−CCCM.10: EP 1 (NEW)

• Community Health Needs Assessment

• Community outreach and education

• 6 community sponsored events annually

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Revised Standards

CCCPI Performance Improvement

−CCCPI.1 organized and data-driven approach to quality and performance improvement

• EP7 PI committee meets minimum of 4x/year

• EP8 (NEW) Attendance quorum and member requirements

−CCCPI.2 Process for monitoring appropriateness of procedures

• EP 4 has been updated to include diagnostic coronary angiography

Comprehensive Cardiac Center Certification: Performance MeasuresPaula Farrell, BSN, RN, CPHQ

Associate Project Director – Clinical, Department of Quality MeasurementThe Joint Commission

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Performance Measures

−Centers seeking certification are required to select and report to The Joint Commission one measure for each of the following domains:

• Acute myocardial infarction (AMI)

• Coronary artery bypass grafting (CABG)

• Cardiac rehabilitation

• Diagnostic cardiac catheterization procedures

• Heart failure

• Implantable cardioverter defibrillator (ICD) procedures

• Percutaneous coronary intervention (PCI)

• ST-elevation myocardial infarction (STEMI)

• Valve replacement/repair

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Performance Measures

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−A nationally audited registry or similar data collection tool is used to monitor data and measure outcomes

−Aggregate monthly data values reported on a quarterly basis for each measure to The Joint Commission via CMIP on the Connect® portal

−4 months of collected data should be reported to The Joint Commission prior to the on-site review

−Looking Forward: Standardized measures are being developed, with a goal roll out 1/1/2020

Comprehensive Cardiac Center Certification: Roadmap to CertificationZach George, MBA, CPA

Associate Director, Business DevelopmentDisease Specific CertificationThe Joint Commission

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On-Site Review

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− You establish the ready-date

− Pre-announced, 30 days advance notice

− Two Reviewers, Two Days

− Be able to demonstrate consistent application of Joint Commission Standards and Clinical Practice Guidelines you’ve identified

− Will review the most recent 4 months of data on Performance Measures

− Tracer Methodology, walk through your processes/protocols by patient

− Preliminary Report provided during closing conference at the end of the 2nd day

− Remember this is an open-book test, your chance to show off the great things your program is doing

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Roadmap to Certification

ONLINE APPLICATION

• Complete through Connect® Portal

STEPS TO APPLICATION

• Review Standards in E-dition® and analyze gaps• Identify Clinical Practice Guidelines• Identify Performance Measures• Complete Performance Improvement Plan

ON-SITE REVIEW (typically occurs 4-6 months after application is submitted)

• 30 day advance notice• Upload most recent 4 months of data for Performance

Measures prior to visit• Two Reviewers, Two Days

No Data Uploaded at Application

MEET YOUR ASSOCIATE DIRECTOR

• [email protected]

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Benefits of Comprehensive Cardiac Center Certification

• Integration, Staff, Patients, Payers

• Promotes achievement Systematic approach to clinical care

• Promotes a culture of excellence across the organization

• Reduces variability and improves the quality of patient care

• Creates a loyal, cohesive clinical team

• Provides an objective assessment of clinical excellence

“As an organization committed to continuous quality improvement, achieving certification gives us a tremendous opportunity to keep pushing ourselves to

do better for our patients as The Joint Commission representatives share ideas and resources to help us improve , actually assisting the organization and

creating a higher quality program.”

-Jenevra FoleyOperations Director, Michigan Medicine

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Thank You!

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The Joint Commission Disclaimer

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− These slides are current as of 11/6/18. The Joint Commission reserves the right to change the content of the information, as appropriate.

− These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

− These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.

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