The Accreditation for Cardiovascular Excellence (ACE) is the exclusive international provider of interventional cardiology, electrophysiology, congenital heart disease and endovascular catheterization lab accreditation, and a valuable resource for asserting a commitment to the highest standards of care in invasive cardiology. Since 2011, (ACE) has reviewed the structure, internal processes, patient safety practices, and clinical outcomes of cardiac catheterization laboratories. To achieve ACE accreditation, facilities must demonstrate compliance with rigorous ACE quality standards that are based on published guidelines, expert consensus documents, and scientific data.
But what does accreditation mean on a practical level? Cardiac catheterization laboratory administrators, regulators, payers, and other stakeholders frequently ask about the value of the ACE review process to facilities that have been accredited through these reviews.
For the first time, stakeholders have quality metrics that confirm the value of achieving full ACE accreditation for diagnostic cardiac catheterization and percutaneous coronary intervention (cath/PCI) programs. Three new studies presented at the 2015 Society for Cardiovascular Angiography and Interventions (SCAI) Scientific Sessions in May 2015, validate the diverse benefits of ACE accreditation for cardiac catheterization laboratories, clinicians, and patients. [1-3]
While no cath lab is perfect, these studies indicate that ACE-accredited facilities are significantly more likely than non-accredited centers to meet nationally established standards for multiple structural, process-related, and procedural domains. In addition to providing credible data for stakeholders, these studies provide important guidance on how to evaluate cath/PCI programs against accepted quality standards.
Better Case-Level Quality Outcomes
In another component of the ACE review process, physician reviewers randomly select and review a 10% sample of PCI cases, or a minimum of 10 cases per operator for interventionalists and a 5% sample of diagnostic cases for all operators. Key performance variables include indications for the procedure, documentation of ischemia, diagnostic and revascularization appropriate use criteria (AUC) scores, angiographic quality, disease severity, lesion outcome, complications and overall case assessment. The ACE expert reviewers also evaluate metrics from the most recent facility ACC-NCDR CathPCI Registry report.
To identify potential performance differences between facility types, the first analysis compared case data from 1,728 patients undergoing invasive cardiac procedures at the 24 ACE-accredited facilities to data from 445 patients treated at the four facilities that did not initially meet the rigorous standards for ACE accreditation. All case review data were entered into a uniform case report form and analyzed with standard statistical software (JMP 12.0.0).
The analysis found statistically significant differences across multiple performance domains that differentiate the invasive procedures performed at ACE-accredited cardiac cath labs from those performed at non-accredited facilities. This means that ACE-accredited facilities are delivering quality cardiac care that is more likely to be consistent with national standards of cardiovascular excellence.
Multiple endpoints pointed to better angiographic quality in cases performed in the 24 ACE-accredited facilities compared with the four facilities that did not achieve accreditation. For instance, ACE-accredited facilities had more cases with adequate opacification (93 vs. 82%) and adequate lesion characterization (91 vs. 84%) compared with non-accredited facilities, as well as fewer cases with an inadequate number of views (12 vs. 17%).
Facilities achieving ACE accreditation were also more likely to have adequate lesion success (88 vs. 80%) and appropriate overall cases assessment (72 vs. 63%) compared with facilities that did not initially achieve accreditation.
Standardized documentation and reporting of key procedural details are critical for demonstrating appropriate use and medical necessity. An important distinction between facility types involves a significantly higher occurrence of no reported indication in non-accredited facilities (7.3%) compared with ACE-accredited facilities (3.7%). Conversely, ACE-accredited facilities were more likely than non-accredited facilities to report indications such as chest pain (12.3 vs. 9.2%), non ST-elevated myocardial infarction (NSTEMI) (10.6 vs. 8.1%), and valvular heart disease (3.6 vs. 2.1%).
In an analysis of diagnostic and revascularization AUC scoring, ACE-accredited facilities had a higher percentage of cases categorized as appropriate (41 to 67%) compared with non-accredited facilities (19 to 58%), as well as a lower percentage of cases that were either uncertain or did not have sufficient data in the procedure report to score the case.
These studies determine that, at the case level, variables such as indications for the procedure, angiographic quality, and procedural performance metrics including lesion success and complications differentiate procedures performed at ACE-accredited cardiac cath labs from those performed in non-accredited facilities.
To assess the perceived value of the ACE review process, ACE surveys all accredited facilities one year after they achieve full accreditation. All facilities complete a standardized questionnaire to assess structural changes in their program and value to their organization since completing their initial accreditation process. Open-ended comments are also encouraged to provide a more comprehensive assessment of the value of accreditation.
The second study examined these survey results to characterize the perceived value of ACE accreditation among cardiac catheterization laboratories. At the time of the analysis, 41 cardiac cath labs had undergone ACE review. Of these, 14 facilities (34.1%) had reached a minimum of one year since obtaining ACE accreditation.
According to the analysis, the value proposition of ACE accreditation touches every aspect of the cardiac catheterization laboratory, from enhanced patient safety to improved staff confidence and morale.
Most ACE-accredited facilities (93%) reported that accreditation adds substantial value to their organization in terms of improved care quality. In addition, the majority of facilities reported that the ACE external review process facilitated confidence in facility leadership in the laboratory (71%); validated the facilities’ internal review processes (71%); improved morale (64%); and validated the appropriateness of patient selection (64%).
In response to the open-ended questions, cardiac cath labs described multiple additional concrete benefits of ACE accreditation:
• Reduced radiation dosage due to improved monitoring
• Improved engagement in the peer review process by all members of the care team
• Greater standardization of care across individuals and care areas
• Demonstration to hospital administration that the cath lab was a leader in quality improvement and outcomes
Overall, most facilities took pride in their accomplishment in achieving ACE accreditation, with 86% of ACE-accredited cardiac catheterization laboratories reporting that they incorporated their accreditation status into their marketing efforts.
Of particular note, the vast majority of facilities experienced no changes in their physician leadership (93%) and no major equipment changes (86%). Instead, the observed changes in quality, safety, and morale were attributed to the ACE accreditation process.
With most cardiac catheterization laboratories describing clear improvements across a range of quality metrics one year after achieving full ACE accreditation, these findings support the value of ACE accreditation as a component of the quality improvement process.
Improved Structural and Process Factors
As part of the ACE accreditation process, experienced cath lab nurses visit each site and evaluate the facility relative to the ACE published standards. The reviews include more than a dozen structural, equipment, and process factors such as staff experience, equipment status, documentation practices and protocol adherence.
To identify potential structural and process differences between facility types, the third analysis compared 24 ACE-accredited facilities to four facilities that did not initially meet the rigorous standards for ACE accreditation. All facilities that apply to ACE, whether they initially obtain accreditation or not, receive continued coaching by the ACE team, to help them move forward on their quality journey. No lab is perfect, and ACE encourages all labs to apply, even if they are concerned about the likelihood of success because of a perception of gaps in meeting quality standards.
Among structural features, ACE-accredited facilities were more likely than non-accredited facilities to have a medical director with at least five years of experience (96 vs. 50%) and board certification in interventional cardiology (99 vs. 50%). In addition, nursing supervisor roles were more likely to be well defined in ACE-accredited than non-accredited facilities (100 vs. 50%).
ACE-accredited facilities were more likely than non-accredited facilities to meet process standards such as having staff with the appropriate nursing background (99 vs. 50%), having the appropriate personnel for the specific case mix (100 vs. 75%), having appropriate documentation of training (99 vs. 75%), and being in compliance with state regulations for practice (100 vs. 75%).
Together, these findings indicate that metrics such as focus on leadership, staff training and experience, documentation, and the presence of an internal quality program are critical for meeting national quality standards and achieving ACE accreditation.
Cardiac catheterization laboratories accredited by ACE are significantly more likely than non-accredited facilities to meet the highest-quality standards for key structural, process-related, and procedural domains. Furthermore, 93% of ACE-accredited facilities find that accreditation adds substantial value to their organization in terms of improved care quality.
In today’s increasingly competitive healthcare industry, cardiac catheterization laboratories must find practical strategies to differentiate themselves while upholding the highest standards of patient care. We now have data that clarify and support the value of ACE accreditation as an evidence-based tool for demonstrating excellence in cardiovascular care.
Co-investigators on the studies include Gregory J. Dehmer, M.D., MSCAI, MACC (Texas A&M University College of Medicine); Ralph G. Brindis, M.D., MPH, FSCAI, MACC (University of California, San Francisco); Charles E. Chambers, M.D., FSCAI, FACC (Penn State Hershey Medical Center); Mary E. Heisler, RN (ACE); and Christopher J. White, M.D., MSCAI, FACC (Ochsner Medical Center, New Orleans).
Editor’s Note: Bonnie H. Weiner, M.D., MSEC, MBA, MSCAI, FACC, is a past president of SCAI. She is board certified in internal medicine and cardiovascular disease. At Saint Vincent Hospital, Worcester, Mass., Weiner serves as director of interventional cardiology research and director of the cardiovascular medicine fellowship program. Also a member of the Saint Vincent Hospital catheterization lab team, she performs catheter-based procedures, including angiography, angioplasty and stenting.
1. Weiner B, Dehmer G, Brindis R, et al. “What structure and process characteristics identify ACE-accredited catheterization laboratories?” Presented at the 2015 Society for Cardiovascular Angiography and Interventions (SCAI) Scientific Sessions. May 6-9, 2015; San Diego, Calif. Abstract 13849.
2. Weiner B, Dehmer G, Brindis R, et al. “What outcome characteristics identify ACE-accredited catheterization laboratories?” Presented at the 2015 Society for Cardiovascular Angiography and Interventions (SCAI) Scientific Sessions. May 6-9, 2015; San Diego, Calif. Abstract 13862.
3. Weiner B, Dehmer G, Brindis R, et al. “The value of catheterization laboratory accreditation.” Presented at the 2015 Society for Cardiovascular Angiography and Interventions (SCAI) Scientific Sessions. May 6-9, 2015; San Diego, Calif. Abstract 13833.