ACHA ACHD Accreditation Document Requirements for Each of the Criteria. ACHA ACHD Comprehensive Care Center

Transcription

1 ACHA ACHD Accreditation Document Requirements for Each of the Criteria ACHA ACHD Comprehensive Care Center 2016

2 Table of Contents A. ACHD Cardiologist... 3 B. ACHD Medical Program Director... 3 C. Advanced Practice Nurse/Physician Assistant... 3 D. Registered Nurse... 4 E. Cardiothoracic Surgery and Cardiothoracic Intensive Care Unit... 4 F. Heart Failure, Heart Transplant, Heart/Lung Transplantation... 4 G. Interventional Cardiac Catheterization... 6 H. Interventional Electrophysiology... 6 I. Inpatient Services... 7 J. Outpatient Services... 8 K. Transitional Services... 8 L. Patient-Centered Care... 9 M. Echocardiography N. Cardiac Magnetic Resonance Imaging O. Cardiac Computed Tomography P. Pulmonary Arterial Hypertension Q. Exercise Testing and Cardiac Rehabilitation R. Reproductive Services S. Psychology and Social Work Documents Requiring Signatures... 14

3 Note: The letter/number (i.e., F2.) references the specific criteria to which the document applies. A. ACHD Cardiologist(s) A1 Number of ACHD certified or ACHD eligible cardiologists (Select from drop-down) A1 Contact information for ACHD Cardiologist(s) (Enter: name, address, institution(s), , phone number, title, medical license number, years practicing as an ACHD provider, and if their institution is pediatric, adult, or both) A1 ACHD Cardiologists CVs (Upload) A2 Indicate if ACHD Cardiologists are Board certified/board eligible in pediatric or internal medicine cardiology (Select: Yes/No from drop-down) A3 Indicate if the ACHD Cardiologists are Board eligible for ACHD certification/board certified in ACHD cardiology (per ABIM board certification) (Select: Yes/No from drop-down) A4 Indicate if ACHD Cardiologists are ACLS certified (Select: Yes/No from drop-down) o If Yes, upload the ACHD Cardiologist(s) ACLS certification(s) A5 ACHD Cardiologist(s) involvement as ACHD professional(s): o Education of professionals interested in learning more about the ACHD field (Describe) o Publications (Provide links) o Participation in CME ACHD education (Describe) o Time spent in the service of CHD/ACHD organizations (Describe membership/leadership in organizations over the past 5 years) B. ACHD Medical Program Director B1 Indicate if the Medical Program Director is also listed as an ACHD Cardiologist (Select: Yes/No) o If Yes, select the ACHD Medical Program Director from drop-down o If No, enter the name, address, institution(s), , phone number, title, medical license number, and years practicing as an ACHD provider B1 ACHD Medical Program Director s CV (Upload) B2 Letter from the Division Chief that supports/confirms their position as leader of the ACHD program (Upload) B3 Information related to the Adult Congenital Heart Association (ACHA) National Conference (Enter) o Conference attended in the last 5 years (Enter: Year) o If the ACHD Medical Program Director did not attend, indicate who represented your program at the last national conference (Enter: Name) C. Advanced Practice Nurse/Physician Assistant C1 Number of Advanced Practice Nurses or Physician Assistants in your program (Select from drop-down) C1 Contact information for Advance Practice Nurse(s)/Physician Assistant(s) (Enter: name, address, institution(s), , phone number, title, medical license number, years practicing as an ACHD provider, type of Advanced Practice Provider from a drop-down menu, and if their institution is pediatric, adult, or both) C1 Advance Practice Nurse(s)/Physician Assistant(s) CV(s) (Upload)

4 C2 Indicate if the Advance Practice Nurse(s)/Physician Assistant(s) are ACLS certified (Select: Yes/No from drop-down) o If Yes, upload the Advance Practice Nurse(s)/Physician Assistant(s) ACLS certification(s) C3 Advance Practice Nurse(s)/Physician Assistant(s) involvement as ACHD professional(s): o Education of professionals interested in learning more about the ACHD field (Describe) o Publications (Provide links) o Participation in CME ACHD education (Describe) o Time spent in the service of CHD/ACHD organizations (Describe membership/leadership in organizations over the past 5 years) D. Registered Nurse D1 Number of Registered Nurses in your program (Select from drop-down) D1 Contact information for Registered Nurse(s) (Enter: name, address, institution(s), , phone number, title, medical license number, years practicing as an ACHD provider, and if their institution is pediatric, adult, or both) D1 Registered Nurse(s) CVs (Upload) D2 Indicate if the Registered Nurse(s) are ACLS certified (Select: Yes/No from drop-down) o If Yes, upload the Registered Nurse(s) ACLS certification(s) D3 Registered Nurse(s) involvement as ACHD professional(s): o Education of professionals interested in learning more about the ACHD field (Describe) o Publications (Provide links) o Participation in CME ACHD education (Describe) o Time spent in the service of CHD/ACHD organizations (Describe membership/leadership in organizations over the past 5 years) E. Cardiothoracic Surgery and Cardiothoracic Intensive Care Unit E1 Number of ACHD Surgical Directors at your hospital (Select from drop-down) E1 Contact information for ACHD Surgical Director (Enter: name, address, institution(s), , phone number, title, medical license number, years practicing as an ACHD provider, and if his/her institution is pediatric, adult, or both) E1 Surgical Director s CV (Upload) o Upload only if this person is different from the CHD Surgeon's listed above E2 Indicate if the Surgical Director is ACLS certified (Select: Yes/No from drop-down) o If Yes, upload the ACLS certification of the Surgical Director E3 CHD trained/experienced personnel involved in pre-/peri-/post-operative consultation, care and diagnostics (Upload) E4 Number of CHD Surgeons in your program (Select from drop-down) E4 Contact information for CHD Surgeons (Enter: name, address, institution(s), , phone number, title, medical license number, years practicing as an ACHD provider, if their institution is pediatric, adult, or both, if they are the Surgical Director, and if they are Board Certified as a Congenital Heart Surgeon by the American Board of Thoracic Surgery)

5 E4 CHD Surgeons CVs (Upload) E4 Policy/plan for 24/7 CHD surgical expertise and consultation (Upload) E4 Confirm 24/7 surgical availability (Select: Yes/No) E5 ACHD Surgeon responsible for quality assessment/improvement (Enter: first name, last name, and title) E5 ACHD Surgeon responsible for quality assessment/improvement s CV (Upload) E6 Pre-review of ACHD surgical patients by a multidisciplinary conference of various providers (Upload) E6 Documentation stating the discussion and conclusions/recommendations from the multidisciplinary conference that are placed in the patient s chart (Upload) E7 Indicate if your program has cardiac transplantation available for transfer to a center that performs cardiac transplantation (Select: Yes/No) E8 Document stating that CHD Surgery includes, but is not limited to: o a. Congenital cardiac disease diagnosed, operated or intervened in childhood or adulthood. o b. Heart surgery for the natural history or sequelae of congenital cardiac disease (Upload) F. Heart Failure, Heart Transplant, Heart/Lung Transplantation F1 Number of Heart Failure Cardiologists in your program (Select from drop-down) F1 Contact information for Heart Failure Cardiologist(s) (Enter: name, address, institution(s), , phone number, title, medical license number, years practicing as an ACHD provider, if their institution is pediatric, adult, or both, and if they are Board certified or Board eligible Heart Failure Cardiologist(s)) F1 Heart Failure Cardiologist(s) CVs (Upload) F2 Process/plan for evaluation of advanced heart failure in ACHD patients. This process should include information related to the specific team that is consulting. (Upload) Chief of Cardiology Chief of Pediatric Cardiology Director of Heart Failure/Txpl (Internal Medicine) Director of Heart Failure/Txpl (Pediatrics) F3 On-site mechanical circulatory policy/plan, heart and heart/lung transplantation or policy/plan for transfer to a transplant facility (Upload; 3 opportunities to upload this policy/plan, but only #1 is mandatory; #2 and #3 are optional) F4 Policy/plan to ensure ACHD patients with advanced heart failure have access to the same ancillary services that are available to adult acquired heart failure patients. This includes cardiac rehab, nutrition/dietary, exercise, etc. (Upload)

6 G. Interventional Cardiac Catheterization G1 Number of Invasive Cardiologists in your program (Select from drop-down) G1 Contact information for the Invasive Cardiologist(s) (Enter: name, address, institution(s), , phone number, title, medical license number, and years practicing as an ACHD provider. o In a separate table below, enter if they are an adult IM Cardiologist or a pediatric Cardiologist from a drop-down menu and the number of ACHD cases they have had over the past 12 months). G1 Invasive Cardiologist(s) CVs (Upload) G1 Invasive Cardiologist(s) narrative of training/congenital heart experience (Upload) G1 Indicate if the heads of interventional cardiology are in charge of both pediatric and adult hospitals (Select: Yes/No we have different heads of interventional cardiology for pediatric and adult hospitals) o If Yes, enter the head of pediatric and adult interventional cardiology s information (Enter: first name, last name, , and phone number) and upload the head of pediatric and adult interventional cardiology s CV (Upload) o If No, enter the Head of pediatric interventional cardiology s information (Enter: first name, last name, , and phone number) and upload the head of pediatric interventional cardiology s CV Head of adult interventional cardiology s information (Enter: first name, last name, , and phone number) and upload the head of adult interventional cardiology s CV G1 Policy that demonstrates that a consultation by an ACHD cardiologist is performed in all ACHD patients undergoing interventional cardiac catheterization (Upload) Director of Pediatric Cardiology Director of Cardiology Director of Cardiac Catheterization Lab (Pediatric Cardiology) Director of Cardiac Catheterization (Internal Medicine) G2 Copy of a previous (within 3 months) call schedule. This call schedule will include 24/7 coverage of invasive cardiologists (Upload) G3 Confirm that you will be or have uploaded documentation within CT Surgery (Select: Yes/No) G4 Confirm that your facility has 24/7 emergency access to operating room (Select: Yes/No) G5 Confirm access and availability of CT surgery, open chest resuscitation, ECMO (Select: Yes/No)

7 H. Interventional Electrophysiology H1 Number of pediatric or adult EP specialists (Select from drop-down) H1 Contact information for pediatric or adult EP specialists (Enter: name, address, institution(s), , phone number, title, medical license number, years practicing as an ACHD provider, and if their institution is pediatric, adult, or both) H1 Pediatric or adult EP specialists CVs (Upload) H1 Plan for EP procedures (Upload) Director of Pediatric Cardiology Director of EP (pediatric cardiology) Director of Cardiology H2 Plan for 24/7 ACHD EP coverage in collaboration with the ACHD team (Upload) H2 Copy of call schedule (within 3 months) (Upload) H3 Confirm 24/7 ACHD Surgical availability including Mechanical Circulatory Support (Select: Yes/No) H4 Confirm 24/7 emergency access to operating room (Select: Yes/No) H5 Confirm availability and access to ACHD CT surgery, open chest resuscitation, ECMO, and IABP (Select: Yes/No) I. Inpatient Services I1 Indicate if you have a policy/plan for ACHD consultation within 24 hours of admission to the hospital for all ACHD patients ( 18 years of age) (Select: Yes/No) o I1 Pediatric Hospital Document from the Division Chief describing the policy/plan for ACHD consultation within 24 hours of admission to the hospital for ACHD patients ( 18 years of age) (Upload) Document requires signature(s). See exact signatures required for this document Medical Program Director of ACHD o I1 Adult Hospital Document from the Division Chief describing the policy/plan for ACHD consultation within 24 hours of admission to the hospital for ACHD patients ( 18 years of age) (Upload) Document requires signature(s). See exact signatures required for this document Medical Program Director of ACHD I2 Indicate if the facility has access to ACHD imaging, invasive cardiac procedures, CT surgery while inpatient (Select: Yes/No) I3 Policy/plan available to ensure care is provided in the pediatric hospital appropriate for the patient s medical issues, regardless of age (Upload)

8 I3 Policy/plan available to ensure care is provided in the adult hospital appropriate for the patient s medical issues, regardless of age (Upload) I4 Policy/plan for ongoing ACHD education of inpatient nursing staff (Select: Yes/No. If Yes, upload) Director of Nursing (or equivalent) I5 Specifically for the pediatric hospital policy/plan for emergency procedures, protocols and staff education in place to treat critically-ill ACHD patients and/or transfer to adult facility when appropriate (Upload) I6 Specifically for the pediatric hospital policy/plan or short narrative for access to general internal medicine and adult sub-specialists either by in-house consultation or transfer to adult facility. Sub-specialists including, but not limited to: IM consult, intensivist, pulmonologist, nephrologist, hematologist, neurologist, gastroenterologist, OB/GYN, Infectious disease, and general surgery. I7 Copy of a previous (within 3 months) ACHD inpatient care team call schedule. (Upload) I8 Designated ACHD team member responsible for quality assessment/improvement (Enter: first name, last name, and title) J. Outpatient Services J1 Number of half-day clinic sessions per week (Enter) J1 Number of outpatient facilities where patients are seen (Select from a drop-down menu) J1 Outpatient Locations, including satellite locations (Enter: site name, address, phone number, and check a box to indicate if the facility is pediatric, adult, or a combination) J1 Indicate which ACHD Cardiologists do work at each location (Check boxes) J2 Documentation of policy/plan for cardiopulmonary resuscitation of adults (Select: Yes/No. If Yes, upload) J3 Website listing for the ACHD program (Select: Yes/No. If Yes, enter URL) J3 Phone number patients use when they need to contact the on-call team or they are calling after normal business hours (Enter) J4 Availability for an initial appointment within 4 weeks for new patients (Select: Yes/No. If Yes, upload process and documentation to schedule initial appointments for new patients) J5 Evaluation of urgent patients by the ACHD team within 48 hours (Select: Yes/No. If No, upload)

9 J6 Indicate if office notes or the electronic medical records have an indication that communication to the referring physician has been completed (Select: Yes/No) J7 list of each of the sub-specialists and the established relationships with the ACHD team. Types of sub-specialists include, but are not limited to, nephrology, endocrinology, hematology, rheumatology, and gastroenterology (Upload) J8 Policy/plan to promote the establishment of medical homes for ACHD patients (Select: Yes/No. If Yes, upload) J9 ACHD Patient Care Meeting/Patient Case Conference documentation (within 3 months) (Upload) J10 Indicate if you ensure discussion around advanced care directives during your outpatient visits (Select: Yes/No) J10 Policy/plan for advanced care planning for ACHD patients seen in your pediatric care facility (Select: Yes/No/N/A this is strictly an adult facility. If Yes, upload) J10 Policy/plan for advanced care planning for ACHD patients seen in your adult care facility (Select: Yes/No. If Yes, upload) J11 Process to provide ongoing patient education and patient education material (Select: Yes/No. If Yes, upload) J12 Indicate if you have a verifiable database (e.g. method of documentation) of ACHD patients and services (Select: Yes/No) o If Yes, enter the title of the verifiable database of ACHD patients and services J14 Policy/plan for ongoing ACHD education of nursing staff in outpatient clinic (Select: Yes/No. If Yes, upload). J15 ACHD team member responsible for quality assessment/improvement (Enter: first name, last name, and title) K. Transitional Services K1 Policy/plan to provide transition education for patients and providers (Select: Yes/No. If Yes, upload)

10 Transition Nurse Coordinator Chief of Pediatric Cardiology K2 Policy/plan for planned patient transfer from pediatric to ACHD care (Select: Yes/No/N/A. If Yes, upload) Transition Nurse Coordinator Chief of Pediatric Cardiology K3 Indicate if you collaborate and support pediatric cardiology providers in the care of adolescent and adult CHD patients and ensure/promote access to consultation and ongoing discussion after referrals (Select: Yes/No. If Yes, upload) L. Patient-Centered Care L1 Indicate if you integrate patient-centered care (PCC)* into the program mission statement (Select: Yes/No. If Yes, upload) L2 Indicate if you have policies/plans promoting PCC (Select: Yes/No. If Yes, upload) L3 ACHD team member responsible for PCC assessment, improvement, and sustainment (Enter: first name, last name, and title) L4 Indicate if you have team members participate in training programs/educational sessions designed to promote PCC (Select: Yes/No) o If Yes, upload a description of their participation in training programs/educational sessions designed to promote PCC L5 Indicate if you demonstrate ongoing liaison with patients and their families by establishing a Patient and Family Advisory Council (PFAC) or having a written strategy to create a PFAC) (Select: Yes/No) o If Yes, upload documentation regarding the Patient and Family Advisory Council (PFAC) L6 Indicate if you use a structured tool to collect patient feedback on their experience and satisfaction, and include a strategy for incorporating this feedback for improving quality care (Select: Yes/No. If Yes, upload) L7 Written strategy for healthcare providers to partner with, educate, and engage patients/families in all stages of care delivery (Upload) M. Echocardiography M1 Indicate if you have 24/7 echocardiography (echo) (Select: Yes/No) o If No, upload a policy/procedure regarding echocardiography within your hospital/system M2 Number of CHD sonographers (Select from drop-down) M2 Contact information for the CHD Sonographers (Enter: name, address, institution(s), , phone number, title, and years practicing as a CHD sonographer)

11 M2 CHD Sonographers CVs (Upload) M2 CHD Sonographers additional certifications (Upload) M3 Echocardiographer on staff experienced in CHD, who is responsible for written protocols (Enter: first name, last name, and title) M3 Contact information for the CHD team member specialized in echocardiography (Enter: name, address, institution(s), , phone number, title, and the number of years they have been performing and interpreting echo s) M3 CHD team member specialized in echocardiography s CV (Upload) M3 CHD team member specialized in echocardiography s additional certifications (Upload) M4 Indicate if the echo program meets with the ACHD program at least once a year to review performance and quality (Select: Yes/No) o If Yes, upload meeting schedule and attendees names and titles M5 ACHD team member responsible for quality assessment/improvement of Echocardiography (Enter: first name, last name, and title) N. Cardiac Magnetic Resonance Imaging N1 Indicate if you have access to cardiac magnetic resonance imaging (MRI) (Select: Yes/No. o If No, upload the process by which an MRI is scheduled performed, interpreted, and communicated to the ACHD team and patient N2 Designated Radiologist(s) and/or Cardiologist(s) experienced in CHD that meets the qualifications of the American College of Radiology (ACR) Practice Guideline for Performing and Interpreting Cardiac Magnetic Resonance Imaging (MRI) (Level 3 certified) (Enter: first name, last name, and title) N2 Number of Radiologist(s) and/or Cardiologist(s) experienced in CHD work with your program (Select from drop-down) N2 Contact information for the Radiologist(s) and/or Cardiologist(s) experienced in CHD that meets the qualifications of the American College of Radiology (ACR) Practice Guideline for Performing and Interpreting Cardiac Magnetic Resonance Imaging (MRI) (Level 3 certified) (Enter: name, address, institution(s), , phone number, title, and medical license number) N2 Radiologist(s)/Cardiologist(s) CVs (Upload) N2 Radiologist(s)/Cardiologist(s) additional certifications (Upload) N3 Upload meeting schedule and attendees names and titles of the meeting between the MRI Program and ACHD Program to discuss performance and quality (Upload) N4 ACHD team member responsible for quality assessment/improvement of MRI service (Enter: first name, last name, and title) O. Cardiac Computed Tomography O1 Indicate if you have access to cardiac Computer Tomography (CT) Scan (Select: Yes/No). o O2 If Yes, enter the first name, last name, and title of the designated radiologist(s) and/or cardiologist(s) experienced in CHD that meet the qualifications of the American College of Radiology (ACR) Practice Guideline for Performing and Interpreting Cardiac CT (Level 2 certified)

12 O3 Confirm that the CT Program meets with the ACHD Program at least once a year to review performance and quality (Select: Yes/No) O4 Designated ACHD team member responsible for quality assessment/improvement (Enter: first name, last name, title) P. Pulmonary Arterial Hypertension P1 Contact information for the PAH consultant (Enter: name, address, institution(s), , phone number, title, medical license number, and years they have been practicing as an ACHD provider) P1 PAH Consultant s CV (Upload) P2 ACHD team member responsible for quality assessment/improvement of PAH (Enter: first name, last name, and title) P2 Meeting schedule to review performance and quality (Upload) Q. Exercise Testing and Cardiac Rehabilitation Q1 Indicate if you have access and onsite availability to exercise tests (Select: Yes/No) Q1 Indicate if you have access and onsite availability to metabolic cardio-pulmonary testing (Select: Yes/No) Q1 Indicate if you have access and onsite availability to stress imaging (nuclear, MRI, echo) (Select: Yes/No) Q1 Indicate if you have access and onsite availability to standardized six-minute walk test (Select: Yes/No) Q2 Indicate if you have access and availability to cardiopulmonary rehabilitation programs (Select: Yes/No) Q3 Indicate if you have ACHD team members available for collaboration with medical staff performing and interpreting exercise testing and cardiopulmonary rehab (Select: Yes/No) Q3 Individual who oversees exercise testing for ACHD patients (Enter: first name, last name, and title) Q4 ACLS certification of individual who oversees exercise testing for ACHD patients (Upload) Q5 ACHD team member responsible for quality assessment/improvement within the exercise testing and cardiopulmonary rehab (Enter: first name, last name, and title) R. Reproductive Services Please note: There are two options for providing Reproductive Services information: 1) You can provide all related documentation within one document or 2) You can upload documentation individually If you will be uploading one document, it must encompass all aspects below: Policy/plan that encourages all female ACHD patients to have gynecological care Policy/plan for discussion with patients of appropriate birth control methods and sexual function as it relates to CHD Policy/plan for discussion with all female CHD patients to provide pre-pregnancy counseling and family planning Policy/plan for discussion of sexual counseling regarding sexual dysfunction **If you choose to provide all related documentation within one document, it will need to be signed by:

13 Medical Program Director of ACHD Head of Maternal Fetal Medicine (MFM) R1 Policy/plan that encourages all female ACHD patients to have gynecological care (Select: Yes/No. If Yes, upload) Head of Maternal Fetal Medicine (MFM) R2 Policy/plan for discussion with patients of appropriate birth control methods and sexual function as it relates to CHD (Select: Yes/No. If Yes, upload) Head of Maternal Fetal Medicine (MFM) R3 Policy/plan for discussion with all female CHD patients to provide pre-pregnancy counseling and advice regarding family planning (Select: Yes/No. If Yes, upload) Head of Maternal Fetal Medicine (MFM) R4 Policy/plan for discussion of sexual counseling regarding sexual dysfunction (Select: Yes/No. If Yes, upload) Head of Maternal Fetal Medicine (MFM) R5 Policy/plan to ensure ACHD providers articulate and document a plan for delivery in collaboration with maternal/fetal medicine and anesthesiology (Select: Yes/No. If Yes, Upload) R5 ACHD providers have consulting privileges in the obstetrical unit where ACHD patients are admitted (Select: Yes/No) R6 Indicate if there is access to genetic counseling (Select: Yes/No) o If Yes, upload the process for access to genetic counseling R7 ACHD team member responsible for quality assessment/improvement within regard to reproductive services (Enter: first name, last name, and title) S. Psychology and Social Work S1 Number of Licensed Social Worker(s)/care managers (Select from drop-down) S1 Contact information for the Licensed Social Worker(s)/Care Manager(s) (Enter: name, address, institution(s), , phone number, title, medical license number, and years practicing as an LSW) S2 Social Worker/Care Manager s CV (Upload) S2 Policy/plan for referral to mental health services (Select: Yes/No. If Yes, upload)

14 o Document requires signature(s). See exact signatures required for this document Documents Requiring Signatures The template documents will indicate if the document requires a signature. The documents requiring signatures are listed below. F2: Process/plan for evaluation of advanced heart failure in ACHD patients. This process should include information related to the specific team that is consulting. Signatures: Chief of Cardiology Chief of Pediatric Cardiology Director of Heart Failure/Txpl (Internal Medicine) Director of Heart Failure/Txpl (Pediatrics) Medical Program Director of ACHD G1: Policy that demonstrates that a consultation by an ACHD cardiologist is performed in all ACHD patients undergoing interventional cardiac catheterization. Signatures: Director of Pediatric Cardiology Director of Cardiology Director of Cardiac Catheterization Lab (Pediatric Cardiology) Director of Cardiac Catheterization (Internal Medicine) Medical Program Director of ACHD H1: Plan for EP Procedures. Signatures: Director of Pediatric Cardiology Director of EP (pediatric cardiology) Director of Cardiology Medical Program Director of ACHD I1, I3, I6: Inpatient Criteria. Signatures: Medical Program Director of ACHD I4: Policy/plan for ongoing ACHD education of inpatient nursing staff. Signatures: Medical Program Director of ACHD Director of Nursing (or equivalent) J2, J8, J10, J11, J14: Outpatient Criteria Signatures: Medical Program Director of ACHD K1, K2: Transition Services Signatures: Medical Program Director of ACHD Transition Nurse Coordinator Chief of Pediatric Cardiology

15 L2: Policies/procedures to promote PCC. Signatures: Medical Program Director of ACHD R1, R2, R3, R4: Reproductive Services Signatures: Head of Maternal Fetal Medicine (MFM) Medical Program Director of ACHD S2: Policy/plan for referral to mental health services. Signatures: Medical Program Director of ACHD