Appendix D: Training Center Review Process and Forms

Transcription

1 Appendix D: Training Center Review Process and Forms

2 Program for TC Monitoring/Mentoring Process: Guidelines for Implementation Overview The American Heart Association's ultimate goal is to ensure quality programs and better outcomes. Therefore, the focus will shift from being administrative and documentation focused to course monitoring and mentoring of the TC s course curriculum. The current process for TC evaluation and monitoring has been more subjective rather than objective. This process will give the reviewer an objective method of scoring, references to AHA guidelines, and reviewer tips. This will ensure fairness (consistency) and equality among reviewers while giving the TC the tools necessary to improve the quality of its courses. When infractions do occur, the process will lend itself to mentoring versus disciplinary actions. This process was developed to offer a consistent program for the review of TCs. The intent is to offer the Regional Faculty member/reviewer objective standards with annotated references to be used as guidelines. The Regional Faculty member/reviewer will be able to offer an objective score with rating, compliance, and requirements. This process will also allow you to focus your assessment on improving the organization s performance. It allows reviewers an opportunity to discuss the data obtained and trended and view patterns on how the organization uses the data as opportunities for performance improvement. Goals: The Regional Faculty member/reviewer will Ensure that all AHA standards have been addressed. Make overall observations about compliance. Provide consultation and education as time permits. Objectives: At the end of the review process, the TC will be able to Allocate resources to measure, analyze, and improve the organization's processes/performance. Use AHA materials and maintain security. Develop and maintain course and instructor files. 1.0 Assignment of National/Regional Faculty to Training Center by AHA Staff Submit to the TC in writing the name of the assigned RF member. Is there joint agreement on RF assignment? If not, reassignment will occur.

3 The TC Mentoring/Monitoring by RF Process Assign RF to TC by AHA Staff Submit in writing RF assignment to TC AHA contacts RF and TC to schedule date for initial TC Orientation Recommendations for improvement: give to TC Coordinator AHA staff sends paperwork to RF No Did TC approve RF assignment? No QA-P&P, list of Training Sites, list of Instructors, course agendas, etc. Yes Legend Requires AHA Action Process Yes Is this a current TC? TC Orientation Does TC meet requirements for oneyear agreement? No Repeat visit recommended by AHA Evaluation Decision Outcome Successful Monitoring reported to Regional ECC office Yes Face-to-Face Introductory Meeting Date for course monitoring where TC coordinator will be present mutually agreed upon RF to receive course agenda > 79 on overall monitoring Course Monitoring (Recommendations based on course monitoring scores) < 70 on monitoring in any category Yes Emphasis placed on opportunities for improvement based on course observations Compulsory Administrative TC Review within 90 days Yes Emphasis placed on completeness and understanding of AHA guidelines AHA contacts RF and TC to schedule date for TC Review AHA staff sends most current paperwork to RF QA-P&P, list of Training Sites, list of Instructors, course agendas, etc. No Agreement denied > 95 overall monitoring Best Practices Award on monitoring in any category Yes Does TC review indicate possible course infractions? Conditional one-year renewal No in any category Is TC status to be renewed? TC Review Recommendations < 70 in any category > 79 on overall review Two-year agreement with self-evaluation continuum RF will receive scheduled course dates from the TC for the next 3 mo. Unannounced Course Monitoring PI process will be outlined by TC within 30, 60, or 90 days and then reviewed by AHA for approval Yes No > 95 on overall review Refer to AHA staff Best Practices Award TC Review Process, April 2004, page 2

4 Reviews will be scheduled by Regional AHA office and mutually agreed on by TC and RF. (For new TC applicants, a review will be conducted within 30 days of application approval.) 2.0 Course Monitoring (by assigned RF) Conduct a face-to-face introductory meeting. Determine the date of course review (to be mutually agreed on). Receive course agenda from TC. 3.0 Scoring (The following recommendations are based on course monitoring scores.) A score greater than 95% on overall monitoring is excellent compliance and leads to a best practice award. A score greater than 79% is acceptable compliance, and course monitoring will be reported to Regional ECC Office. A score of 70% to 79% in any category is not acceptable compliance and initiates unannounced course monitoring. The RF member should have received a course schedule for the next three months at this time. A score of less than 70% is not acceptable compliance. Additional compliance within 30 days and a focused administrative review within 90 days should occur. 4.0 TC Administrative Review Reviewer Note: If the review is initiated because of unsuccessful course monitoring, emphasis is to be placed on opportunities for improvement based on course monitoring observations. If this review follows new TC orientation, emphasis is to be placed on completeness and understanding of AHA guidelines. AHA contacts RF and TC to schedule date for TC Review. AHA staff sends RF the most current paperwork (eg, QA P&P, list of Training Sites, list of Instructors, agendas, etc). TC recommendations based on scoring: Greater than 95% on overall monitoring is excellent compliance and leads to Best Practice Award and a two-year agreement with self-evaluation continuum. Greater than 79% on overall review is acceptable compliance and leads to a two-year agreement with self-evaluation continuum. From 70% to 79% on any category is not acceptable compliance and initiates the TC to outline a PI process within 30 to 90 days, as determined by the AHA, for a conditional one-year renewal. Less than 70% is not acceptable compliance. At this time renewal status must be determined by AHA staff in collaboration with the Regional ECC Committee. If renewal status is deemed appropriate, the TC is to outline a PI process within 30 to 90 days, as determined by AHA, for a conditional one-year renewal. Does this review initiate possible course infractions? If yes, initiates course monitoring. If no, initiates another TC review. TC Review Process, April 2004, page 3

5 Training Center Course Monitoring Review The Course Monitoring Review is divided into three sections: Section I Section II Section III Facility/Class Structure Course Content Equipment/Materials Available Purpose of Review: How the TC allocates resources to accommodate class size How the TC incorporates course content How the TC uses required equipment and AHA materials Where Will the Review Take Place? The review will be held at a location of your choice, ie, where the course is taught. When Will the Review Take Place? Following an initial Administrative Review. Conducted every two years following successful completion of a Training Center Review. Unannounced following a noncompliant course and/or Administrative Review. Unannounced following complaints to Regional Office. Who Will Participate: Training Center: TC Faculty AHA: Regional Faculty Staff (optional) What Will Occur: Regional Faculty will Monitor course to ensure that all pertinent standards have been met. Make overall observations about compliance. Provide consultation and education, as time permits. What Are Some Tips for Success? Be familiar with the Instructor/Provider manual for the discipline being reviewed. Be familiar with the exams for the discipline being reviewed. Be familiar with your TC policies and procedures. Scoring: The scoring section includes a question(s) to help you focus on the performance expectation in the standard and identifies the levels of compliance expressed in frequency of compliance or quantitative or qualitative terms. The scoring reflects the level of compliance by section. Each standard is scored independently by Yes answers. An NA response will be scored as a Yes. In an area where more than one component is being reviewed, a Yes must be able to be scored for all. If any part scores a No then the entire component is a No. Ratings: 1 95% to 100% Assessment provides evidence of excellent compliance. 2 80% to 94% Assessment provides evidence of acceptable compliance. 3 70% to 79% Assessment does not provide evidence of acceptable compliance. 4 <70% Assessment does not provide evidence of acceptable compliance.

6 American Heart Association Emergency Cardiovascular Care Program Training Center Course Monitoring Review Training Center: Review Date: Location: Time arrived: Time left: Type of ECC course being reviewed: BLS ACLS PALS Initial Renewal Instructor Name of TC Coordinator: CATEGORY 1 FACILITY/CLASS STRUCTURE Note to reviewer: Some convenient references are made to the BLS, ACLS, and PALS Instructor and Program Administrative Manuals (BIM, AIM, PIM, and PAM respectively) for your evaluation criteria. 1. Is facility accessible? Comment: BIM, Pt 2, Chapter 5; AIM, Pt 3, Chapter 3; PIM, Pt 1, Chapter 2 2. Is space adequate? Comment: BIM, Pt 2, Chapter 5; AIM, Pt 3, Chapter 3; PIM, Pt 1, Chapter 2 3. Does student-instructor ratio meet AHA guidelines? Number of students: Number of instructors: PAM, Chapter 6; Memo 12/10/01; BIM,Pt 2, Chapter 5; AIM, Pt 2, Chapter 3; PIM, Pt 2, Chapters 1, 3 4. Is remediation provided to students who need it? Describe the method of remediation: PAM, Chapter 6; BIM, Pt 1, Chapter 4; AIM, Pt 6, Chapter 3; PIM, Pt 1, Chapter 4 5. Are students given the opportunity to evaluate the course? The following questions are for notation, not scoring: Does the TC use the AHA course evaluation form? Yes o Does the form give the student the opportunity to evaluate their instructor(s)? Yes No Does the form indicate how the student may send the form directly to the AHA? Yes No PAM, Appendix C 6a. Is there adequate floor and/or table space available to practice CPR? If not, please comment: BLS ACLS PALS BIM, Pt 2, Chapter 5 (Also see PAM, Chapter 8, and BIM, Pt 1, Chapter 1) 6b. Is a physician Instructor present or immediately available by phone, fax, or other means? Comment: PAM, Chapter 6 Physician name and phone number Numeric score for this section: of 6 of 6 of 6 Percent score for this section: % % % Additional comments on this section: Note to reviewer: Question 6a. is specific to BLS as many facilities must have added space for manikin practice, which may require special needs for the disabled (temporarily or permanently). TC Course Monitoring Review, April 2004, Page 1 of 4

7 CATEGORY 2 COURSE CONTENT 1. Are students provided with a course outline? PAM, Chapter 5; BIM, Pt 2, Chapter 5 2. Is course outline consistent with AHA guidelines? Comment: BLS ACLS PALS Memo 3/12/01; BIM, Pt 2; AIM, Pt 2, Chapters 2, 5; PIM, Pt 2, Chapter 1 3. Is core content covered? Comment: PAM, Chapter 6; BIM, Pt 2; AIM, Pt 1, Chapter3; Pt 2, Chapter 2; PIM, Pt 1, Chapter 2 4. Are skills performance checklists used and competency evaluated? If not, please comment: If megacode is used for competency evaluation, please indicate group size: BIM, Pt 1, Chapter 4; Pt 3, Appendix A; AIM, Pt 1, Chapter 5; Pt 2, Chapter 5; Pt 5, Chapter 1; Appendix; PIM, Pt 2, Chapter 7 5a. Provider course only: Is skills practice time appropriate? If not, please comment: PIM, Pt 1, Chapter 3; Pt 2, Chapter 1 5b. Instructor Course only: Did participants give presentations with peer feedback? If not, please comment: A A A A A A BIM, Pt 2, Chapter 8; AIM, Pt 5, Chapter 3; PIM, Pt 1, Chapter 3 6. Is the most current written examination used? Date on exam: PAM, Chapter 5; BIM, Pt 1, Chapter 4; AIM,Pt 1, Chapter 2; PIM, Pt 1, Chapter 4 7. Is proficiency in performing CPR, including AED, evaluated during the course? If not, please comment: BIM, Pt 3, Appendix A; AIM, Pt 2, Chapter 5; Pt 5, Chapter 3; PIM, Pt 1, Chapters 2-5, Appendix Numeric score for this section: of 8 of 8 of 8 Percent score for this section: % % % Additional comments on this section: Note to reviewer: Questions 1, 2, and 3: TCs must have their own outline made available to every student during the course and to the reviewer before the course. This outline should reflect the core content of the course and that content should be consistent with AHA guidelines. Question 4: Skills performance check sheets provided in the AHA Instructor manuals may be used. If not, then the skills check sheets used must reflect whether the core skills for that discipline have or have not been met. Question 5a.: Can be broken down into two questions: Was every participant given equal opportunity to practice? Was practice time sufficient so that successful return demonstration of those skills could have been met? TC Course Monitoring Review, April 2004, Page 2 of 4

8 CATEGORY 3 EQUIPMENT/MATERIALS AVAILABLE 1. Does each student have appropriate textbooks available for use before, during, and after the course? PAM, Chapter 5; BIM, Pt 1, Chapter 3; AIM, Pt 1, Chapter 1; PIM, Pt 2, Chapter 1 2. Is the required equipment available? If anything is missing, please comment: BLS ACLS PALS PAM, Chapter 6; AIM, Pt 2, Chapter 5; PIM, Pt 2, Chapter 7; Appendix B 3. Is all equipment clean and in good working order? Comment: PAM, Chapter 6; AIM, Pt 2, Chapter 5; PIM, Pt 1, Chapter 6 4. Are AHA audiovisual materials used? Please comment: PAM, Chapter 5; BLS video, BIM, Pt 2, Chapters 3-5; exception, Pt 2, Chapter 7; ACLS, PALS toolkit, video and CD NA NA NA Numeric score for this section: of 4 of 4 of 4 Percent score for this section: % % % Additional comments on this section: Note to reviewer: Question 4: The check off category NA counts in the scoring and is made available because some options are allowed regarding the use of AHA audiovisual aids, such as the renewal course where it is optional or when media equipment fails or becomes unavailable and the Instructor provides the information in the same manner. In any case, please comment on how the material is presented. TOTAL SCORING BLS ACLS PALS Total numeric score: of 18 of 18 of 18 Total percent score: % % % TC Course Monitoring Review, April 2004, Page 3 of 4

9 Section I Rating (1-4) Section II Rating (1-4) Section III Rating (1-4) TOTAL TRAINING CENTER SCORING BLS ACLS PALS of 6 = % = of 6 = % = of 6 = % = of 8 = % = of 8 = % = of 8 = % = of 4 = % = of 4 = % = of 4 = % = of 18 = % = of 18 = % = of 18 = % = Rating (1-4) RATING COMPLIANCE REQUIREMENTS 1 (95% to Assessment provides evidence of excellent Compliant, no requirements, best practice for total score. 100%) compliance. 2 (80% to 94%) 3 (70% to 79%) 4 (<70%) Assessment provides evidence of acceptable compliance. Assessment does not provide evidence of acceptable compliance. Assessment does not provide evidence of acceptable compliance. Compliant, no requirements. Noncompliant, initiates an unannounced course monitoring. Noncompliant; additional documentation within 30 days and a focused administrative review within 90 days. REVIEWER S SIGNATURE/COMMENTS Reviewer s overall comments: Reviewer(s ) s Name: Name: Reviewer(s ) s Signature: Signature: Date: Lead Instructor s signature indicates that Regional Faculty member was present. Lead Instructor s Signature: Date: TC Course Monitoring Review, April 2004, Page 4 of 4

10 American Heart Association Emergency Cardiovascular Care Program Training Center Administrative Review Training Center (TC): Review Date: Location: Review Type: (Circle one: initial, one-year, course initiated) Discipline: This administrative review may be used for more than one discipline. Directions: Score 1 for every question marked Yes or N/A. Questions not in boldface type are for information only and are not part of the scoring guidelines throughout the document. Note to reviewer: Some convenient references are made to the BLS, ACLS, and PALS Instructor s Manuals and the Program Administration Manual (BIM, AIM, PIM, and PAM, respectively) for your evaluation criteria. SECTION I ORGANIZATION/ADMINISTRATION-FOCUSED FUNCTIONS REVIEWER TIPS: The TC Coordinator must be present for the TC review for each discipline. If the TC Coordinator is not present, STOP THE REVIEW AND RESCHEDULE IT. 1. The TC Coordinator(s) for each discipline must be available during a TC administrative review to answer any questions from reviewers and ensure that the requirements are understood. (See PAM, Chapter 5) a. Was the TC Coordinator present and participating during the entire administrative review? 2. Each TC must carry and maintain general liability insurance coverage or waiver. TCs covered under waivers, ie, sovereign immunity, must initiate and keep on file a letter stating such coverage. (See PAM, Chapter 5) (International is N/A) a. Does the TC have a current certificate for general liability insurance? (Check appropriate amount below) $5,000,000 for National TCs $1,000,000 for ACLS/PALS $300,000 for BLS b. Does the TC have a current letter on file stating coverage by waiver, ie, sovereign immunity? BLS ACLS PALS REVIEWER TIPS: Question 2: TC must answer Yes to a or b to receive a positive score of 1. (Attach a current copy of appropriate document to send to Regional ECC staff.) 3. Each TC may maintain its records in hard copy or electronically. All electronic files must be backed up on a regular basis. All records and backed-up information must be maintained for at least three years from issue date. All electronic files must be capable of printing as hard copy. TC records must be accessible during a TC review. (See PAM, Chapter 5) a. Can the TC document that it stores records, including TCF/Instructor files? (Put a checkmark by applicable answers below.) Hard copy Electronically If stored electronically: Are files backed up on a regular basis? es o Can all electronic files be printed as hard copies? es o b. Can the TC show that all records are maintained for a minimum of three years from the date of issue? REVIEWER TIPS: Question 3b: Mark N/A for new TC applicants only and add a positive score of 1. A A A REVIEWER TABULATION: SECTION I Score summary of Page 1 of 4 of 4 of 4 TC Administrative Review, April 2004, Page 1 of 12

11 SECTION I: ORGANIZATION/ADMINISTRATION FUNCTIONS continued BLS ACLS PALS 4. Each TC must maintain the following documents: TC Agreement, general liability insurance or waiver, official AHA correspondence, list of Training Sites and contacts, website agreement, and policies and procedures. (See PAM, Chapter 5) Is there evidence that the TC maintains the following documents: a. Original or copy of the current signed TC Agreement b. Website agreement (if applicable) c Documentation of any deficiencies identified during a review Corrective action taken? d. Current list of Training Sites and contact information 4.1 Copies of official correspondence from AHA: National and Regional? Can the TC show that there is a process for reviewing/distributing national and regional correspondence, ie, filed by date? es o Does the TC have a process for timely distribution of information? Yes No Can the TC show that the timeline was followed? Yes No Can the TC show that the basic content of appropriate AHA correspondence was distributed to TCF/Instructors? Yes No Can the TC show that appropriate AHA correspondence was distributed to Training Sites if applicable? Yes No NA A A A A A A REVIEWER TIPS: Question 4c: New TC applicants will answer N/A and receive a positive score. Question 4.1: Training Sites that are TC applicants should have copies of AHA correspondence on file. 5. Each TC must have administrative policies and procedures (P&P) that address quality assurance, continuous quality (performance) improvement, internal dispute resolutions, equipment maintenance/decontamination, Training Site management/relations, and management of TCF/Instructor communication/updates. (See PAM, Chapter 5) Does the TC have policies and procedures that address the following issues? a. Written Quality Assurance Plan (updated annually)? b. Can the TC show evidence of continuous quality improvement activity? (Performance Improvement: data, trends, and outcomes)? c. Equipment maintenance/decontamination? Do policies and procedures address the cleaning of manikins and clothing if applicable? d. Internal dispute resolution? Has the TC had any internal disputes? _es _o_a If Yes, were outcomes successful? _es_o_a e. Management of TCF/Instructor communication/updates? f. Training Site management/relations? (May have contract in lieu of policies and procedures; N/A for new applicant TC) REVIEWER TIPS: Question 5: Should be reflected in paperwork. 6. Each TC will support Chain of Survival initiatives within its resources, ie, mass training CPR, public access events, Operation Heartbeat/Operation Stroke initiatives through instructors, equipment, financial, manikins, or organizational support. (See PAM, Chapter 5) a. Is there evidence that the TC supports Chain of Survival initiatives? (Check all that apply.) Mass training CPR or public access events by: Instructors/TCF Equipment Financial Manikins Organizational support Other (be specific): A A A A A A REVIEWER TIPS Question 6: TC must show evidence of participating in one event to answer Yes and get a positive score of 1. REVIEWER TABULATION: SECTION I Score summary of Page 2 of 12 of 12 of 12 TC Administrative Review, April 2004, Page 2 of 12

12 SECTION I: ORGANIZATION/ADMINISTRATION FUNCTIONS continued BLS ACLS PALS 7. Each TC will have administrative capability to support the functions of the Training Network, eg, issuance of cards, maintenance of records, submission of training reports, maintenance of Instructor/TCF files, etc. (See PAM, Chapter 5) a. Does the TC have the administrative capability to support the functions of the Training Network? Issuance of cards Maintenance of records Submission of training reports Maintenance of Instructor/TCF files Instructors TC Faculty BLS ACLS PALS REVIEWER TIPS: Question 7: TC must meet all four components to answer Yes and get a positive score of Each TC will use an AHA disclaimer on all marketing tools and use the ECC logo appropriately. Each TC will offer courses to the community unless prohibited by law or policy. (See PAM, Chapters 5, 8) a. Is the AHA disclaimer clear on all marketing tools where a course fee is indicated? b. Is the authorized Provider logo used appropriately? A A REVIEWER TIPS: Question 8a: If law or policy prohibits the TC from offering community courses and there are no marketing materials or community courses, mark as a Yes for disclaimer use. Question 8b: If TC does not use the ECC Provider logo, mark N/A and score as Each TC has a computer with Internet access to receive national and regional memos, exams, etc. (See PAM, Chapter 5) a. Does the TC have a computer with Internet access or is one available to the TC for its use? b. Does the TC have access to a computer with external ? (Bulletin 10/02) REVIEWER TIPS: Question 9: If the TC has difficulty receiving AHA correspondence/exams, confirm that it has the Adobe Acrobat Reader software, which is a free download. Offer to help with downloading the program. 10. Each TC must maintain an adequate number of Instructors and TC Faculty to meet the needs of its customers. (See PAM, Chapter 5) a. Does the TC maintain an adequate number of Instructors and TC Faculty to meet the needs of its customers? (Please indicate total number of the following): REVIEWER TIPS: Question 10: Suggested ratios: Number of Instructors to meet largest class size offered; suggested 48 as largest. BLS/ACLS/PALS 1 TCF and/or RF member to 8 Instructors, 1 Instructor to 8 students 11. Each TC will appoint TC Faculty to ensure that the TC is able to conduct Instructor Courses. (See PAM, Chapter 5) a. Is there evidence that the TC has appointed TC Faculty? A REVIEWER TABULATION: SECTION I Score summary of Page 3 of 7 of 7 of 7 TC Administrative Review, April 2004, Page 3 of 12

13 SECTION I: ORGANIZATION/ADMINISTRATION FUNCTIONS continued BLS ACLS PALS 12. Each TC will have a current list of instructors. (See PAM, Chapter 5) a. Can the TC show evidence of updated list of Instructors/TCF aligned with TC? b. Does the TC identify Instructors who teach but are not aligned with it? c. Does the Instructor/TCF list include a minimum of the following information? ame* Address* Phone number* Discipline(s)* Instructor card renewal date* (optional) Items marked with an asterisk (*) must be included in each file reviewed to obtain a Yes score. A A A 13. TCs are responsible for the overall activities of Training Sites (TS). (See PAM, Chapter 5) a. Can the TC show evidence of TS administrative reviews? b. Can the TC show evidence of TS course reviews? c. Can the TC show evidence of a current list of Training Sites? d. Can the TC show evidence of conducting TS updates? A A A A A A A A A A A A 14. Each TS will comply with all AHA and TC policies and procedures. (See PAM, Chapter 5) a. Is there evidence that the TS complies with all AHA policies and procedures? b. Is there evidence that the TS complies with all TC policies and procedures? A A A A A A 15. Each TC must document that the QA plan is operational and monitors course quality, TCF/Instructor performance, and TC administrative operations. (See PAM, Chapter 5) a. Can the TC show evidence of documented QA activity? b. Can the TC show any documentation of continuous quality improvement? (Performance Improvement: data, trends, and outcomes) A A REVIEWER TIPS: Question 15: Mark N/A for new TC applicants and add a positive score of 1 for each. 16. Each TC has or will have the Program Administration Manual readily available for TCF/Instructors. (See TC Agreement) a. Does the TC have a current Program Administration Manual? A A A A b. Is it easily accessible (in a common location) for use by TCF/Instructors? REVIEWER TIPS: Question 16: The TC only needs one PAM; however, manuals for all disciplines must be accessible. REVIEWER TABULATION: SECTION I Score summary of Page 4 of 13 of 13 of 13 TC Administrative Review, April 2004, Page 4 of 12

14 SECTION I: ORGANIZATION/ADMINISTRATION FUNCTIONS continued BLS ACLS PALS 17. Each TC will ensure that TCF/Instructors have a current textbook to teach each level of course taught within the TC. Toolkits are available to TCF/Instructors to teach each level of course taught within the TC. (See PAM, Chapter 6) a. Can the TC demonstrate that TCF/Instructors have the most current and appropriate textbooks and toolkits are made available to teach? Does the TC purchase all textbooks for each TCF member/instructor? Must TCF/Instructors purchase their own textbooks? Do the TC and TCF/Instructors share the cost of textbooks? 18. Each TC will submit required reports by stated deadline. (See PAM, Chapter 5) a. Can the TC show evidence of submitting reports by stated deadline? Course/participant statistics A REVIEWER TIPS: Question 18: Mark N/A for new TC applicants and add a positive score of 1 for each. A A REVIEWER TABULATION: SECTION I Total score: Add scores of previous summaries and above question. of 38 of 38 of 38 PROGRAM ENHANCEMENT (NO SCORING) BLS ACLS PALS Does the TC use any AHA self-instructional learning system, eg, Heartcode? Does the TC offer contact hours? Training courses Retraining courses ursing Respiratory Other; be specific: Does the TC offer CME for physicians? Training courses Retraining courses Does the TC offer courses in a language other than English on a routine basis? Does the TC offer courses in a language other than English on special request? Spanish French Creole Sign Other; be specific: Does the TC subscribe to the publication Currents? Is there a process in place for storing Currents? Is there evidence that the TC encouraged its TCF/Instructors to subscribe to Currents? It is recommended that each TC Coordinator maintain current Instructor status in at least one discipline. (See PAM, Chapter 5) a. Is there evidence that the TC Coordinator maintains Instructor status in at least one discipline? b. Is there evidence that the TC Coordinator attended any Instructor updates? TC Administrative Review, April 2004, Page 5 of 12

15 SECTION II COURSE-FOCUSED FUNCTIONS 1. Each TC or its TS must offer classes open to the community unless prohibited by law or institutional policy. (See PAM, Chapter 5) a. Is there evidence that the TC/TS offers classes to the community? BLS ACLS PALS A A REVIEWER TIPS: Question 1: If the TC is prohibited by law to open classes to the community, check NA and score as a Yes. 2. Each TC shall have an agenda for each course taught. (See BIM, Part 2, Chapter 5; AIM, Part 2, Chapter 5) a. Does the TC have an agenda for each course taught? b. If the agenda has been adapted for the individual needs of the TC, does the agenda reflect required core content? c. Do the agendas for Instructor Courses reflect qualified faculty? A A REVIEWER TIPS: Question 2: Program agendas are used to allow both the instructor and students to know the format of the course taught within that TC. 3. The TC conducting the course is responsible for card issuance and security. (See PAM, Chapter 5; Extranet) a. Does the TC use current AHA cards? b. Is there evidence of a process in place for securing cards? c. Is there evidence of a process in place for issuing cards for a two-year period? d. Can the TC show evidence of controlling the access of the security number for ordering cards? e. Can the TC demonstrate that it issues cards within 30 days of receipt of paperwork? f. Can the TC show evidence that cards are completed correctly (eg, date: month/year)? 4. Each TC must maintain course documents. (See PAM, Chapter 5; Appendix C) Does the TC maintain the following in its course files? a. Agendas b. Completed roster c. Written exam for students who are not yet complete d. Psychomotor skills evaluations for students who are not yet complete e. Dispute resolutions if applicable (attached to roster) f. Instructor Candidate Application (Instructor Courses only) REVIEWER TIPS: A A A A A A A A Question 4: Review 10 or 5%, whichever is greater. If the section you are reviewing is missing from any course files, that section would score a No. Due to the volume of courses, there may be a master agenda for the files and not one in each course roster for BLS. This should be reviewed as appropriate. Question 4f: If the TC has not held an instructor course, check NA and count as a Yes for the score. REVIEWER TABULATION: SECTION II Score summary of Page 6 of 16 of 16 of 16 TC Administrative Review, April 2004, Page 6 of 12

16 SECTION II: COURSE-FOCUSED FUNCTIONS continued BLS ACLS PALS 5. Each TC will use a Course/Instructor evaluation tool for every participant in each course taught. (See PAM, Chapter 6) a. Can the TC produce the course/instructor evaluation form? b. Is there evidence that the TC uses this form for every class? c. Is there evidence that the Course/Instructor evaluation tool is summarized? d. Summary of Course/Instructor evaluations maintained in course files and individual evaluations maintained for those with potential issues/problems? e. Is there evidence that individual Instructors are evaluated? Is there evidence that the TC used the information on the Course/Instructor evaluation tool for improvement? Is there evidence that the overall TC program administration is evaluated, ie, course structure, overall management, etc? REVIEWER TIPS: Question 5e: Both items listed must be present for a Yes and positive score. 6. Each TC is responsible for providing the current exam to its TCF/Instructors, maintaining exam security, and communicating the importance of maintaining security to TCF/Instructors. (See PAM, Chapters 5, 6; PIM, Part 1, Chapter 3) a. Does the TC use current exams? Is the precourse exam given before the course? (Only required in PALS) b. Is there evidence of a process in place for securing exams? c. Is there evidence of a process in place for who has access to exams? d. Is there evidence of a process in place for distributing the exams to TCF/Instructors? e. Is there evidence that course exams are issued to students and proctored? N N N 7. Each TC will complete a roster meeting AHA guidelines at the close of the course and retain it for a minimum of three years. (See PAM, Appendix A, TC Agreement; Appendix C) a. Does the TC use rosters with AHA guidelines for all courses? b. Is there evidence that rosters are used for every class? c. Are all areas of the roster completed? 7-1. Whether an AHA roster is used or not, are all of the following components included? a. Name of organization (TC and TS if applicable) b. Type of course c. Instructors listed and their station or position Was a physician instructor available (ACLS/PALS only)? d. Number of participants e. Number of participants remediated f. Number of participants incomplete REVIEWER TABULATION: SECTION II Score summary of Page 7 of 19 of 19 of 19 TC Administrative Review, April 2004, Page 7 of 12

17 SECTION II: COURSE-FOCUSED FUNCTIONS continued BLS ACLS PALS g. Instructor-student-manikin ratio (determine from number of participants/instructors listed) h. Total hours of instruction (start and finish times) i. Signed and dated by Lead Instructor or Course Director j. Test scores (optional) REVIEWER: Do not score this question. REVIEWER TIPS: Question 7-1: Review 10 or 5%, whichever is greater. If any aspect is missing, per the roster, that section becomes a No. 8. Each TC will have adequate space for courses that is conducive to learning. (See BIM, Part 2, Chapter 5) a. Does the TC have adequate space to conduct courses? Does the TC consistently use one facility? Yes No Does the TC use multiple facilities? Yes No If using multiple facilities, how does the TC ensure that the atmosphere is conducive to learning? REVIEWER TIPS Question 8: Review rosters for average number of participants. Note criteria in BIM: Adult Learning. Questions not in boldface type are for information only. 9. Each TC will have a textbook available for each participant before, during, and after each course. (See PAM, Chapter 5) Is there evidence that the TC provides access to textbooks: a. Prior to the course b. During the course c. After the course d. Does the TC have an adequate supply of appropriate textbooks for courses offered? REVIEWER TIPS: Question 8: Review rosters for average number of participants. Note criteria in BIM: Adult Learning. Questions not in boldface type are for information only. REVIEWER TABULATION: SECTION II Total score: Add scores for all questions in this section. of 44 of 44 of 44 SECTION III INSTRUCTOR-FOCUSED FUNCTIONS 1-1. Each TC must maintain a current file on TCF/Instructors in all disciplines. (See PAM, Chapter 5; Appendix D; Extranet) a. Is there evidence of a file for each TCF member/instructor? BLS ACLS PALS REVIEWER TIPS Question 1: Review 10 or 5%, whichever is greater. Review ALL TCF files. If any aspect is missing, per folder, that section becomes a No All files should be complete. Note the following criteria: a. Name b. Job status (eg, MD, RN, EMT-P, etc) c. Mailing address addresses optional d. Phone number e. Copy of card TC Administrative Review, April 2004, Page 8 of 12

18 Reviewer Tabulation: SECTION III Score summary of Page 8 of 6 of 6 of 6 SECTION III: INSTRUCTOR-FOCUSED FUNCTIONS Continued BLS ACLS PALS f. Initial recognition date g. Renewal date h. Instructor Monitoring Form every two years for renewal instructors and within 1 year of Instructor Course for Instructor candidates i. Instructor Renewal Checklists: Written exam Psychomotor skills Provider card (optional) j. Instructor Activity Notice to Primary TC (if teaching outside primary TC) k. Instructor Candidate Letters of Alignment with a TC on file l. Instructor Course Completion letter to Primary TC A A A m. Records Transfer Requests Were records transfer requests completed within 30-day time frame? A A A 2. Each TC will maintain documentation of TCF/Instructors teaching activity (four courses in a two-year period). (See PAM, Chapter 5) a. Is there evidence of teaching activity for TCF/Instructors? Individual Instructor file Master list Both 3. Each TC will ensure an adequate number of courses each year to allow all TCF/Instructors to maintain their status. (See PAM, Chapter 5) a. Is there evidence of an adequate number of provider courses? b. Is there evidence that the TC has conducted any Instructor Courses? _A _A _A 4. Each TC will update TCF/Instructors with the latest information on AHA courses, science guidelines, policies and procedures, and training bulletins. (See PAM, Chapter 5) Is there evidence that appropriate faculty attended required AHA updates? (Use most current required update as documentation of evidence) a. AHA courses b. Science guidelines c. Policies and procedures d. Training bulletins e. Is there evidence that the TC updates TS with the latest information? A A REVIEWER TIPS: Question 4d: Training sites applying for TC status should have copies of AHA correspondence on file. A REVIEWER TABULATION: SECTION III Total score: Add scores for all questions in this section. of 22 of 22 of 22 TC Administrative Review, April 2004, Page 9 of 12

19 SECTION IV EQUIPMENT-FOCUSED FUNCTIONS 1. Each TC is responsible for ensuring that appropriate equipment in sufficient quantity is available and in good working order at each course. (See PAM, Chapter 6) a. Can the TC produce a list of training equipment for courses taught? b. Is there a sufficient amount of equipment available for each course? c. Is the equipment in good working order? BLS ACLS PALS 2. Each TC is responsible for ensuring that equipment is appropriately cleaned/decontaminated. (See PAM, Chapters 5, 6) a. Does the TC provide records showing that training equipment was cleaned? b. Are enough AED trainers available? c. Is there evidence that the TC has inspected course equipment in their Training Site(s)? A REVIEWER TIPS: Question 2: If the TC does not maintain Training Sites, c will have to be scored as an NA. Count the NA as a Yes. A A Reviewer Tabulation: SECTION IV Total score: Add scores for all questions in this section. of 6 of 6 of 6 TC Administrative Review, April 2004, Page 10 of 12

20 NOTE: The following is a basic list of equipment necessary for a successful course. For specific equipment requirements, refer to the Instructor Manual in the appropriate discipline. REVIEWER: This is general information. There is no score for this section. Manikins: Number of manikins: Adult Child Infant Are manikins accessible for inspection? If manikins are available, are they in good working order? Adequate space for storage? AEDs: umber of AED trainers available. Defibrillators/simulators (ACLS/PALS): umber of defibrillators umber of simulators Airway equipment: umber of masks umber of valves umber of bag masks Intubation equipment (ACLS/PALS): umber of handles/blades Tracheal tubes (assorted sizes) Combitubes (ACLS only) Laryngeal mask airways BLS ACLS PALS Intraosseous needles for PALS (ACLS optional): _umber of needles Bones or simulations for intraosseous access SECTION I Rating (1-4) SECTION II Rating (1-4) SECTION III Rating (1-4) SECTION IV TRAINING CENTER SCORING BLS ACLS PALS of 38 = % = of 38 = % = of 38 = % = of 44 = % = of 44 = % = of 44 = % = of 22 = % = of 22 = % = of 22 = % = of 6 = % = of 6 = % = of 6 = % = Rating (1-4) TOTAL of 111 = % = of 111 = % = of 111 = % = Rating (1-4) TC Administrative Review, April 2004, Page 11 of 12

21 RATING COMPLIANCE REQUIREMENTS 1 (95%-100%) Assessment provides evidence of excellent Compliant, no requirements, best practice for total score. compliance. 2 (80%-94%) Assessment provides evidence of acceptable compliance. 3 (70%-79%) Assessment does not provide evidence of acceptable compliance. 4 <70%) Assessment does not provide evidence of acceptable compliance. Compliant, no requirements. Noncompliant, additional documentation within 30 days. Noncompliant, additional documentation within 30 days and a focused administrative review within 90 days. A score of 70% to 79% (rating of 3) in any individual section will result in the TC supplying additional documentation within 30 days. A score of less than 70% (rating of 4) in any individual section will result in additional documentation and a focus review within 90 days. Comments: Regional Faculty: Print Signature Date: Regional Faculty: Print Signature Date: Regional Faculty: Print Signature Date: AHA Staff: Print Signature Date: TC Coordinator: Print Signature Date: TC Administrative Review, April 2004, Page 12 of 12

22 American Heart Association Emergency Cardiovascular Care Program Training Center Administrative Self-Review Training Center: Review Date: Location: Discipline: This administrative review may be used for more than one discipline. Directions: Score 1 for every question with a Yes or NA marked. Non-boldface questions are for information only and not part of the scoring guidelines throughout the document. Note to reviewer: Some convenient references are made to the BLS, ACLS, and PALS Instructor s Manuals and Program Administrative Manual (BIM, AIM, PIM, and PAM, respectively) for your evaluation criteria. SECTION I ORGANIZATION/ADMINISTRATION-FOCUSED FUNCTIONS 1. Purposely omitted. BLS ACLS PALS 2. a. Does the TC have a current certificate for general liability insurance? $5,000,000 for National TCs $1,000,000 for ACLS/PALS $300,000 for BLS b. Does the TC have a current letter on file stating coverage by waiver, ie, sovereign immunity? 3. a. Is there evidence that the TC stores records, including TCF/Instructor files? (Check applicable boxes below.) : Hard copy Electronically If stored electronically, are files backed-up on a regular basis? es o Is the TC capable of printing all electronic files as hard copies? es o b. Is there evidence that all records are maintained for a minimum of three years from the date of issue? 4. Is there evidence that the TC maintains the following documents? a. An original or copy of the current signed TC Agreement b. Website agreement (if applicable) c. Documentation of any deficiencies identified during a review Corrective action taken? A d. Current list of Training Sites and contact information A 4.1 Copies of official correspondence from AHA: National and Regional? Can the TC show evidence that there is a process for reviewing/ distributing national and regional correspondence, ie, filed by date? Y N Does the TC have a process for timely distribution of information? Y N Can the TC show documentation that the timeline was followed? Y N Can the TC document that the basic content of appropriate AHA correspondence was distributed to TCF/Instructors? Y N Can the TC show documentation that appropriate AHA correspondence was distributed to TS if applicable? Y N NA A A A A REVIEWER TABULATION: SECTION I Score summary of Page 1 of 8 of 8 of 8 TC Administrative Self-Review, April 2004, Page 1 of 12

23 SECTION I: ORGANIZATION/ADMINISTRATION FUNCTIONS continued BLS ACLS PALS 5. Does the TC have policies and procedures that address the following issues: a. Quality Assurance Plan (updated annually)? b. Continuous Quality Improvement (Performance improvement-data, trends, and outcomes?) c. Equipment maintenance/decontamination? Does policies and procedures address cleaning of manikin and clothing if applicable? d. Internal dispute resolution? Has the TC had any internal disputes? _A If yes, were the outcomes successful? _A e. Management of TCF/Instructor communication/updates? f. Training Site management/relations? (May have contract in lieu of policies and procedures) Instructors TC Faculty BLS ACLS PALS A A 6. a. Is there evidence that the TC supports Chain of Survival initiatives? Mass training CPR, or public access events, by providing: Instructors/TCF Equipment Financial Manikins Organizational support Other REVIEWER TIPS: Question 6: TC must show evidence of participating in one of the above to obtain a Yes and a positive score of a. Does the TC have administrative capability to support the functions of the Training Network? Issuance of cards Maintenance of records Submission of training reports Maintenance of Instructor/TCF files REVIEWER TIP: Question 7: TC must meet all four components to obtain a Yes and a positive score of a. Is the AHA disclaimer clear on all marketing tools where a course fee is indicated? b. Is the ECC provider logo used appropriately? REVIEWER TIP: A A A A Question 8a: If law or policy prohibits TC from offering community courses and there are no marketing materials or community courses, mark Yes for disclaimer use. Question 8b: If TC does not use the ECC Provider logo, mark NA and score as a. Does the TC have access to a computer with Internet access? b. Does the TC have access to a computer with external ? REVIEWER TIPS: Question 9: If there are problems/issues with receiving AHA correspondence/exams, make sure TC has the free download Adobe Acrobat Reader. 10. a. Does the TC maintain an adequate number of TCF and Instructors to meet the needs of its customers? Please indicate total number of the following: REVIEWER TIPS: Question 10: Suggested ratios-number of Instructors to meet largest class size offered; suggested 48 as largest. BLS/ACLS/PALS 1 TCF and/or RF to 8 Instructors 1 Instructor to 8 students 11. a. Has the TC appointed TCF? REVIEWER TABULATION: SECTION I Score summary of Page 2 of 14 of 14 of 14 TC Administrative Self-Review, March 2004, Page 2 of 12

24 SECTION I ORGANIZATION/ADMINISTRATION FUNCTIONS continued BLS ACLS PALS 12. a. Can the TC show evidence of updated Instructor/TCF aligned with TC? b. Does the TC identify Instructors who teach but are not aligned with the TC? c. Does the TC TCF/Instructor list include a minimum of the following information? ame* Address * Phone* Discipline(s) * Instructor card renewal date * (optional) The items with an (*) must be included in each file reviewed to obtain a Yes score. A A A 13. a. Can the TC show evidence of Training Site (TS) administrative reviews? b. Can the TC show evidence of TS course reviews? c. Can the TC show evidence of a current list of Training Sites? d. Can the TC show evidence of conducting TS updates? A A A A A A A A A A A A 14 a. Is there evidence that the TS complies with all AHA policies and procedures? b. Is there evidence that the TS complies with all TC policies and procedures? A A A A A A 15. a. Can the TC show evidence of documented QA activity? b. Can the TC show any documentation of continuous quality improvement? (Performance Improvement: data, trends, and outcomes) REVIEWER TIPS: Question 15: Mark NA for new TC applicants and add a positive score of 1 for each. 16. a. Does the TC have a current Program Administration Manual? b. Is it easily accessible (in a common location for use) for TCF/Instructors? REVIEWER TIPS: Question 16: The TC only needs one PAM; however, manuals need to be accessible for all disciplines. 17. a. Can the TC demonstrate that TCF/Instructors have the most current and appropriate textbooks and toolkits are made available to teach? Does the TC purchase all textbooks for each Instructor/TCF member? Do Instructors/TCF have to purchase their own textbooks? Does the TC share the cost of textbooks with Instructors/TCF? 19. a. Can the TC show evidence of submitting reports submitted by stated deadline? Course/participant statistics REVIEWER TABULATION: SECTION I Total score: Add scores of previous summaries and above questions. of 37 of 37 of 37 TC Administrative Self-Review, March 2004, Page 3 of 12

25 PROGRAM ENHANCEMENT (NO SCORING) BLS ACLS PALS Does the TC use any AHA self-instructional learning system, for example, Heartcode? Does the TC offer contact hours? Training courses Retraining courses ursing Respiratory Other; be specific: Does the TC offer CME for physicians? Training courses Retraining courses Does the TC offer courses in a language other than English on a routine basis? Does the TC offer courses in a language other than English on special request? Spanish French Creole Sign Other, be specific Does the TC subscribe to Currents? Is there a process in place for storing the publication Currents? Is there evidence that the TC encourages TCF/Instructors to subscribe to Currents? It is recommended that each TC Coordinator maintain current Instructor status in at least one discipline. (See PAM, Chapter 5) a. Is there evidence that the TC Coordinator maintain Instructor status in at least one discipline? b. Is there evidence that the TC Coordinator attended any Instructor updates? SECTION II COURSE-FOCUSED FUNCTIONS 1. a. Is there evidence that the TC/TS offers classes to the community? BLS ACLS PALS A A REVIEWER TIPS: Question 1: If the TC is prohibited by law to open classes to the community, check NA and count as a Yes. 2. a. Does the TC have an agenda for each course taught? b. If the agenda been adapted for the individual needs of the TC, does the agenda reflect required core content? c. Do agendas for Instructor Courses reflect qualified faculty? A A A A REVIEWER TIPS: Question 2: Program agendas are used to allow both the Instructor and student to know the format of the course taught within that TC. REVIEWER TABULATION: SECTION II Score summary of Page 4 of 4 of 4 of 4 TC Administrative Self-Review, March 2004, Page 4 of 12

26 SECTION II: COURSE-FOCUSED FUNCTIONS continued BLS ACLS PALS 3. a. Does TC use current AHA cards? b. Is there evidence of a process in place for securing cards? c. Is there evidence of a process in place for issuing cards for a two-year period? d. Can the TC show evidence of controlling the access of the security number for ordering cards? e. Can the TC demonstrate that it issues cards within 30 days of receipt of paperwork? f. Can the TC show evidence that cards are completed correctly? (ie, date: month/year) 4. Does the TC maintain the following in its course files? a. Agendas? b. Completed roster? c. Written exam for students who are Incomplete? d. Psychomotor skills evaluations for students who are not yet complete? e. Dispute resolutions if applicable? (attached to roster) A f. Instructor Candidate Application? (Instructor Courses only) A REVIEWER TIPS: A A A A Question 4: Review 10 or 5%, whichever is greater. If the section you are reviewing is missing from any course files, that section scores a No. Due to the volume of courses, there may be a master agenda for the files and not one in each course roster for BLS. This should be reviewed as appropriate. Question 4f: If the TC has not held an Instructor Course, check NA and count as a Yes for the score. 5. a. Can the TC produce the course/instructor evaluation form? b. Is there evidence that the TC uses this form for every class? c. Is there evidence that the course/instructor evaluation tool is summarized? d. Is a summary of course/instructor evaluations maintained in course files and individual evaluations maintained for those with potential issues/problems? e. Are individual Instructors evaluated? Is there evidence that the TC used the information on the course/instructor evaluation tool for improvement? Is there evidence that the overall TC program administration has been evaluated, ie, course structure, overall management, etc? REVIEWER TIPS: Question 5e: Both items listed in e must be present for a Yes and a positive score. REVIEWER TABULATION: SECTION II Score summary of page 5 of 17 of 17 of 17 TC Administrative Self-Review, March 2004, Page 5 of 12