Using Certification for Program Improvement

Using Certification for Program Improvement Gayla Oakley RN, FAACVPR Dir. Cardiology Services and Prevention Boone County Health Center Albion, Nebraska Objectives 1. Understand the certification application and requirements. 2. Identify the importance of program certification. 3. Identify methods or process of improving your program through certification The AACVPR Cardiac and Pulmonary Rehabilitation Program Certification process is the only peer reviewed accreditation process designed to review individual programs for adherence to standards and guidelines developed and published by the AACVPR and other professional societies. 1

For the purposes of AACVPR Certification A program must comply with current standards and guidelines as approved by the AACVPR Board of Directors. The certification committee s role is to measure your program according to these standards. Certification AACVPR Program Certification is valid for a period of three (3) years with the expectation that all stated program certification requirements will be adhered to throughout h t the entire period. Because you were certified does not mean that the information that you submitted last time will be automatically accepted for the next recertification. The requirements change from year to year as research and guidelines change. Be Prepared BEFORE You Apply Certification is for Early Outpatient Cardiac or Pulmonary rehabilitation. Your program must be in operation for one year prior to applying. In order to participate in the AACVPR Program Certification process, you must have a current AACVPR member within your program. Review the application content and requirements. Certification and Recertification applications are now identical. 2

If You re Not SURE Check the certification application resource page and and the following available resources on the AACVPR website www.aacvpr.org Position Papers Scientific Statements Guidelines JCRP Cardiac and Pulmonary Rehab Fundamentals Certification Application Resource Page Application Manual Application Webcast FAQ Section Discussion Forum Members Only Section Enhanced educational opportunities The Application Staff Competency AACVPR defines competency as skills, knowledge and critical thinking required to operate effectively in a Cardiac or Pulmonary yprogram. Ways to assess competency Check off stations, Test/quizzes, Return demonstration, Article review with post test For the purposes of certification must provide evidence of annual assessment of clinical/professional staff for competency and specific to CR/PR rehab 3

Staff Competency Core Competencies(New for 2012) Individuals who provide cardiac or pulmonary rehab services should possess a common core of professional and clinical competencies, regardless of their academic discipline. For the purposes of AACVPR Program Certification programs must provide evidence of a minimum of two assessed competencies specific to the Core Competencies Core Competencies Cardiac Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals: 2010 Update. Core Competencies Cardiac Patient assessment Nutritional counseling Weight management Blood pressure management Lipid management Diabetes management Tobacco cessation Psychosocial management Physical activity counseling Exercise training evaluation 4

Core Competencies Pulmonary Clinical Competency Guidelines for Pulmonary Rehabilitation Professions. Core Competencies Pulmonary (1) Assessment: Pathophysiology and comorbidity Professional communication Patient education and training Exercise Psychosocial (2) Intervention: Professional communication Patient education and training Exercise Psychosocial Emergency procedures (3) Outcome evaluation and follow up Staff Competency Requirements Competencies must be assessed for all professional/clinical staff who directly report to the Cardiac or Pulmonary Rehab director or manager. Staff competencies must be submitted in the required table format. Staff listed on the submitted Staff Competency Table must match the clinical staff members listed on the Program Intake Form exactly. You do not need to report competencies for the program medical director, ancillary or administrative staff, or consultants. A minimum of two assessed competencies specific to the Core Components 5

Name of Employee Angie Swantek Required Table Format for Staff Competencies Competency with Date EKG Quiz 5/5/2011 Competency with Date Glucometer return demo 6/15/2011 Competency with Date Waist circ return demo 7/20/2011 Competency with Date Crash cart scavenger hunt 8/9/2011 Janet Feik EKG Quiz 5/5/2011 Glucometer return demo 6/15/2011 Waist circ return demo 7/20/2011 Crash cart scavenger hunt 8/9/2011 Sharon Kunzman EKG Quiz Glucometer return Waist circ return Crash cart 5/5/2011 demo demo scavenger hunt 6/15/2011 7/20/2011 8/9/2011 Cindi Oberhauser EKG Quiz 5/5/2011 Glucometer return demo 6/15/2011 Waist circ return demo 7/20/2011 Crash cart scavenger hunt 8/9/2011 Abbie Nelson EKG Quiz 5/5/2011 Glucometer return demo 6/15/2011 Waist circ return Crash cart demo scavenger hunt 7/20/2011 8/9/2011 DO NOT: Staff Competency Automatic Denial Submit general emergency, safety drills and in services in the hospital facility, such as fire drills, infection control, safety inspections or health and safety reviews. Submit documentation outside the stated date range. Submit competencies not specific to cardiac or pulmonary rehab. Fail to submit a min. of two core competencies. Submit competencies that are not in the required table format AND do not match staff on Program Intake Form. Fail to respond to reviewer clarification questions within three business days. What is an Individualized Treatment Plan? Summary of the planned care of the patient from initial assessment to discharge from the Cardiac or Pulmonary Rehabilitation program. For the purpose of certification/recertificatio n the ITP must be developed and completed for each patient in the CR/PR program and must include all components. 6

Individual Treatment Plan (ITP) Requirements Upload COMPLETED Cardiac or Pulmonary ITP that is HIPAA compliant ITP must be a single document. (It does not need to be one page.) ITP must be for an actual patient that has completed all required components Assessment and reassessment scores must be on the ITP, do not submit assessment tools. ITP must be completed in the data collection period Must Include the Following Clearly Labeled Components Education Assessment Education Intervention Education Reassessment Education Discharge Exercise Exercise Exercise Exercise Assessment Intervention Reassessment Discharge Nutrition Assessment Psychosocial Assessment Nutrition Intervention Psychosocial Intervention Nutrition Reassessment Psychosocial Reassessment Nutrition Discharge Psychosocial Discharge Individual Treatment Plan (ITP) Automatic Denial DO NOT Submit a blank ITP or one competed that was not an actual patient. Submit an ITP that did not contain all of the 16 required components that are clearly labeled Submit multiple documents i.e. assessment tools, letters to physicians/patients., progress notes, etc. Submit check boxes only indicating done but no data given. Submit ITP that is dated outside the collection period Fail to respond to reviewer clarification questions within three (3) business days. 7

Assessment Psychosocial Intervention Psychosocial Evaluation Psychosocial Follow-up Psychosocial Assessment Nutrition Assessment Education Intervention Nutrition Evaluation Nutrition Follow-up Nutrition Evaluation Nutrition Assessment Education Intervention Education Evaluation Education Follow-up Education Emergency Preparedness (Cardiac) CARDIAC REHAB: For the purpose of AACVPR certification, the following emergency equipment and supplies must be immediately available to Cardiac Rehab and documentation maintained of verification of readiness preformed every day the rehab program is in operation. Calling 911/EMS alone to bring these supplies/medications is not acceptable. Defibrillator/AED Portable oxygen, tubing, mask/nasal cannula Intubation equipment and advanced airways Crash cart with emergency equipment and ACLS medications. 8

Emergency Preparedness (Pulmonary) PULMONARY REHAB: For the purpose of AACVPR certification, the following emergency equipment and supplies must be immediately available to Pulmonary Rehabilitation unit and documentation maintained of verification of readiness preformed every day the rehab program is in operation. Calling 911/EMS alone to bring these supplies/medications is not acceptable. Defibrillator/AED Oxygen source and delivery apparatus Resuscitation mask (Ambu bag) Ability to monitor oxygen saturation (pulse oximeter) Bronchodilator medications Glucose Emergency Preparedness Requirements One (1) month's documentation of daily verification of readiness for each day the program is in operation. An explanation should be provided for any missing dates during that month. For each equipment/supply listed, indicate where the item is located in relation to the Cardiac or Pulmonary Rehabilitation ti unit. Evidence of four (4) annual department medical emergency inservices specific to Cardiac or Pulmonary Rehabilitation held during the data collection period. Brief description of medical emergency in service Submitted in services may include mock code blues, review of crash cart/defibrillator, critique of an actual code, etc. Emergency Preparedness Automatic Denial DO NOT: Fail to have all required emergency supplies and equipment immediately available to the Cardiac or Pulmonary Rehabilitation unit. Fail to provide the location in relation to the rehab unit of each required equipment/supply. pp Fail to submit one (1) month's documentation of verification of operational readiness with explanation of missing dates. Fail to submit dates and brief description of four (4) medical emergency in services. Submit general hospital emergency and safety drills and inservices such as fire drills, infection control, safety inspections, or health and safety reviews. Submit documentation out of the data collection period; Fail to respond to reviewer clarification questions within three (3) business days. 9

Medical Emergency In service Date Brief description of medical emergency in service Date Brief description of medical emergency in service Date Brief description of medical emergency in service Date Brief description of medical emergency in service Policies and Procedure Requirements Documentation that policies and procedures specific to Cardiac or Pulmonary Rehabilitation have been reviewed annually by the program medical director and director/coordinator/manager during the collection period. Policies and Procedure Automatic Denial DO NOT: Fail to submit evidence that department policies are reviewed annually. y Fail to submit evidence that department policies are reviewed by the medical director and program director, coordinator, manager. Fail to respond to reviewer clarification questions within three (3) business days. Submit documentation that is not in the collection period. 10

Example of P&P Signature Page REVIEW OF CARDIOPULMONARY REHAB POLICIES & PROCEDURES Policies & Procedures are to be reviewed annually. The Medical Director and the Cardiopulmonary Rehab Manager will share responsibilities for the review. Month/Year Reviewed Medical Director Manager Exercise Prescription The exercise prescription is individualized, approved by the physician for each CR/PR patient and it must contain all required elements; mode, frequency, duration, intensity and progression. In addition to required elements, O2 saturation and titration for pulmonary rehab patients only. The Ex Rx can be a component of the Individual Treatment Plan but it must be submitted for both the ITP (page1) AND the exercise prescription (page 5). A written policy must be in place that details how an exercise prescription is developed and modified for each patient. The policy must contain all required element of the exercise prescription; mode, frequency, duration, intensity, progression plus oxygen saturation and titration for pulmonary rehabilitation. Exercise Prescription Requirement Individual Exercise Prescription (EX RX) Initial exercise prescription. Physician signature approving the exercise prescription. Includes mode, duration, frequency, intensity and progression. O2 saturation and titration for PR patients only. Intensity targets must be within AACVPR and ACSM guidelines Progression must be more specific than as tolerated or as dictated by absence of signs and symptoms The document called the Exercise Prescription from a telemetry monitoring system, MUST include all required elements of the exercise prescription. Completed and for an actual patient. Completed during the data collection period 11

Exercise Prescription Requirement Exercise Prescription Policy Describes in detail how all required elements of the exercise prescription listed above are developed and modified. Exercise Prescription Components Mode: Bike, Treadmill, Elliptical Intensity: How hard (heart rate range, RPE, Mets) Intensity targets must be within AACVPR and ACSM published guidelines Duration: How long Frequency: How often Progression: How do you advance the patients. Need some type of methodology. As tolerated or as per clinical signs and symptoms is not accepted. Oxygen Saturation and Titration (Pulmonary only) Progression Pattern Based on Risk Stratification and LOS Risk Determined Low Risk Moderate Risk High Risk Up to 80% of Maximum HR Up to 70% of Maximum HR Up to 60% of Maximum HR Initial Duration 45 Minutes Initial Duration 35 minutes Initial Duration 25 minutes Duration/Intensity change every 3 sessions Duration/Intensity change every 6 sessions Duration/Intensity change every 9 sessions Weight training after 18 sessions Weight training after 24 sessions Weight training after 36 sessions 12

Exercise Prescription Automatic Denial DO NOT Fail to submit any of the required components of the exercise prescription. Submit blank or not for an actual patient in your program. Fail to have evidence of physician signature. Fail to submit a policy that addresses all components of the exercise prescription. Submit daily exercise session sheets only. Submit document outside of the data collection period. Fail to respond to reviewer clarification questions within three business days. Medical Emergencies For the purposes of AACVPR certification/recertification, written program specific policies/protocols for the following: Cardiopulmonary Arrest Angina Acute Dyspnea Tachycardia Bradycardia Hypertension Hypotension Hyperglycemia Hypoglycemia 13

Medical Emergencies Requirement A department specific policy addressing all of the medical emergency conditions. They can be in separate policies/protocols for each specific condition or in one combined policy. Policies specific to Cardiac or Pulmonary Rehabilitation. Medical emergency policies must be detailed beyond calling 911 Policies specific to the role of the Cardiac or Pulmonary Rehabilitation staff in managing the emergency situation. Medical emergency policies must address the treatment of the patient from onset of signs and symptoms until resolution of the emergency (transfer to ED, hospital admission, resolution of symptoms, discharge home, etc. Medical Emergencies Automatic Denial DO NOT: Submit department policies addressing all of the medical emergency conditions. Submit policies that do not include specific details related to staff involvement in treatment activities. Submit policies that are ACLS protocols/algorithms only. Fail to respond to reviewer clarification questions within three business days 14

Outcome Assessment Outcome measures are tests to evaluate if a desired end is met. They can be used to evaluate individual patient progress, to determine overall effectiveness of the program. Cardiac outcome categories: Clinical Behavioral Health Service Pulmonary outcome categories: Functional status/exercise capacity Symptoms Measurement Quality of Life Service 15

Outcome Assessment Cardiac Clinical Clinical outcomes measure objective clinical data, such as MET level, BMI, lipid levels, (6) six minute walk results, blood pressure, etc. Behavioral Behavioral outcomes measure the patient s ability to make changes in life style: minutes of exercise, knowledge test, diet changes, number of cigarettes smoked Health Health outcome measure changes in health/quality of life status: Quality of Life survey (QOL) Service Service outcomes can measure: patient satisfaction, effectiveness of program, access or utilization of services, cost of care Outcome Assessment Pulmonary Function Clinical outcomes measure objective clinical data, such as MET level, BMI, lipid levels, (6) six minute walk results, blood pressure, etc. Symptom management dyspnea Measurement for symptoms of dyspnea and fatigue, such as Borg Dyspnea Scale, MRC Scale, UCSD SOBQ, CRQ, etc. Quality of Life Health outcome measure changes in health/quality of life status: Quality of Life survey (QOL) Service Service outcomes can measure: patient satisfaction, effectiveness of program, access or utilization of services, cost of care **See pulmonary outcomes toolkit or AACVPR Pulmonary Rehab Guidelines** Cardiac Outcomes Requirement Description of one clinical, behavioral, health and service outcome. Outcome according to the AACVPR Outcomes Matrix Document from the data collection period. Description of the assessment tool used. Report on a minimum of 30 patients (N). If less than 30 patients completed your program during the data collection period, submit data for 100% of the patients who did complete. Pre program score. Post program score. Percent change, units of change or change towards goal between the preand post program scores. Conclusion, a summary of results of the outcome measurement on the pre and post program scores. Process or programming improvements made to CR program as a result of the outcome based on the conclusion. 16

Pulmonary Outcomes Requirement Description of one outcome measure for each of the following; Function, Symptoms, Quality of Life and Service. Outcomes correspond with the Pulmonary Outcomes Tool Kit. Document from the data collection period. Description of the assessment tool used. Report on a minimum of 30 patients (N). If less than 30 patients completed your program during the data collection period, submit data for 100% of the patients who did complete. Pre program score. Post program score. Percent change, units of change or change towards goal between the pre and post program scores. Conclusion, a summary of results of the outcome measurement on the pre and post program scores. Process or programming improvements made to PR program as a result of the outcome based on the conclusion. Outcomes Automatic Denial DO NOT: Submit outcome measure that does not fall into the appropriate category according to AACVPR outcomes matrix or Pulmonary Tool Kit.(found on the AACVPR web site). Fail to meet sample size requirements. Fail to submit any of the required elements. Fail to respond to reviewer clarification questions within three business days. Service Outcome Required Elements One Service outcome measured in your program during the collection period. Description of the assessment tool used. Summary of conclusions based on the outcome change found. Description of process or programming improvements made to the CR/PR program as a result of the outcome. Automatic Denial Service measured not on AACVPR Outcomes Matrix Not in collection period Failure to respond within three business days. 17

Attestation Statement You must attest that all material and information submitted with this application is true and accurately represents program operations at this facility and would welcome a site visit if randomly selected. Submission Here you can see a list of any pages that are incomplete. When all pages are complete, the submit button appears. Don t forget to click SUBMIT! Application Tips For Success Fill in the program roster with all staff prior to starting the application. Be sure that you have a primary and secondary contact person or you will not be able to go further on the application. All documentation will be requested with the initial application. No additional or newly created documentation will be allowed after the application is submitted. pp Only submit what is asked for. More is not always better. When documentation is required, there are two options for submitting that information; fax or upload. FAX: A fax cover sheet with the barcode, specific for that page, will be provided when you click on fax information. BE SURE that you do not use the same fax sheet for each page. The barcodes are page specific. If the document goes to the wrong page, you may not get credit for it. UPLOAD: Upload documents via an attachment when you can. The document is clearer and easier to review. 18

Application Tips For Success All submitted documentation must be HIPAA compliant with all patient identifiable information blacked out or removed, including patient name, date of birth, medical record number, admission number, address, phone number, spouse s name, etc. All submitted documentation must be actual patient and/or program documentation. Blank sample forms will not be accepted. Submitted documentation should be neat and legible, with correct spelling and grammar. There are text boxes for required narratives. Keep it brief and concise. There is a maximum number of character allowed. Application Tips For Success The following automated message will be sent when the review of your application has started. I have begun the review of your AACVPR Program Certification application. Please check your dashboard daily as you may be contacted t multiple l times during the next 2 3 weeks. If you are asked to clarify, you need to respond to that request within three (3) business days. We recommend that you authorize a second person within your staff to also be able and available to respond to these requests. Failure to do so could result in automatic denial of your program. An automated message will be sent when the initial review is completed. Application Tips For Success If you have questions while completing the application and can t locate the answer, Certification Specialists are available Monday through Friday during business hours to assist applicants by email, live chat, or you can contact the call center 312/321 5146, option 1 Application fee for certification and recertification will be set annually by the AACVPR Board of Directors All application fees must be paid in full by the final application submission deadline. The application will not be reviewed without payment. 19

Application Tips For Success All applications must be received by the application submission deadline. No extensions will be granted. All applications must be submitted online via the AACVPR Certification Center. All communication between the applicant and reviewer will be via the application dashboard. Applicants must respond to reviewer questions regarding their application within three (3) business days. Printable versions of the current year s application will be available on the AACVPR website. When a required table or form format is required there will be a link in the application to obtain the form APPROVALS AND DENIALS The AACVPR Program Certification Committee shall recommend approval or denial of the application to the AACVPR Board of Directors. Prior to the denial of a program, the inter rater reliability testing process will be followed. It is utilized in the certification process in order to assess the consistent evaluations of the same application. This strengthens the certification process and helps assure reliability of the review. Individual programs recommended for denial may not appeal. The AACVPR Program Certification Committee reserves the right to perform a site inspection if indicated. Importance of Program Certification 1. Provide the best program possible for your patients AACVPR certification demonstrates that your program is aligned with current guidelines for the appropriate and effective early outpatient care of patients with cardiac or pulmonary disease. 20

Importance of Program Certification 2. Patient referral/enrollment Physicians can refer patients to your certified program with confidence, knowing that you can be an extension of their care to the patient. Certification offers peace of mind to knowledgeable healthcare consumers. Certification can also help patients decide between your program and an uncertified program in the area. Patients and family members can feel confident in knowing that your staff has the experience and skills necessary to deal with the variety of issues that a life changing cardiac or pulmonary diagnosis can lead to. 3. Recognition Importance of Program Certification Hospital administrators embrace program certification as a vehicle to demonstrate excellence for state department of health or TJC surveyors. 4. Reimbursement Importance of Program Certification Insurance companies recognize that performance measures in patient care are part of the essential standards required for AACVPR certification. 21

Tips for Success READ the entire application before you begin the process. Be prepared BEFORE you apply. Remember that this is a CERTIFICATION process, not a MENTORING process. Take advantage of all the available RESOURCES. The application and requirements may CHANGE every year. Q & A 22