EP Accreditation

Achieving ACC EP Accreditation: Experience at Mount Carmel Health System

Elizabeth Siferd, RN, CCRN

Mount Carmel Health

Grove City, Ohio

Elizabeth Siferd, RN, CCRN

Mount Carmel Health

Grove City, Ohio

Mount Carmel Hospital was established in 1886 by the order of the Sisters of the Holy Cross. Over the years, Mount Carmel has grown to include three hospitals and a surgical center in the Columbus, Ohio area. The EP program at Mount Carmel West began in the early 1990s. Since that time, three of the four hospitals now have electrophysiology programs, performing device implants, electrophysiology studies, catheter ablations, event recorder implants, left atrial appendage closures, and laser lead extractions. The Mount Carmel Health System has nine practicing electrophysiologists, and volumes in FY 18 exceeded 900 ablations, 1500 implants, and 48 left atrial appendage occlusions. This increase in volume and technical advances in EP procedures has resulted in the need for standards specific to its unique skill set and requirements.

Recently, the American College of Cardiology (ACC) developed its Electrophysiology (EP) Accreditation, linking process improvement to patient outcomes and promoting the consistent processes across the care continuum. In April 2019, the ACC recognized three Mount Carmel Health System hospitals as being the first recipients of this accreditation: Mount Carmel St. Ann's in Westerville, Ohio, and Mount Carmel East and Mount Carmel West in Columbus, Ohio. In this article, we discuss our journey to EP accreditation.   

Accreditation Process

The essential components of EP accreditation are: governance, quality, pre-procedure, peri-procedure, post-procedure, and clinical quality.

The process for achieving accreditation began with purchasing Accreditation Services and beginning the training. A multidisciplinary team consisting of our director, three site managers, and three electrophysiologists was established to work with a lead from the ACC, who was assigned to guide our healthcare system in this experience. Our director, Curtis Patrick, made this journey to accreditation a priority for his management team.

To assess our practices, the team performed a gap analysis and reviewed areas for improvement. Staff education and a post-procedure debrief were chosen as our performance improvement (PI) goals for the journey. For example, to bring full circle the features of a pre-procedure time-out, a post-procedure debrief was developed and implemented. Each EP lab site now uses a form for post-procedure debrief, which includes the date, procedure, discussion of complications and plan of care, supply issues, safety issues, equipment issues, educational opportunities, issues to escalate to the manager, and manager feedback. These aspects were previously discussed, but no formal debrief or documentation form was in place.

It was also decided that staff education would occur each month at rotating sites, with our electrophysiologists providing lectures on EP basics, specifics, and new technology.

Validation came after a site review was conducted by the ACC, and our charter was approved. For the ensuing months, we collected data from our PI goals. Since accreditation was achieved, we have continued PI collection and discuss these results in our quarterly EP ACC Accreditation meetings, which consist of management, EP physicians, and EP lab staff members. In order to advance to an ongoing accreditation, new PI initiatives and metrics are being developed in each meeting for use towards our renewal application in three years.

"The process began the year before our accreditation," said Louise Robbins, RT(R), manager of the Electrophysiology Lab at Mount Carmel Grove City (previously at the now closed Mount Carmel West Hospital). “Dr. Hackett, who is on the ACC board, asked if I would be a reviewer for an upcoming EP accreditation. I received a document that contained proof of the proposed accreditation, read each element, and decided if the content was concise and easily understood. After much time reviewing the content, it was clear to me that Mount Carmel was already meeting at least 95% of the requirements for accreditation. As a system, the hospitals all operate highly efficient EP labs — we have dedicated physicians and amazing outcomes. What I came to understand is that a good portion of our work was not documented as a ‘standard’ or a ‘process.’  Therefore, the managers and their staff collaborated to create flow charts and checklists to ensure that we were hitting the mark 100% of the time. This gave us the opportunity to really look at metrics that would improve each lab individually and as a system. Overall, the accreditation journey was not about celebrating what we already did, it was about how much better we could be — not to mention the exciting opportunity to collaborate with the ACC on the ‘best practice’ in our EP labs.”

“The accreditation journey unified our efforts across the organization, accelerating standardization and adoption of proven practices which improve clinical outcomes and operational efficiency. This is fully reflective of the quality and commitment to the highest standard,” says Curtis Patrick, Regional Director of Cardiovascular Imaging and Intervention. “The process and the allure of the achievement helped me synergize the activities of the managers and medical directors across the system, accelerating the pace with which we were able to create and amend policies and care paths. The power of the common goal should never be underestimated. The process of updating our EP lab charter was also extremely beneficial. It laid out very clearly the span of control and oversight for certain committees and roles, which had become murky in recent years. We are more agile and flexible now.”

“The EP Accreditation from the ACC was important to our physicians, nurses, and staff, because it demonstrates our dedication to providing state-of-the-art EP care to our patients,” says F. Kevin Hackett, MD, FACC, physician chair of the Mount Carmel Heart and Vascular Center. “We look forward to continuing to work with the ACC to maintain our accreditation.”

In the months since achieving accreditation, we have seen the difference that our performance improvement processes have made in the daily care of our EP patients, especially in our post-procedure debrief with the physician, staff, and patient. We take pride in our improved system-wide goals and achievements, and look forward to meeting the challenges and changes that each new day brings.