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Advanced Certification for Heart
Failure (ACHF)History and Revisions for January 2017
Tabitha V. Vieweg, RN, BSN, MBAAssociate Project Director, Specialist
Department of Standards and Survey Methods
Division of Healthcare Quality Evaluation
October 04, 2016
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Continuing Education Credit
This webinar is approved for 1.0
Continuing Education Credit from:
American Society for Clinical Laboratory Science
(PACE)
American Nurses Credentialing Center (ANCC)
Accreditation Council for Continuing Medical
Education (ACCME)
American College of Healthcare Executives (ACHE)
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Continuing Education Credit
CE/CME/CEU are available for the live audio only. Credits will not be
available for webinar replays
In order to claim credits you must have:
Individually registered for the webinar through The Joint Commission
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Listened to the webinar in its entirety. Only those listening live on the
day of the call will be eligible to receive credit. This is an educational
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Completed a post program evaluation/attestation. A link to the post
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Disclosure Statement
The employees and/or speakers for this presentation have
disclosed that they do not have any financial arrangements or
affiliations with corporate organizations that either provide
educational grants to this program or may be referenced in this
activity.
Furthermore, each of the previously named speakers has also
attested that their discussions will not include any unapproved
or off-label use of products.
Tabitha V. Vieweg, RN, BSN, MBA
Associate Project Director, Specialist
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OBJECTIVE
Participants will understand the upcoming
changes to the Advanced Certification for
Heart Failure program
Participants will receive information useful to
demonstrate compliance with the
requirements for the Advanced Certification
for Heart Failure program
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HISTORY
The Advanced Certification for Heart Failure
program originally launched in 2012
Performance measures added 2014
Based on American College of Cardiology
Foundation/American Heart Association
(ACCF/AHA) Guideline for Management of Heart
Failure
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Eligibility Criteria - General
Owned/Operated in United States
Accredited by The Joint Commission
Fits “types of services certified” (provides patient
care/interaction)
Served a minimum of 10 patients at time of
application
Uses Clinical Practice Guidelines
Uses Performance Measures
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Eligibility Criteria - ACHF
Meets all general criteria
Has an established inpatient treatment
program
Provides ambulatory care services for heart
failure (hospital owned/based or
collaborative relationship with cardiologists)
GWTG HF – Bronze Level
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Program Structure
Follows Disease Specific Care format
– DSPR – Program Management
– DSDF – Delivering/Facilitating Care
– DSSE – Supporting Self Management
– DSCT – Clinical Information Management
– DSPM – Performance Measurement
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Performance Measures
Standardized performance measures
– 6 mandatory; 7 encouraged
– https://www.jointcommission.org/adv_c
ertification_heart_failure_standardized_
performance_measures/
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ACHF– Revisions January 2017
Collaborative process with AHA
2013 ACCF/AHA Guidelines
Regular maintenance cycle
Standards and Survey Process Committee
Approval 4/1/16
Prepublication/field notification May 2016
Revised requirements effective January 1,
2017
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General Revisions to ACHF
Revisions to be consistent with other advanced certification
programs
– Clinical and Administrative leadership of the program
– Order sets and pathways reviewed annually and updated
as necessary
– Performance measures reviewed by interdisciplinary team
and quality department
– Committee review and evaluation of protocols and practice
patterns
Care coordinator = staff who coordinate care
Additional detail based on 2013 ACCF/AHA Guidelines,
Technical Advisory Panel discussion, and field review feedback
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ACHF- Revisions January 2017
DSPR.3, EP 1
– Services provided to patients
– Highlight these in your opening conference
presentation
DSPR.3, EP 4b
– Regular support group meetings for
patients/families
– If you don’t have enough patient/family interest,
where do you refer them?
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ACHF- Revisions January 2017
DSPR.5, EP 1c
– Services provided for HFrEF and HFpEF
–Be sure to include patients with both
types of heart failure when providing on-
site reviewers with a list of possible
tracers
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ACHF- Revisions January 2017
DSDF.3, EP 2 – additional detail from CPG
– Assessment of volume status at follow-up
visits
– Diagnostic testing
– Repeat ejection fraction frequency
– Venous Thromboembolism prophylaxis
– Follow-up echocardiogram to assess the
need for ICD
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ACHF- Revisions January 2017
DSDF.3, EP3
– Guideline Directed Medical Therapy
(GDMT)
–GDMT is the term used by the
ACCF/AHA cardiac task force to
represent all Class 1a recommendations
for the treatment of heart failure.
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ACHF- Revisions January 2017
DSDF.4, EP2
– Topics addressed at discharge and during
follow-up visits
–A tool would be helpful for the patient
record; not all items need to be
addressed in depth every time (e.g.,
patients with post-discharge support)
– Plan of care topics
–Consider building in to EHR
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ACHF- Revisions January 2017
DSSE.3, EP 1
– Topics for patient education
–Listed somewhere in the EHR so the
team knows what’s been covered vs.
what needs to be discussed/reinforced
DSPM.3, EP1
– Performance measures are based on
CPGs with the goal of improving quality of
care (in addition to the standardized
measures)
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General Tips for a Successful
Review – Opening Conference
Materials needed for this session:
– Disease specific care program organization chart,
if applicable
– Roster or sign in sheet of organization
representatives attending this session
– PowerPoint presentation is not required, but is
helpful
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General Tips for a Successful
Review – Opening Conference
Overview of program
– Program mission, goals, objectives
– Program structure
– Program leadership/management
– Composition of interdisciplinary team
– Scope of services
– Target population of program
– How CPGs are incorporated into the program
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General Tips for a Successful
Review – Planning Session
Items to have available for reviewers for their
planning session:
– Composition of the program’s IDT
– Program’s mission and scope of services
– Current list of patients being treated as well as a
list of patients treated in the past 4 months; if
possible please include the following:
– Primary diagnosis, admit date, discharge date,
patient age, gender and ethnicity, if available
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General Tips for a Successful
Review – Planning Session (con’t)
Items to have available for reviewers for their planning session
(con’t):
– Order sets, clinical pathways, protocols used to care for
patients
– Patient educational materials for the program
– Written performance improvement plan
– Performance measure data
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General Tips for a Successful Review –
Individual Tracer Activity
Reviewers will select patients to follow the course of
their care, treatment or services
– Observing program staff and patient interaction,
care planning process
– Speaking with staff, patients and families
– Verifying processes
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General Tips for a Successful Review –
Individual Tracer Activity (con’t)
Record review with staff
Visit units and departments involved in patient care
Patient tracer activity for advanced certification for
heart failure includes transitions between inpatient
care and outpatient care
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General Tips for a Successful
Review – System Tracer/Data Use
Materials needed:
– Performance measure data reports
– Action Plans showing the program’s use of data
Possible discussion topics:
– Data gathering and preparation
– Performance Improvement Plan
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General Tips for a Successful Review –
System Tracer/Data Use (contd.)
Possible discussion topics (contd.):
– How data is used in improving quality of care and
patient safety
– How patient satisfaction data is used
– Strengths and weaknesses in the process used to
obtain data
– Data reporting and dissemination of findings
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General Tips for a Successful
Review – Competence/Credentialing
Review of personnel and credentialing files
– A minimum of 5 will be selected
– At least one per discipline (RN, MD, SW, RD, PT,
etc.)
– Program-specific competence and credentials
requirements
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General Tips for a Successful
Review – Competence/Credentialing
(con’t)
Review of personnel and credentialing files (con’t)
– Methods for assessing competence of
practitioners and team
– Any unique orientation, on-going education,
training and in-service requirements
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General Tips for a Successful
Review – Wrap-up
Issue Resolution
– The opportunity for the reviewer to follow-up on
any outstanding issues that could not be resolved
earlier
Reviewer Report Preparation
Program Exit Conference
– Verbal report of findings/observations
– Final determination after Central Office review
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Questions?
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Contact Information
Tabitha V. Vieweg, RN, BSN, MBA
Associate Project Director, Specialist
Department of Standards and Survey Methods
630-792-5996
Patrick Phelan, MBA
Associate Director, Business Development
The Joint Commission
630-792-5145
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The Joint Commission Disclaimer
These slides are current as of 10/1/2016. The Joint Commission reserves the right to change the content of the information, as appropriate.
These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.
These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.
