Running head: ACE ACCREDITATION
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ACE Accreditation
Kelly Cross
SUNY IT
Nursing Leadership
NUR 444-36W
Thomas Norton
December 8, 2013
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Abstract
For my leadership project I participated in a massive undertaking for a facility to receive national
accreditation from the Accreditation for Cardiovascular Excellence. During my preceptorship, I
was asked to be a major part of this project and participated on every level of identifying,
describing, implementing and evaluating change in the current processes and create the new
policies, protocols, education, culture to align with the criteria set forth by the accrediting body,
that we hoped to achieve. This project took many months and is still not complete. There were
many items that needed to be addressed and many small projects that spawned from this large
one. This was a great learning experience and one I can look back on and hope to be as good as
those that were around me for this experience. I will continue to work on this project since I
would like to see it come to fruition and I have enjoyed the content of it. The objectives and
goals proposed at the beginning of the project had to be changed due to the magnitude of the
project, and we are now approximately 3 months behind those initial measures.
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ACE Accreditation
Project Purpose/Objective/Description
The global objective of this project is to improve quality outcomes, provide
standardization to the processes, reduce organizational and fiscal liability, and obtain
Accreditation for Cardiovascular Excellence (ACE) for the cardiac catheterization lab.
Accreditation provides a metrics that every person in the department can utilize to provide
quality based care at each point of care within the process. There are many domains that are
involved in this process. They include: facility, leadership structure, equipment, physician and
other providers, nursing personnel, technical staff, medical records, coders, procedure
indications, outcomes analysis, qa/qi processes, informed consent, and procedure preparation and
conduct (cvexcel.org, 2013).
I was brought in at the entry level since my preceptor had just begun this process. She
essentially put me in charge of the project and I reported out to her weekly on my progress. I
attended all meetings and workshops associated with this project, and it was understood from the
beginning that I was to follow through with the entire project after this class was over. I attended
meetings with my preceptor that addressed issues with physicians working in the department,
and overcoming barriers to this process. I would be lying if I didn’t say it was overwhelming in
the beginning. Some of the analysis I was asked to do I had not done previously so I had to seek
out assistance in those areas first, to make sure I did a good job with this project. For example,
providing gap analysis in excel format. I am an excel zero and this took a little while to learn.
Another aspect that was difficult was getting to know all the players and making sure no one was
left out of the loop. Organized meetings took place. I coordinated work groups that focused on
different aspects of the domains involved. Medical records and coders were involved to discuss
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the procedure types and to go over some previous issues with mismatched dictation and coding .
Quality members were involved and with nursing, helped to create a new informed consent that
met the ACE criteria, as well as work with pharmacy to develop new policies for other reportable
issues e.g. contrast induced nephropathy. I attended all of these meeting, correlated data and sent
updates to the gap analysis out via email weekly. I worked with the education department to
ensure the personnel had all the necessary training as required by the accrediting body and
assured the department director that the staff was all up to date and their records were intact.
With regard to all the physician criteria, they were made aware of the necessary changes they
needed to make during their procedures, notified regarding the increased amount of continuing
education credits they had to obtain, made aware of the changes necessary in their dictation of
the reports, informed regarding new peer review that was now mandated from each operator, and
other general information crucial to the success of this endeavor. The physicians were quite
annoyed on a few occasion, understandably so, and at these times I let the medical director take
the lead in addressing their concerns. I did not feel it was my responsibility to engage in
discussion without the high level people who were responsible for the department there. I was in
attendance for most of the meetings with the physicians but I did hear of some heated discussions
that happened and I was not in attendance for. Other high level project requirements such as,
obtaining administrative approval for the accreditation, was done without my input or
attendance. I was, however, asked for my opinion by the CEO of the organization regarding the
necessity of such an accreditation. I am sure he knew the answer but was quizzing my
knowledge of the process and benefits of the status. I am certain I gave a good answer as he
smiled and patted my shoulder.
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I started out by providing a gap analysis of the current processes of the institution and
the measurable metrics of the accreditor. That is a bit of torture to be honest and was very time
consuming. The process started with filling out the application. This is 14 pages of statistics,
policy, protocols, entering continuing education credit for physicians, techs and nurses,
providing administrative documentation of financial support for the accreditation, and other more
secretarial things. Following the gap analysis, work teams were established to work on the areas
of known deficiency. My purpose through this process was not only to participate in all of these
work groups, but, to monitor the process, keep track of and submit the necessary changes,
provide the evidence to back up the policy changes, submit to medical executive committees for
final hospital approval, coordinate and participate in the general education regarding the process
changes and what ACE accreditation entails, and finally, to be a resource for every person in this
process.
Description and Benefits
What is ACE Accreditation and what is the significance of it? Accreditation is the
process of meeting organizational and evidence-based standards developed by impartial
consumers, and/or national organizations. Accreditation indicates that the accredited
organization has achieved an appropriate level of organizational proficiency and that it has
reliable mechanisms in operation to continually improve the quality of services. Accreditation
acknowledges a level of organizational competence that is comparable to other organizations
accredited by the same accrediting body. It also identifies areas in need of improvement and
provides suggestions on how those improvements could be made (Avery et al., 2012). Those
improvements are consistently updated and always evidence-based. The accrediting agency
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usually provides a team of highly trained and experienced professionals to come into your
facility and review the parameters. Accreditation requires that an organization have numerous
management controls in place related to accountability and efficient, effective use of available
resources in providing services (Avery et al., 2012). The benefits to the community, of receiving
services from an accredited facility are many. The consumer can be assured that there are known
quality improvement processes in place, the staff are all proficient in their role, the care delivered
meets quality standards approved by impartial, third party investigators, there are mechanisms
for accountability in place, and finally, the care received in the future will be equally great
(mcf.gov.bc.ca, 2013). The benefits to the organization include efficient and organized care
delivery, level of care and functioning of staff meet external criteria and can be compared to
other accredited facilities, improved culture, staff morale and improved work management
relationships, decrease in the number and severity of complaints from both patients and staff,
improved brand recognition and community awareness of the facility, feedback processes open
for input, and decreases in third party payor deficiencies and inquiries (mcf.gov.bc.ca, 2013).
The decision to go for ACE accreditation is one that is made by several people, including,
hospital administration, quality initiative teams, nursing, and physicians. The review is a
scrutinized process that the facility undergoes every other year to ensure that appropriate use
criteria, peer review, quality controls and other significant metrics are followed to ensure great
patient outcomes. ACE focus is predominantly in the following areas: low volume operators,
appropriate use reviews, angiographic reviews, and clinical data reviews for every case
completed (cvexcel.org, 2013).
Some might be asking why a facility needs to undergo this intensive scrutiny and spend
tens of thousands of dollars for a status. Healthcare has changed and continues to change across
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the continuum. Things are no longer left to physician discretion, as they used to be. Every
treatment, every outcome, every event is a reportable incident. There are many different quality
metrics reported; from core measures, to meaningful use, to caudi, clabsi, vap, appropriate use
criteria, structured database registries, and many others (cvexcel.org, 2013). Every one of these
metrics is reported out to the Centers for Medicaid and Medicare Services (CMS) as well as Joint
Commission for Healthcare Accreditation Organization (JCAHO), Department of Health (DOH),
and in the case of cardiac services; New York State Percutaneous Intervention Reporting System
(NYS PCIRS), and the American College of Cardiology’s National Cardiology Database
Registry (ACC-NCDR). Participation in all of these is required. These regulatory bodies are all
in charge of your facilities reimbursements; poor outcomes equal less reimbursement. The
amount of reimbursement is different for each facility and is based on a formula of insurances,
county, population, etc. but for my facility specifically, it is a loss of over 11 million dollars (J.
Priore, personal communication, November 21, 2013). We are talking about percentage points
of billions of dollars and the amount of each point is great. It is a pay for performance culture in
every healthcare arena. There is no choice to submit all of your facilities information for
scrutiny. Efforts employed by the government to help to decrease health care costs include the
Recovery Audit Contractor (RAC) program, the Comprehensive Error Rate (CERT) program,
and other pay for performance regulatory bodies. These programs review all documentation, and
if any criteria such as illegible handwriting, missing dates and times, policies not followed, etc.
are present, the payment made to the facility is decreased significantly. Another program that
was enacted called the Improper Payments Act, entered into public law in 2012, gives insurance
companies the right to reduce and recover any and all improper payments whether it is for
improper coding or improper procedures and testing, and other specific criteria (cbo.gov, 2013).
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Hospitals cannot afford to have a single, presumably innocent, mistake made throughout every
single patients stay. That’s a lofty bar to reach for any hospital. The decision to become
accredited is essentially telling all of these regulatory agencies that your facility is dedicated to
providing high-quality service backed up with accountability, internal and external controls, and
intensive medical staff review of every case performed. You are telling them that the staff are all
highly trained and that any procedure done in this department is guaranteed to be done in the best
of places.
Significance to Nursing
Typically, accreditation processes are multidisciplinary in nature; ACE is no different.
However, the nurses role in this accreditation process is the cornerstone to it’s’ success. Nursing
has been implementing and measuring quality long before any of these regulatory restrictions
were put into place (Mitchell, 2008). Florence Nightingale herself implemented infection control
measures to help decrease infection and mortality on the battlefield. Throughout nursing’s
history, we have thought of the nurse role in a narrow perspective and really focused on things
like medication errors, patient falls and pressure ulcer development but the nurse role has
morphed and the responsibility on the nurse to maintain communication, provide the patient
plan, keep the patient happy during their stay, stay current in the literature, and provide the
patient with a knowledgeable highly skilled level of care has become the concentration. Patient
satisfaction is directly tied to nurse satisfaction and without these nurses, the hospitals financial
troubles increase greatly (Studor, Robinson, & Cook, 2010). Furthermore, it is always the nurse’s
responsibility to coordinate and implement care across all disciplines that touch the patient
(Mitchell, 2008).
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Communication is of the utmost importance in healthcare. When we consider errors and
the role of nursing as the prime communication link in almost all health care settings, it becomes
evident how important the quality controls in place are utilized and implemented. Root-cause
analyses of errors provide categories of causality including failure to follow standard operating
procedures, poor leadership, breakdowns in communication or teamwork, overlooking or
ignoring individual fallibility, and losing track of objectives (Mitchell, 2008). This evidence was
used in developing the cause portion of the National Quality Forum’s patient safety taxonomy
and is currently referenced in numerous publications (Mitchell, 2008).
The accreditation process, though multidisciplinary, relies heavily on nursing to
implement policies and procedures, to provide accurate documentation, to communicate to the
patients, to provide skilled care pre, during and post procedure, to provide accurate follow up,
and , lastly, to be the glue that holds these processes in place. These processes will make it much
easier for the nurse to care for his or her patient and give the support necessary to each individual
providing care.
Leadership/Organizational Theory
The leadership theory that best fits this scenario is the transformational theory. This
theory was developed in 1978 by James Macgregor Burns. He identified two types of leaders;
transactional leaders who are concerned with the day-to-day operations and transformational
leaders who are committed to a vision that empowers others (Kelly & Tazbir, 2014). He defined
transformational leadership as one in which “leaders and followers raise one another to higher
levels of motivation and morality” (Kelly & Tazbir, 2014, p. 12). This type of leadership can
elevate the behaviors of both the leader and the staff person to engage in collective work with the
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common goal of achieving a preferred position in the future. This leader is influential and
respected. He or she is also able to empower the staff to gain a meaningful yield from their work.
In 1985, Bernard Bass extended Burns’ theory and found that a qualitative change in
performance and relationships occurs in transformational leadership to the benefit of the
individual and the organization. Four factors, called the “Four I’s,” form this type of leadership:
idealized influence, inspirational motivation, intellectual stimulation, and individualized
consideration (Ireland & Hitt, 2005). Effective transformational leaders identify with various
roles in change processes; however, they most always function as the change agents (Kelly &
Tazbir, 2014). They are front-line leaders and instrumental in empowering staff to forward think
and maintain the timeline.
In the development phase of this project, we met with the staff and prepared them with
the vision for what we wanted to accomplish. We provided them with the necessary tools to
become familiar with the ACE process and what the expected metrics were. A timeline was
established and we vaguely outlined the next steps. The director for the department rallied
everyone and promoted this major change as such a positive event that the staff were all set to
help and were asking for things they could help with. Committees were formed and consistent
dates and times were established to help keep us all on the same path.
In the implementation phase of this project, the work done in the committees was
reviewed and compared with the strict guidelines provided by ACE. Updates were provided to
all members and the next steps were identified at each meeting. There was a great amount of
trust placed in these teams to get the necessary components of the application completed, as well
as in myself, to keep things organized and provide the necessary updates making sure nothing
was missed. In this phase, the transformational leader really stepped up and kept the pace of the
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meetings going, bent over backwards to keep everyone as happy as they possibly could be, and
made sure to give kudos to groups where they really strived to get a job done and succeeded.
She was a champion for the cause and it really was evident to me how she was getting the job
done. She was my preceptor and I am grateful for the experience of watching her in action.
Evaluating this project is going to fall short of the original goal because the site has not
had its’ on-site review from the credentialing agency yet. I have every faith they will be
accredited simply based on the due diligence of the leader and the exceptional level of work the
staff accomplished, validated against the criteria provided by the accrediting body.
Analysis/Evaluation
The process of participating in a project of this caliber was stressful for me. I became
overwhelmed almost immediately with the amount of responsibility placed on me and felt
strongly that I would need assistance. Over a period of a few weeks, as I familiarized myself
with the tools provided by ACE, I became more comfortable and was able to dive in a bit.
Organizing the meetings was a bit of a challenge because I didn’t know all the people involved
and they were not aware of the project. I had to reach out to folks not associated with me to seek
assistance. I managed through the basic communication channels to get what I needed and
typically met no resistance. I also sought out resources within my own institution to help with
this process and to help me organize myself. My greatest resource for personal use was the
quality director. She helped me to see the whole picture and pointed me in directions that were
very beneficial. My preceptor was of invaluable resource as well. She helped me to open
communication with those not familiar with me or the scope of this project which helped me
immensely when I needed to reach out to people for assistance. Meeting with her also provided
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some clarity in resolving the few issues I did come up with. For instance, I was tasked with
reaching out to the Radiation Safety Officer for the current DOH regulations regarding
fluoroscopy dose, times, etc. He was not very forthwith information and I was hitting a wall.
Instead of wasting time with multiple attempts, we reached out to the state ourselves and
acquired the regulations and sought guidance from them, so we could move forward with
preparing a new policy. We certainly got his attention when we presented him with the new
Radiation Safety Policy that he needed to sign off on. He made a few changes and we sent it off
to the medical executive committee meeting for final administrative approval. There were many
different things happening at one time and it was a lot to keep it all straight. Another barrier that
I came across within the institution was a particular person who had the overall attitude about the
accreditation status that was a huge waste of money, $40,000 for the first two years of
accreditation, and $25,000 for each year thereafter. In my relationship with this person, who I
knew from previous experiences, I took more of a Laissez-Faire approach. I opted not to engage
the change agent (preceptor) in my interactions with this person and instead, just left this person
to their opinions. I made no great attempts to try to sway the opinion and made no great attempts
to seek out their advice. My rationale was that the group as a whole was very positive and there
will always be one person who doesn’t agree. It was a moot point from my perspective, and once
the decision was made to move forward with the project, opinions no longer mattered; autocratic
in a sense.
Communicating has never been one of my strong suits. I am consistent in my inability to
find just the right words and things end up sounding either too long or too fast, etc. Participating
in a complex project like this forced me to interact with others I may not usually interact with
and I took advantage of the meetings to listen to those folks doing the talking. I kept my verbal
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communications to a minimum and listened. I received a bit of prompting from my preceptor to
keep me focused and moving forward. The process of collecting all the data can be taxing and
from the student perspective, it was a lot with a regular full-time job to do. She stepped in and
helped me out on different occasions and when necessary, offered me the follow-up instead of
vice-versa. Throughout all my interactions with people and the job that lay ahead, I utilized a few
key effective decision making practices. I made sure to jump to no conclusions. This could have
been very bad had I made a decision based on one concept only to find out it doesn’t exist there.
It could have been easy to do when dealing with so many people and so many decisions to be
made but I made sure to have the correct information, based on fact before presenting
information to the group. I made sure that patient centered care was at the core of all the
decisions. I would not bring forward any suggestions for change unless the patient was the focus
either through the nursing care delivered or through the policies and protocols developed for
procedures, and both had to be evidenced-based. I made sure to steer clear of those that had the
“We always did it this way” type of attitude. That type of thinking is not going to expedite
change. Instead, I offered rationales and evidence to back up the proposed changes to practice
and hoped the evidence would speak for itself. Like anything else in life, when you introduce
change it is often met with resistance. With regard to this project, the changes have not been
fully implemented as of yet. I do not expect much resistance since the staff are all aware of the
project and have been provided with the content change. At the heart of nursing is the concern
for the care delivered to the patient. I believe most nurses and physicians will accept change
when they know it is for the best care of the patient.
The timeline initially proposed did not meet the needs of the project. As it turns out, there
was a lot of work to be done with regard to content change, development of appropriate use
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criteria, development of physician peer review, physician continuing education credits, staff
education, and other key components of this project. The application process is ongoing. Until
you have all of your changes implemented, you cannot formally file the application. The
policies, protocols, peer review forms, QA data, numbers, etc. is all submitted with your
application. Those processes are ongoing at this time. To date, approximately 70% the policies
are completed, the protocols are almost complete, the peer review process is underway but needs
to be boosted with more participation from the physician staff without being reminded, the staff
are all credentialed and education requirements are intact, but, there is still work to be done.
Our new proposed date to file the application is March 15, 2014 with an on-site review to be
completed by May 1, 2014 and a formal accreditation by June 30 of 2014. This has pushed our
overall time frame back approximately 3 months. My original timeframe of having the
application filed by December of 2013 was off. There was no way that could have happened.
There were too many identified metrics that needed to be re-written, tweaked or removed
altogether. This was not apparent until I really got into the required criteria.
After working on this project, I can see how big mistakes can happen and how important
it is to have that champion, change agent who is really driving the entire team. Without this
person, I cannot see how anything would ever get done. I have realized that at this point in my
career, I may not be a good change agent. I am ever evolving and as leaders, that’s what we do. I
am a manager with more of a day-to-day focus and lack the vision, and resources, on some
levels, to be a motivational leader. As the stress within the organization grows so does the stress
of the staff and some days, I have no answers for them. I hope this continues to grow within me
as I continue to take on more responsibility and grow within my organization. I feel strongly that
a supportive and positive feedback culture would greatly help a lot of managers, however, that
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does not always exist. In today’s culture of increased stress and patient satisfaction, and patient
experience, and computerized documentation, the positive can often get lost. It is our first duty to
care for the patient and our second duty to care for each other.
I did not meet all of my objectives. They are as listed:
1. Upon completion of this project, I will provide the quality improvement data to substantiate
the investment of annual certification fee.
2. Upon completion of this project, through collation of quality data, the necessary changes
required for accreditation will be identified.
3. Upon completion of this project, the department will be aligned with the standard of care per
the accrediting body.
Objective number one was met. I did participate and evidenced-based data was obtained and
presented to the senior level administrators. Approval was received for this project. Objective
number two is complete. Through the use of a gap analysis we were able to identify where the
unacceptable processes were and make the necessary changes to provide exemplary care. The
changes are ongoing. They are in various phases; however, where the changes need to be made
has been identified. Objective three is not complete and until we have a site-review, won’t be
able to become accredited. This process hopefully, will be completed by June 30, 2014.
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References
(2013). Accreditation publication. Retrieved from
http://www.mcf.gov.bc.ca/accreditation/publications.htm
Avery, N. M., Fulop, L., Clark, E., Fisher, R, Gapp, R., Guzman, G., Poropat, A., Herington, C.,
McPhail, R., & Vecchio, N. (2012). Towards an enhanced framework for improvement in
quality healthcare: A thematic analysis of outstanding achievement outcomes in hospital
and health service accreditation. Asia Pacific Journal of Health Management, 7(2), 7985. Retrieved from
http://ehis.ebscohost.com.ezproxy.sunyit.edu/ehost/pdfviewer/pdfviewer?vid=5&sid=88e
b79a6-63f5-4ceb-af9f-9552baf8d8df%40sessionmgr4002&hid=4203
Improper Payments Elimination and Recovery Improvement Act of 2012, U.S. Congress § H.R.
4053 (2002 & Suppl. 2012).
Ireland, R. D., & Hitt, M. A. (2005). Achieving and maintaining strategic competitiveness in the
21st century: The role of strategic leadership. Academy of Management Executive
Journal, 19(4), 63. Retrieved from www.sagepub.com/upm-data/31998_PartII.pdf
Kelly, P., & Tazbir, J. (2014). Essentials of nursing leadership & management (3rd ed.). Clifton
Park, NY: Cengage Learning.
Mitchell, P. (2008). Defining patient safety and quality care. Patient safety and quality: An
evidence-based handbook for nurses. Retrieved from
http://www.ncbi.nlm.nih.gov/books/NBK2651/
Studor, Q., Robinson, B., & Cook, K. (2010). The HCAHPS handbook: Hardwire your hospital
for pay-for-performance success. Gulf Breeze, Fl: Fire Starter Publishing.