• Baptist Health South Revamps Cath Labs Using SCAI-QIT to Achieve ACE Accreditation

    April 08, 2013

    This content is from the Spring 2013 issue of SCAI News & Highlights.

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    When problems or controversies arise in the cath lab, SCAI’s Quality Improvement Toolkit (SCAI-QIT) offers a means of remediation for systems and procedures, but many Quality Champions report the most benefit can be gained by applying the Toolkit’s comprehensive guidelines before minor issues become serious oversights. That is just what Baptist Health South Florida did to become the country’s first hospital network to achieve Accreditation for Cardiovascular Excellence (ACE) accreditation.

    Focusing on Prevention

    In the wake of allegations of inappropriate use at other institutions, interventional cardiologists and administrators are working that much harder to prove their organizations’ worth. Unfortunately, Miami is believed by some to be the “center of the universe of Medicare fraud,” said Jane Kiah, M.S., R.N., director of cardiac and interventional services for the Baptist Cardiac & Vascular Institute, in Miami. From Ms. Kiah’s perspective, it is more important than ever to be prepared for regulatory review and internal as well as external audits.

    “With national attention being paid to the COURAGE trial and the media exposing practices that weren’t entirely appropriate, we wanted to make sure that we weren’t going to be vulnerable to any of the same,” said Ms. Kiah. “We went looking and digging deep in our closets to see that we were where we wanted to be and that we were ready for all of the scrutiny that is being put on this service line.”

    Valuable Investment

    Seeking ACE accreditation is a time and resource costly endeavor, but the payoff is in knowing that patients are getting the gold standard of cardiovascular interventions and that safety guidelines, procedural protocols, physician documentation, and data and document control are optimized. Baptist Health implemented a key SCAI-QIT recommendation, namely to volunteer a “physician champion” – a Quality Champion – to introduce guidelines and to ease other providers into initially unsettling procedures.

    “One of the biggest changes was to designate a physician to champion angio review,” said Ms. Kiah. “Having a physician champion helped us sell the process and helped physicians understand decision making based on guidelines. The angio review program includes all operators who look at randomly selected cases, not just the complicated or mortality cases. The physicians discuss clinical issues in an open format and learn from one another. The Toolkit really helped me put that plan into place.”

    At Baptist Health, Marcus St. John, M.D., FSCAI, was appointed physician champion. For him, it was important to pave the way for new protocols by creating a collaborative environment that was mutually supportive and non-punitive. “Physicians can be tricky people to work with – we don’t always like to listen to other people,” he laughed. “We are in a private practice setting and in theory we are all competitors, but we have to rise above that.”

    Unpacking the Tools

    Baptist Health’s SCAI-QIT project manager Jeannie Caudill, R.N., worked with the cath labs at South Miami Hospital in preparation for accreditation. Ms. Caudill went step-by-step, using SCAI-QIT’s tools to create manuals and action plans for all strata of the organization. “We really worked on our radiation policy, which seemed to be lacking,” said Ms. Caudill. “We did a lot of research with the radiation safety manager developing a new tracking system and now we review it case by case.”

    Many systematic improvements in dictation, documentation, and the creation of new auto-fill procedural forms were executed as a result. Just some of the data Dr. St. John said could have been inadvertently missed during dictation and reporting were small, but significant details regarding lesion type, TIMI flow, or fractional flow reserve measurements and others that can inform appropriateness.

    Peer Review for Progress

    Baptist Health also instituted quality meetings between physicians and staff as well as quarterly case reviews and compulsory review of unique cases. “It’s surprising to me that this many decades into it we didn’t have a peer review process,” said Dr. St. John. “We now choose a randomly selected number of cases every quarter to review and, if particular actions deviate slightly or substantially from the norm, cases come under review.”

    It took roughly six months to prepare for accreditation using the SCAI-QIT. Baptist Health was found to have an expertly operating program and initially earned provisionary ACE accreditation, pending some additional review and improvement.

    This prompted them to take a closer look at nephropathy risk, which led to more systematic patient hydration and clearing of contrast lines during each new procedure. This simple task was found to lower contrast dosing by as much as 20 CCs.

    Real Rewards

    Baptist Health, now fully accredited, is seeing significantly fewer denials from payers, which Ms. Kiah attributes to SCAI-QIT initiatives and ACE accreditation, and their urging of physicians and administrators to dive into their data and make an honest appraisal of improvements that need to be made.

    “I think more and more cath labs will seek it as a commitment and an investment,” she said. “It really forces you to look at all angles of your program.”


    The SCAI-Quality Improvement Toolkit was developed with founding support from and support from Daiichi Sankyo, Inc. and Lilly USA, LLC and AstraZeneca. The Society gratefully acknowledges this support while taking sole responsibility for all content developed and disseminated through this effort.

    Take Your Cath Lab to the Next Level

    SCAI-Quality Improvement Toolkit

    All of the tools in SCAI’s Quality Improvement Toolkit, including the AUC Calculator application, are free, provided by the Society to support the efforts of interventional cardiologists and their cath lab teams to take their QI efforts to the next level, regardless of where they are starting. To review the tools and register as a Quality Champion, which includes full access to SCAI’s QI Listserve, visit www.SCAI.org/QIT.

    Accreditation for Cardiovascular Excellence

    Cath lab programs across the United States are turning to ACE for help in evaluating their processes, identifying opportunities for improvement, and announcing to their communities that they have achieved key benchmarks for quality. Accreditation for Cardiovascular Excellence provides formal, objective, and independent evaluation and monitoring as well as external validation that the facility meets the highest standards for patient care and safety. To learn how to apply for ACE accreditation, and about ACE’s angiographic and appropriate use review services, visit www.cvexcel.org.