Does your chest pain care deserve accreditation?

Number of accredited centers is growing fast

Would you like your organization’s care of patients with chest pain to be something to brag about? Consider obtaining accreditation from the Columbus, OH-based Society of Chest Pain Centers (SCPC).

Accreditation will demonstrate to physicians, patients, and the community that you follow the highest standards in caring for chest pain patients, according to Mary Sharp, chief nursing officer at Southern Hills Medical Center in Nashville, TN.

"Following evidence-based protocols helps us achieve the best patient care outcomes and consistent practice," she adds.

The accreditation process is a powerful performance improvement tool, enabling you to measure the quality of the care you are giving to patients with acute coronary syndrome (ACS), says Lynnette Boyer, ARNP, administrative officer for ambulatory care and coordinator of the chest pain center at North Florida/South Georgia Veterans Health Care System in Gainesville, FL.

Heart attacks are the leading cause of death in the United States for both men and women, with more than 5 million Americans visiting hospitals each year with chest pain.

The SCPC uses a protocol-driven approach to reduce time to treatment during the critical early stages of a heart attack, when treatments are most effective, and better monitor patients when it is not clear whether they are having a coronary event.

Surveyors don’t play gotcha’

To receive accredited status, your organization must meet or exceed a set of stringent criteria and complete on-site evaluations by a review team, but the process is more educational than punitive, Boyer says.

"The goal is to see that every single piece of the puzzle is being done correctly, and as efficiently and time-sensitively as possible," she explains. "This is not like JCAHO [the Joint Commission on the Accreditation of Healthcare Organizations]; this is not gotcha.’ They are going to come in and advise you how to facilitate improvement. They want to see that you are sincerely trying to improve the care you give."

You must document key elements and metrics that indicate your chest pain center has processes in place to consistently evaluate and treat patients presenting with chest pain, and that hospitals routinely follow their treatment results via ongoing quality improvement initiatives, explains Matthew T. Roe, MD, MHS, principal investigator for Crusade, a national quality improvement initiative to increase the practice of evidence-based medicine for patients with diagnosed non-ST-segment elevation acute coronary syndromes, coordinated by Duke Clinical Research Institute in Durham, NC.

"This recognizes hospitals that have a commitment to uniform, high-level care of chest pain patients," he says.

The steering committee of Crusade has agreed to work with the SCPC in the accreditation process and will recommend that all 400 Crusade hospitals accredit their chest pain centers.

To receive accreditation, your chest pain center must demonstrate expertise in the following areas:

  • integrating the emergency department with the local emergency medical system;
  • assessing, diagnosing, and treating patients quickly;
  • effectively treating patients with low risk for ACS and no assignable cause for their symptoms;
  • having a functional design that promotes optimal patient care;
  • ensuring chest pain center personnel competency and training;
  • maintaining organizational structure and commitment;
  • continually seeking to improve processes and procedures;
  • supporting community outreach programs that educate the public to promptly seek medical care if they display symptoms of a possible heart attack.

Once an organization is accredited, the team returns for a site visit every three years to ensure you have achieved their recommendations for improvement. A $15,000 fee covers the site visit and consultation.

You can use your organization’s accredited status as a marketing tool, and it is a bonus during JCAHO surveys, Boyer explains.

"JCAHO loves this — when they come out to do a survey and you’ve already got accreditation from the SCPC, it’s obvious you care about quality." There may soon be another powerful incentive, she adds.

"When 26 states use an accreditation, it becomes a standard, and 23 states currently have SCPC- accredited hospitals," Boyer says. "Medicare will probably start to require it. Just like with trauma center accreditation, you will have chest pain center accreditation."

At Community Health Partners Regional Medical Center in Lorain, OH, the SCPC’s criteria were used as a framework to assess processes and systems, says Jane M. Jones, CPHQ, director of quality systems. Current practices were compared with the criteria in the accreditation manual, and changes were made to improve care.

After an application was submitted along with supporting documentation such as order sets, policies, and guidelines, a four-hour site visit was scheduled.

This consisted of a visit to the chest pain unit followed by a review of the accreditation tool with team members including cardiologists, the chest pain medical director, chest pain coordinator, emergency department director and educator, quality personnel, and administrators.

"This approach was well-received by all members of the team and especially by the physicians," Jones says.

The tool reviews the entire continuum of care for ACS patients and, therefore, requires the organization to take a systems look at its patient care processes, she continues.

"When this occurs, gaps in the delivery of care can be identified and action plans developed to improve the quality and safety of patient care," Jones says.

Quality role is key

The quality manager is key in achieving accreditation and should be the one to complete the application for accreditation, Boyer stresses.

"This is a data-driven accreditation program — without the data you’ll never get accredited," she says. "You’ll need buy-in from upper administration, the emergency department, and cardiology, but data are everything."

The quality manager should be responsible for the following, according to Jones:

  • Establish the process and outcome measures to identify how well systems and processes are functioning.

"This includes nationally known ACS quality measures such as EKG within 10 minutes of arrival or thrombolytics within 30 minutes, but may include unique process measures specific to an individual organization," she adds.

  • Identify methods for data collection, preferably concurrent instead of retroactive chart review.
  • Identify measurement goals for the organization, as well as best practice benchmarks.
  • Aggregate data and analyze them for patterns and trends. "This may require some segmentation of the data into various shifts, days of week, and providers," says Jones.
  • Develop a quality scorecard to report the measurement results and compare these against the organization’s goals and benchmarks.

"Ensure the results are communicated to appropriate individuals within the organization, reviewed for improvement opportunities and actions taken as necessary to either improve or sustain high-quality outcomes," Jones explains.

  • Cycle this process on a regular basis.

"Do you get that EKG within 10 minutes of arrival, do you get those troponins drawn within 60 minutes, and do you get those thrombolytics on board in less than 30 minutes?" Boyer asks. "The quality manager measures to make sure all of that is happening."

This can be done in a variety of ways, such as monitoring a percentage of patient charts, but without these data, there will be no accreditation, she notes.

"If you can’t monitor your improvement process, how do you know you improved?" Boyer asks.

"The data points are not difficult — anyone with an Access database could design a template for this," she continues.

At Boyer’s system, 100% of ACS charts are audited to check that all performance measures are met. "And if they don’t find it in there, it didn’t happen," she explains.

At Southern Hills, quality managers aggregate, oversee, analyze, and set in place methods to improve clinical outcomes and satisfaction with care.

Here are steps that occur:

  • Data are collected and entered into several databases, on both a concurrent and retrospective basis.
  • A registered nurse and the cath lab director abstract the data, and they are reviewed in appropriate committees for opportunities to improve performance.
  • The core measures nurse provides education as needed on a concurrent basis to ensure practice guidelines are followed consistently.

Process is saving lives

Chest pain is the leading cause of malpractice lawsuits alleging misdiagnosis, says Boyer. "So the quality manager’s job is twofold: One, that the patient gets the care they need in a timely fashion, and secondly, to reduce litigation," she adds.

The accreditation process has improved outcomes dramatically at her facility, according to Boyer. "It’s a wonderful way to improve your process of care. I would encourage even the smallest hospital to take a look at it — in fact, especially the smallest hospitals. This says they’re giving the same level of care as all the other hospitals — that little old VA is doing a standard of care similar to Cornell," she adds. "It’s a great way to keep the institution cutting edge."

Here are examples of improvements made at the North Florida/South Georgia Veterans Health as a result of the SCPC accreditation process:

  • Cases are reviewed collaboratively with emergency medical services (EMS).

"Previously, we did not have as close a relationship with EMS as we have now," says Boyer. "Thanks to the process, we now help them with their quality reviews, by doing ACS case reviews to see where we can improve."

The organization also is planning drills coordinated with emergency medical services (EMS) to find improvement opportunities.

As a result, EMS now is giving better documentation about when aspirin was given, routinely provides 12-lead EKGs, and in turn, receives feedback about care provided in the field and follow-up information on patient outcomes.

  • Faster troponin results are obtained.

"We never got the troponins done in a timely fashion," says Boyer. "Now we have point-of-care troponin so we know within five minutes if the result is positive or negative," she says.

  • Two dedicated observation beds in the ED were added for ACS.
  • New algorithms were developed.

"Ours were way out of date," Boyer notes. "We are also looking at new competencies for nurses."

  • A technician was added at triage.

"The triage process didn’t work very well before, so we put a tech there who is instantly ready to do the EKG," says Boyer. The VA also is considering purchasing a new EKG machine that can be transmitted down to cardiology instantly.

  • Signage was improved.

All signage inside and outside is being changed to better direct patients to the point of care. "Our signage was terrible outside, and we didn’t realize it — it was embarrassing," she says. "We didn’t think about it from the patient’s point of view, and a delay in care can cost a life."

[For more information, contact:

Lynnette Boyer, ARNP, Coordinator, Chest Pain Center, North Florida/South Georgia Veterans Health Care System, 1601 S.W. Archer Road, Gainesville, FL 32607. Phone: (352) 376-1611. Fax: (352) 379-4174. E-Mail:

Jane M. Jones, CPHQ, Director of Quality Systems, Community Health Partners Regional Medical Center, 3700 Kolbe Road, Lorain, OH 44053. Phone: (440) 960-4000. Fax: (440) 960-4416. E-mail:

Matthew T. Roe, MD, MHS, Division of Cardiology, Duke Clinical Research Institute, Room 0311 Terrace Level, 2400 Pratt Street, Durham, NC 27705. Phone: (919) 668-8700. Fax: (919) 668-7000. E-mail:

Mary Sharp, CNO, Southern Hills Medical Center, 391 Wallace Road, Nashville, TN 37211. Phone: (615) 781-4199. E-mail:

To obtain a manual including an application for accreditation, which costs $150, go to the SCPC web site at Click on "Accreditation of Chest Pain Centers," "Accreditation Manual Request Form." Or contact the SCPC, 3000 W. Broad St., Box 9, Columbus, OH 43204. Phone: (614) 274-9710. Fax: (614) 274-9716. E-mail:]