Setting out on an accreditation journey can seem daunting. Success requires aligning diverse stakeholders, investing in quality tools and education, and prioritizing process improvement.

Over the past decade, Baylor St. Luke's Medical Center in Houston, TX, has partnered with ACC Accreditation Services to earn multiple recognitions: HeartCARE Center designation, Cardiac Cath Lab Accreditation, Electrophysiology Accreditation, Transcatheter Valve Certification, and platinum status in the Chest Pain – MI Registry Performance Achievement Award.

These accolades did not come easy. Their commitment to delivering high-quality patient care and a culture of continuous improvement is what led to their quality achievements. And at this year's ACC Quality Summit, Seth Stephens, DNP, APRN, ACNP-BC, CPHQ, AACC, system director for the cardiovascular service line at CommonSpirit Health, and Karen N. Mullins, MSHS, BGS, RN, patient safety program manager for Baylor St. Luke's Medical Center, part of CommonSpirit Health, joined Accreditation Review Specialist Kevin Wehrle, RN, AACC, to share the impact of their investment in ACC Accreditation.

Collaborating to Achieve Excellence

When selecting an accreditation program, Stephens and Mullins prioritized alignment with existing registries and quality tools, brand recognition and reputation, and a comprehensive scope of services to support their improvement goals.

"We found that the ACC really focused on and aligned with things that were important to us," said Stephens. "A high focus on quality, high focus on performance improvement, and really thinking about programmatic structure and how we wanted our service line to be governed."

Wehrle has been their accreditation review specialist since the beginning, meeting regularly to share best practices and encourage innovation within their program. In describing their relationship, Mullins calls Wehrle "a true and lasting partner."

"Kevin has seen us from very early on when we had very little to no quality infrastructure to now being a very highly functional quality improvement machine," said Stephens.

This "machine" is powered by collaboration across cardiovascular service lines and extends to the Hospital Quality and Regulatory Committee, Hospital Board and Physician Quality Committee, ensuring improvement efforts are informed by case review and quality data with input from relevant stakeholders at section meetings and medical review boards.

Improving Outcomes in the Cath Lab

Guiding their quality improvement initiatives in the cath lab, the team targeted two NCDR metrics: Risk Standardized Acute Kidney Injury (AKI) and Risk Standardized Bleeding.

"Focusing on standardized AKI would help us with our patient satisfaction, improve our supply chain, increase our revenue and improve our productivity," said Mullins. Many of the same benefits were anticipated in reducing bleeding events.

To lower AKI rates in PCI patients, the team implemented a preprocedure hydration protocol, increased intravenous pump availability, improved frailty documentation with abstraction accuracy and a clinician pocket guide, and reviewed AKI cases on a monthly basis with cath lab leadership.

These changes delivered measurable results. Within two months, hydration orders rose by 28%, and from the second quarter of 2022 to the third quarter of 2024, Risk Standardized AKI decreased by nearly 2%.

To reduce bleeding rates, the team continued their efforts to accurately document frailty, reviewed bleeding cases monthly, and prioritized education on closure devices and extracorporeal membrane oxygenation site maintenance. These efforts led to a 0.6% decrease in PCI In-Hospital Risk Standardized Bleeding over the same period.

"We did make improvement, and we are sustaining those improvements," said Mullins. "But there's still more work to do."

Quantifying Return on Investment

Stephens emphasized that the true value of accreditation lies in the culture of process improvement it fosters.

Despite decommissioning two of 11 cath labs due to aging equipment, PCI volume increased at their site, thanks to a highly engaged team focused on efficiency.

"We have a cath lab team of frontline leaders and physicians that met every two weeks on efficiency projects where we looked at all of our times...and with looking at each of those pieces in the process, instead of our volume going down, our volume actually went up," Stephens said.

This is a clear example of how quality improvement can improve financial performance. Both Stephens and Mullins stress that investing time and resources into quality can lead to tangible returns.

Their efforts to reduce AKI and bleeding resulted in an estimated avoidance of 32 cases of AKI, translating to approximately $384K in cost savings, and 89 bleeding cases, equating to about $1.6 million saved. Altogether, they estimate $1.9 million in cost avoidance and more than 100 lives positively impacted throughout this accreditation cycle.

"We have abundantly demonstrated the return on investment that we've made both culturally and in dollars and cents," said Stephens. "And we're able to articulate that to our C-Suite leaders when they ask every year, 'Are you sure you need to do that?'"

4 Tips For Supporting CV Trainees in QI

ACC Quality Summit Subcommittee Chair Olivia N. Gilbert, MD, MSc, FACC, has helped many of her own residents and fellows foster a passion for quality. She shares four tips on how clinicians, program directors and institutions can help support their trainees in leading through quality improvement (QI) initiatives.

"It's hard for trainees these days," says Gilbert. "They're getting pulled in so many directions and the expectations are getting higher. I think we need to set up a construct for success."

Build Infrastructure to Anticipate Trainee Needs

Gilbert emphasizes how a structured environment that removes common barriers for trainees, like lack of funding, mentorship or project ideas, can make a real difference. Institutions can provide resources to help trainees identify strategic QI projects, access funding sources and seek mentors to help bridge these barriers.

Empower Trainees With Accessible Data and Analytics Tools

Highlighting the shift from manual chart reviews to more efficient data analysis using diagnostic coding and electronic health record-based datasets, Gilbert suggests that training the next generation of clinicians in these new approaches is vital. Joining up-and-coming tools with high-quality data from established repositories like NCDR will provide the full picture needed to move quality forward.

Promote and Celebrate Trainee Work

Encouraging trainees to submit their abstracts to meetings on the national stage, like ACC Quality Summit, and platforms for publication, like JACC: Case Reports, inspires confidence and reinforces the value of the QI work they are doing. Celebrating their findings both validates their efforts and can help motivate them to continue engaging in the field of quality, according to Gilbert.

Foster Collaboration With Peers and Mentors

Gilbert highlights the value of peer relationships in sustaining enthusiasm, building community and learning from one another. Mentors also play a pivotal role in connecting resources, sharing differing perspectives, and providing oversight.

Katherine A. Burns, DO, one of Gilbert's fellows at Wake Forest Baptist Medical Center, submitted her abstract, "Prognostic Performance of CAHP and MIRACLE2 Scores in Out-of-Hospital Cardiac Arrest With STEMI," to be part of ACC Quality Summit 2025.

Burns and her colleagues found that while both CAHP and MIRACLE2 had "excellent discrimination" for in-hospital mortality, CAHP exhibited "superior independent prognostic value."

"I hope our project can aid in forming more accurate and meaningful prognoses with regards to outcomes and provide practicing interventionalists with more confidence in making the decision on whether or not to intervene," Burns says.

This QI work has opened more lines of inquiry. With her interest in the cath lab, Burns hopes to take on additional projects centered around device utilization and electronic medical record workflows with provider alerts.

"I'm thankful Wake Forest has empowered me with the time, tools and resources to start pursuing my ideas on QI in earnest," she says.

Keywords: Cardiology Magazine, ACC Publications, Quality Improvement, Patient Safety, Certification, Registries, Accreditation, ACC Accreditation