Quality Improvement for Institutions | Shared Implementation for ACTION Registry, Chest Pain Center Accreditation Drives Quality Improvement

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In 2017, Indiana University Health (IU Health) expanded its participation in ACC’s ACTION Registry, adding two hospitals to the five that were already participating in ACTION. During ACTION Registry implementation, one of the two hospitals also achieved Chest Pain Center Accreditation from ACC Accreditation Services.

Although the institution hadn’t necessarily planned to implement ACTION and Chest Pain Center Accreditation at the same time, “it fell into place,” with each complementing the other, says Amber Clampitt, RN, BSN, CCA, coordinator for quality abstraction at IU Health. In a poster presented at ACC’s 2018 NCDR Annual Conference, Clampitt, et al., outlined the strategies and outcomes each hospital used in implementing the ACTION Registry.

“Bringing on ACTION coincided with the Chest Pain Center Accreditation, but we were also focused on quality improvement,” Clampitt says. “We had some areas we could see that we needed to improve so the process for that was trying to engage leadership who would be directly impacting patient care.”

When data collection began for the ACTION Registry, it became clear that it would be most effective for each hospital to have its own implementation strategy. For Hospital A, the focus was on identifying opportunities to improve documentation and connecting with local leaders to provide education about the ACTION Registry. Hospital B required a more comprehensive approach focused on improving care for patients with acute myocardial infarction. The implementation team identified cardiac rehab referrals as an improvement opportunity and convened a multidisciplinary team that included cardiac rehab staff, cardiology practice managers and registry subject matter experts who met bimonthly to identify improvement areas and develop solutions. Developing a successful strategy required continuous data analysis to ensure efforts were leading to an increase in cardiac rehab referrals. By the third quarter of 2017, Hospital B had a cardiac rehab referral rate of 83.6 percent, up from 61.9 percent at the beginning of the year.

Cardiology Magazine Image"You can’t improve process without good solid data sources, so being able to have that [through ACTION] to complement our accreditation was a much better deal than trying to separate those two ways of collecting the data." Michael Fights, RN, MSN, MBA

The constant review of ACTION Registry that led to clear performance improvement in cardiac rehab referral rates proved to be helpful in less obvious ways for the path toward accreditation, according to Michael Fights, RN, MSN, MBA, chest pain coordinator at IU Health Arnett Hospital, who managed the accreditation process. For starters, IU Health didn’t have an existing data platform that would translate for Chest Pain Center Accreditation. “We can’t make the changes unless we have the data. But, without a platform to look at that information, make changes and see the impact on patients, the data are useless,” Fights says. The ACTION Registry provided this platform and Fights was able to work with data coordinators who were already analyzing data for ACTION. “The data coordinators who do the data abstraction day in and day out [for ACTION] gave us the results and took a burden away from me. That allowed us to focus on interpreting the data and seeing what we could do to improve processes.”

At IU Health, all data coordinators who worked on ACTION data abstraction have a clinical background, which enhanced data quality for both the ACTION and accreditation teams. “The people abstracting the data definitely know the ins and outs and understand what is going on with our cardiology patients. They have a different context than if it were outsourced or [analyzed] by someone who didn’t have a cardiology background,” says Andrea Price, MS, RCIS, CCA, director of quality databases at IU Health.

This helped ensure both ACTION and accreditation teams were looking at high-quality, relevant data, which helped drive process improvement, Fights says. “You can’t improve process without good solid data sources, so being able to have that [through ACTION] to complement our accreditation was a much better deal than trying to separate those two ways of collecting the data.”

Keywords: ACC Publications, Cardiology Interventions, Quality Improvement, Leadership, Pain Clinics, Registries, Accreditation, Hospitals, Data Collection, Chest Pain, Myocardial Infarction, Patient Care, Documentation, Information Storage and Retrieval, Referral and Consultation, Patient Care Team

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