• Application Requirements

    Helpful Tips for Completing the Application:

    Congratulations on your decision to submit an application for accreditation! You are demonstrating a high commitment to quality patient care.

    Before you begin the application process it is helpful to have one designated person responsible to organize and submit the information. Since this is an on-line process all documents must be in the form of an electronic file; word documents or pdf files are the most common.

    Here is a list of the documents you will need to submit with the application:

    • CVs for Medical Director of the Cath PCI program and Technical Director or CCL Supervisor
    • Most recent report from outcomes data registry (NCDR)
    • A list of all cardiac catheterization or PCI procedures performed or excluded in the laboratory
    • Documentation of the process to introduce new procedures into the catheterization lab
    • Physician credentialing and recredentialing criteria, including procedure volume requirements.
    • List of credentialed physicians
    • Documentation of ACLS certification
    • Facility policy for radiation safety training
    • Documentation of physician CME and annual competencies assessments for staff
    • Evidence of oversight committee and peer review conferences
    • Copy of patient informed consent form
    • List of minimum requirements for relevant lab values and outside reports prior to a procedure
    • Provide written protocols or standardized order sets for: Anticoagulation, Radial access, Patients
    • at risk for contrast induced nephropathy, treatment of contrast allergy, treatment protocol for anaphylaxis reaction, and protocol for sedation reversal
    • Provide copy of infection control policy
    • Process for monitoring peri-procedural, in-hospital and 30 day outcomes
    • Process for follow up monitoring for stroke, MI death peri-procedural and in-hospital complications
    • Procedure to document radiation exposure to patients and staff and procedure to monitor high exposure
    • Procedure for follow up on renal function in patients at high-risk for contrast nephropathy
    • Example of a recent QA project
    • Policy for radiation safety education.
    • Annual Complication report

    Here is a list of this information you will need to provide:

    • Annual volume for last 2 calendar years
    • All laboratory performance metrics
    • Current complication rates
    • Percent of patients receiving high doses of radiation during procedure
    • Rate of “normal” catheterization procedures