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 CATHPCI program, Administrative Director and Technical Director
- List of credentialed physicians
- Physician credentialing and recredentialing criteria
- 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
- Most recent report from outcomes data registry ( NCDR or other)
- Process for monitoring peri-procedural, in-hospital and 30 day outcomes
- Evidence of oversight committee and peer review conferences
- List of annual competencies for staff, including seldom used equipment
- Policy for radiation safety education.
- Procedure to document radiation exposure to patients and staff and process to monitor high exposure.
- Copy of patient consent form
- List of minimum requirements for relevant lab values and outside reports prior to a procedure
- Written protocols or standardized order sets for the following: anticoagulation for PCI procedures, radial access, contrast allergies, treatment of anaphylaxis reaction, sedation reversal.
- Procedure to identify patients at high risk for contrast induced nephropathy including follow up of renal function.
- Provide a copy of infection control policy for the cardiac cath lab.
Here is a list of this information you will need to provide:
- Annual volumes for last 2 calendar years
- All laboratory performance metrics.
- Percent of patients receiving high doses of radiation during CATHPCI procedure
- Rate of “normal” catheterization procedures as defined by the NCDR CathPCI registry.