Accreditation Program Documents

The following are key ACHA ACHD Accreditation Program documents that you will need to download as you go through the accreditation process.

Follow these links to open the documents:

User Manual

Business Associate Agreement  (BAA)

Comprehensive Care Center

*Each policy/procedure document should indicate whether it is hospital policy or ACHD program policy/clinical guideline.

 ACHA ACHD Accreditation - Comprehensive Care Center Document Requirements for Each of the Criteria

B2 - Letter from Division Chief
E3 - Pre-peri-post-operative consultation care and diagnostics should involve CHD trained or experienced personnel
E4 - 24-7 CHD Surgical Expertise
E6 - ACHD Multidisciplinary Conference
E8 - Definition of Surgery
F2 - Process for Evaluation of Advanced Heart Failure in ACHD patients
F3 -  Policy for ACHD Patients Requiring Transplant
F4 - Policy to Ensure that ACHD Patients with Advanced Heart Failure Have Access to the Same Ancillary Services
G1 - Policy for Consultation from an ACHD Cardiologist Prior to Interventional Cardiac Catheterizations for ACHD Patients
H1 - Plan for EP Procedures
H2 - Plan for 24-7 ACHD EP Coverage in Collaboration with the ACHD Team
I1 - Policy for ACHD Consultation within 24 Hours of Admission to the Hospital for all ACHD Patients (Letter)
I1 - Policy for ACHD Consultation within 24 Hours of Admission to the Hospital for all ACHD Patients (Policy)
I3 - Policy to Ensure Care is Provided in the Pediatric or Adult Hospital Appropriate for the Patient's Medical Issues, Regardless of Age
I4 - Policy to Ensure ACHD Education of Inpatient Nursing Staff
I5 - Policy for Transfer of ACHD Patients to an Adult Facility
I6 - Policy or Short Narrative for Access to General Internal Medicine and Adult Sub-Specialists Either by In-House Consultation or Transfer to Adult Hospital
J2- Cardiopulmonary Resuscitation of Adults
J4 - Process for Scheduling an Initial Appointment for New ACHD Patients within 4 weeks
J5 - Process to Evaluate Urgent Patients
J8 - Policy to Promote the Establishment of Medical Homes for ACHD Patients
J10 - Advance Care Plan Policy for ACHD Patients
J11 - Ongoing Patient Education and Distribution of Patient Education Materials
J14 - ACHD Education of Nursing and Other Staff in Outpatient Clinic
K1 - Policy to Provide Transition Education for Patients and Providers
K2 - Policy for Planned Patient Transfer from Pediatric to ACHD Care
K3 - Policy to Ensure Collaboration with Pediatric Cardiology Providers to Support Ongoing Discussion Regarding the Patients and Referrals
L1 - Policy to Integrate Patient-Centered Care (PCC) into the Program Mission Statement
L2 - Policy to Promote Patient-Centered Care
L5 - Policy for the ACHD PFAC
L5 - Proposal for the ACHD PFAC
L7 - Written Strategy for Healthcare Providers to Partner with, Educate, and Engage Patients and their Families in All Stages
R1 - Policy to Encourage All Female ACHD Patients to Have Gynecological Care
R2 - Policy for Discussion with Patients of Appropriate Birth Control Methods and Sexual Function as it Relates to CHD
R3 - Policy to Ensure that All ACHD Patients Are Provided Pre-Pregnancy Counseling and Family Planning Advice
R4 - Policy for Discussion of Sexual Counseling Regarding Sexual Dysfunction
R5 - Policy to ensure that ACHD Providers Articulate and Document a Plan for Delivery in Collaboration with Maternal
S2 - Policy for Referral to Mental Health Services

Care Center

*Each policy/procedure document should indicate whether it is hospital policy or ACHD program policy/clinical guideline.

ACHA ACHD Accreditation - Care Center Document Requirements for Each of the Criteria

AA2 - Policy for ACHD Cardiologist backup and or assistance
BB2 - Letter from Division Chief
EE1 - Policy for referral of surgical cases to an ACHA ACHD Comprehensive Care Center
EE4 - 24-7 CHD Surgical Expertise
EE6 - ACHD Multidisciplinary Conference
EE7 - Policy for Transfer to Transplant Facility that is also an ACHA-Accredited Program
FF2 - Process for Evaluation of Advanced Heart Failure in ACHD Patients
FF3 -  Policy for ACHD Patients with Advanced Heart Failure for Whom Mechanical Support and or Transplant is a Consideration
GG1 - Policy for Consultation from an ACHD Cardiologist Prior to Interventional Cardiac Catheterizations for ACHD Patients
GG1 - Policy for Referral of Cardiac Catheterization Cases to an ACHA ACHD Comprehensive Care Center
HH1 - Plan for EP Procedures
HH1 - Policy for Referral of ACHD EP Cases to an ACHA ACHD Comprehensive Care Center
HH2 - Plan for 24-7 ACHD EP Coverage in Collaboration with the ACHD Team
II1 - Policy for ACHD Consultation within 24 Hours of Admission to the Hospital for all ACHD Patients (Letter)
II1 - Policy for ACHD Consultation within 24 Hours of Admission to the Hospital for all ACHD Patients (Policy)
II2 - Policy for Transfer to an ACHA ACHD Comprehensive Care Center
II3 - Policy to Ensure Access to Internal Medicine or Subspecialist for Consultation
II4 - Policy to Ensure Care is Provided in the Pediatric or Adult Hospital Appropriate for the Patient's Medical Issues, Regardless of Age
II5 - Policy for Transfer of ACHD Patients to an Adult Facility
JJ2- Cardiopulmonary Resuscitation of Adults
JJ4 - Process for Scheduling an Initial Appointment for New ACHD Patients within 4 weeks
JJ5 - Process to Evaluate Urgent Patients
JJ8 - Policy to Promote the Establishment of Medical Homes for ACHD Patients
JJ10 - Advance Care Plan Policy for ACHD Patients
JJ11 - Ongoing Patient Education and Distribution of Patient Education Materials
JJ14 - ACHD Education of Nursing and Other Staff in Outpatient Clinic
KK1 - Policy to Provide Transition Education for Patients and Providers
KK2 - Policy for Planned Patient Transfer from Pediatric to ACHD Care
KK3 - Policy to Ensure Collaboration with Pediatric Cardiology Providers to Support Ongoing Discussion Regarding the Patients and Referrals
LL1 - Policy to Integrate Patient-Centered Care (PCC) into the Program Mission Statement
LL2 - Policy to Promote Patient-Centered Care
LL5 - Policy for the ACHD PFAC
LL5 - Proposal for the ACHD PFAC
LL7 - Written Strategy for Healthcare Providers to Partner with, Educate, and Engage Patients and their Families in All Stages
PP1 - Policy for Access to PAH Consultation for ACHD Patients
RR1 - Policy to Encourage All Female ACHD Patients to Have Gynecological Care
RR2 - Policy for Discussion with Patients of Appropriate Birth Control Methods and Sexual Function as it Relates to CHD
RR3 - Policy to Ensure that All ACHD Patients Are Provided Pre-Pregnancy Counseling and Family Planning Advice
RR4 - Policy for Discussion of Sexual Counseling Regarding Sexual Dysfunction
RR5 - Policy to ensure that ACHD Providers Articulate and Document a Plan for Delivery in Collaboration with Maternal
SS1- Policy for Providing Coverage by a Licensed Social Worker or Care Manager with ACHD Knowledge
SS2 - Policy for Referral to Mental Health Services
 
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