Implementation of the PHA Pulmonary Hypertension Care Center Accreditation Program

Drs Chakinala and McGoon reviewed the rationale for creating PHA's PHCC program and initiating its early development phase.2 The expressed near-term goals of the PHCC program include aligning professionals, patients, and care-givers with increased pulmonary arterial hypertension (PAH) disease awareness, improving access to expert care, increasing adherence to published diagnosis and management guidelines, fostering collaboration among centers to optimize PAH clinical management and research, and providing guidance to prospective programs desiring to become accredited. Additionally, the PHCC program aims to develop a national patient registry for the purpose of supporting PH-related quality improvement and clinical research. The eventual long-term goal is to clearly define and promote PAH standards of care to improve patient outcomes.

The above articles outline the current context in which the PHCC program was constructed and delineate how the program may contribute to the larger agenda. During the initial development phase, the PHCC Committee has sought to build interest, consensus, and support among multiple stakeholders in the PH community, including health care professionals and patients. The PHA has posted information on its Web site (www.phassociation.org/PHCareCenters), and PHCC Committee members hosted several introductory webinars for various stakeholders, published information in Pathlight for patients and caregivers, and developed a long-range strategic plan. During the past year, the PHCC Committee has attempted to operationalize the PHCC program. The PHCC Criteria Taskforce dedicated more than 12 months to defining the initial set of accreditation criteria. The PHCC Implementation and Accreditation Taskforce focused on identifying the infrastructure necessary to make the program feasible.

As a result of these determinations, the governance structure of the PHCC program was designed. Two committees, the PHCC Oversight Committee (OC) and the PHCC Review Committee (RC), were established to carry out the administrative functions of the PHCC accreditation program. The OC comprises physicians, allied health professionals, a patient, a board of trustees member, an attorney, and PHA staff members. The committee is charged with analyzing and updating the PHCC accreditation criteria, program evaluation tools, and the accreditation scoring system. The OC is also responsible for establishing and governing the PHCC RC and reports to the PHA Board of Trustees. Calls for applications to serve on the OC were announced in Fall 2013, and the 7 selected members will each serve a 3-year term. The RC consists of 22 members including physicians and allied health professionals serving 2-year terms, supported by PHA PHCC staff. The responsibilities of the RC include reviewing site applications, conducting site visits, and determining accreditation status. Calls for applications to serve on the RC were made public in Winter 2013, and membership was selected.

A PHCC will be designated as a PHA-accredited “Center of Comprehensive Care” (CCC) or PHA-accredited “Regional Clinical Program” (RCP) based on the spectrum of resources available and therapies offered. The PHCC accreditation criteria focus on the evaluation of PH patients, diagnosis of PAH, and appropriate use of therapies for Group 1 (PAH) and Group 4 (chronic thromboembolic PH [CTEPH]) patients. The criteria emphasize appropriate resources, staff, and facility; diagnostic evaluations of PH patients (based on published consensus guidelines); access to PAH-specific therapy; and experience in treating PAH. Participation in clinical research is also a focus area for PHA CCCs. Collaboration between centers is an additional objective. PHA-accredited PHCCs will be expected to deliver appropriate and effective care to PH patients.

Our goal is to implement only criteria that are replicable, core to the mission, and add value to the PHCC accreditation program. Implementation of the PHCC program is a complex undertaking that has been described as “a specified set of activities designed to put into practice an activity or program of known dimensions.”3 The ultimate value of the PHCC program is dependent on the quality of our implementation. The PHCC program will be successful only if implemented in an effective manner.

The PHCC accreditation process has been designed to be comprehensive and includes multiple evaluation elements. We are seeking to assess the context within which each program functions, compliance with broadly accepted treatment and management guidelines, and the overall competency of care provided. Applicants are required to complete an online application and provide a roster of their PAH and CTEPH patients, obtain letters of support from ancillary program services, assemble supporting documents, and assist PHA PHCC staff in coordinating a 1-day site visit. Site visits will be performed by 2 PHCC RC members (a physician and an allied health care professional). The RC site visitors will interview key PH program faculty and staff, a PAH patient, and will review the additional supporting documentation. The PAH/CTEPH patient roster will be utilized for a focused chart review aimed at verifying PH diagnosis and management according to published guidelines. Site visitors will provide preliminary feedback to the program leadership and answer questions at the end of the day. Both CCCs and RCPs will need to substantially satisfy the established PHCC criteria. Understanding and adhering to the goals and principles underlying the criteria allows for some flexibility in evaluating how programs provide care individually and have developed resources locally. The RC as a whole will discuss the completed applications and evaluations to make accreditation decisions. Letters regarding PHA accreditation status will be distributed by the RC twice annually. Accredited programs will be required to maintain a roster of Group 1 and 4 patients in anticipation of a PHCC patient registry, currently under development. Duration of PHCC accreditation status is anticipated to be 3 years, after which renewal will be required.

Moving from program exploration to installation, we have been establishing the necessary processes, policies, and tools for the PHCC accreditation program. Program implementation entered the pilot phase in January 2014. The objectives of the PHCC pilot program include:

1. Refining the PHCC application and application instructions

2. Refining the site visit procedures and interview schedules

3. Refining the PHCC review processes and evaluation forms

4. Refining policies and procedures for the PHCC RC

5. Assessing the pilot results to help shape the grading system

6. Training PHCC RC members

The initial pilot program is currently underway and has been invaluable in helping meet these stated goals. The PHA is grateful to the pilot sites for agreeing to participate at an early stage and for providing program development contributions. Feedback from the pilot sites thus far has been quite positive. Undergoing the accreditation process has uniformly allowed program directors and coordinators to reflect on and evaluate their PH protocols, quality improvement initiatives, and ways to improve their patients' experience. They have also noted that the PHCC review process itself has improved the care they offer PH patients. Patients interviewed were overwhelmingly supportive of accrediting programs, thereby offering assurance for themselves, their families, and medical providers that designated specialty PH centers will have the ability to provide the expertise they are seeking. The PHA anticipates the beginning of the full PHCC program implementation and a call for applications in the second half of 2014.

^* PHCC Committee: Murali Chakinala, MD (PHCC Chair), Associate Professor of Medicine, Washington University School of Medicine; Richard Channick, MD (SLC President), Associate Professor of Medicine, Harvard School of Medicine; Steven M. Kawut, MD, MS (Chair, Registry Taskforce), Associate Professor of Medicine and Epidemiology, Perelman School of Medicine at the University of Pennsylvania; Vallerie McLaughlin, MD (SLC Past-President), Professor of Medicine, University of Michigan School of Medicine; Ronald Oudiz, MD (Chair, Criteria Taskforce), Professor of Medicine, David Geffen School of Medicine at UCLA; Abby Poms, RRT, RCP (Co-Chair, Implementation and Accreditation Taskforce), Pulmonary Vascular Disease Center Manager, Duke University School of Medicine; Joel A. Wirth, MD (Co-Chair, Implementation and Accreditation Taskforce), Associate Clinical Professor of Medicine, Tufts University School of Medicine; Roham Zamanian, MD (Chair, Funding and Sustainability Taskforce), Assistant Professor of Medicine, Stanford University School of Medicine.