American Heart Association Audit Compliance

Automate the process of complying with your accrediting agency’s administrative requirements

TC Suite (The combination of TC Manager and the sub-utilities) has a number of features that assist in keeping up with the American Heart Association’s administrative requirements for Training Centers. A specific list of audit items (from the AHA’s TC Administrative Self-Review April 2004) is below:

ORGANIZATION/ADMINISTRATION-FOCUSED FUNCTIONS

Item 3 a. Is there evidence that the TC stores records, including TCF/Instructor files? Are they stored electronically or hard copy or both? Are the files backed up on a regular basis? Is the TC capable of printing all electronic files as hard copies?

TCM keeps records of classes, instructors, and faculty members. It does so electronically, and details can be printed as hard copies for both classes and instructors. The data management screen allows you to backup your data to a backup file to facilitate recovery from corruptions. That file can be put on CD or removable media for safe keeping.

Item 3 b. Is there evidence that the all records are maintained for a minimum of three years from the date of issue?

TCM has manual purge feature that allows records to be eliminated from the database if they are older than a selected number of years. As long as you don’t purge less than 3 year old files, you will be able to print course records on demand. There is no limit to how old the class is – you can always access those records on demand (and thus show evidence of record keeping) as long as it’s in the database.

Item 5 a. Does the TC have policies and procedures that address the following issues: Quality Assurance Plan (updated annually)?

Training Center Quality Manager (TCQM) addresses many of the quality concerns of the AHA audit. TCM clients are welcome to use the downloadable QA template and adapt it to their CTC and AHA Region’s needs. It interfaces well with the TCQM and addresses many of the items in an AHA audit. Please note – you should customize it to the AHA region you are in and not rely on the default document to total compliance. You will also need to review it every year.

Item 5 b. Does the TC have policies and procedures that address the following issues: Continuous Quality Improvement?

Training Center Quality Manager (TCQM) does real-time updating of instructor’s scores with every course entered into the software. Using the policy and procedure plan we’ve provided (particularly the portion on making sure instructors meet a certain % of course evaluation approval) will demonstrate to the auditor a proactive and continuous effort at maintaining quality instruction.

Item 5 c. Does the TC have policies and procedures that address the following issues: Equipment Maintenance/Decontamination?

Training Center Manager (TCM) v3.1 and after has a decontamination statement on the roster itself, identifying the party who performed manikin decontamination for that program.

Item 5 d. Does the TC have policies and procedures that address the following issues: Internal Dispute Resolution?

TCM clients are welcome to use the downloadable QA template and adapt it to their CTC and AHA Region’s needs. It provides a sample process for resolving internal disputes. Please note – you should customize it to the AHA region you are in and not rely on the default document to total compliance. You will also need to review it every year.

Item 5 e. Does the TC have policies and procedures that address the following issues: Management of TCF/Instructor communications/updates?

Training Center Manager (TCM) v3.1 and after has BROADCAST EMAIL button on the INSTRUCTOR management section of the ADMINISTRATIVE section. This button can send email to every instructor active with the center, and a reference copy to the CTC itself. By keeping/printing the reference copy, you will have a evidence of all updates given to the instructors for that CTC.

Item 12 a. Can the TC show evidence of updated instructor/TCF aligned with TC?

Training Center Manager (TCM) has a section for identifying instructor credentials (instructor certifications and the like). You can create an instructor certification type such as GUIDELINES 2005 UPDATE and mark the date when the instructor took the update right in their profile. This will also print when you run a report for the instructor in question.

Item 12 b. Does the TC identify Instructors who teach but are not aligned with the TC?

Training Center Manager (TCM) has a section for identifying instructor credentials (instructor certifications and the like). A field marks the instructor ACTIVE (currently certified and aligned with the CTC), INACTIVE (expired, etc), or ACTIVE – ALIGNED ELSEWHERE.

Item 15 a. Can the TC show evidence of documented QA activity?

Training Center Quality Manager (TCQM) addresses many of the quality concerns of the AHA audit. Entering the course evaluations and generating the course evaluation reports demonstrates that the evaluations are being processed (and not ignored). This, plus appropriate follow-ups on areas of concern should adequately demonstrate to an auditor that on-going QA activity is being performed.

Item 15 b. Can the TC show any documentation of continuous quality improvement?

PROGRAM ENHANCEMENT

Is there evidence that each TC Coordinator maintain current Instructor status in at least one discipline?

Training Center Manager (TCM) has a section for identifying instructor credentials (instructor certifications and the like). You can quickly print the TC Coordinator’s credentials if you maintain an instructor profile for them in the INSTRUCTOR section.

Is there evidence that the TC Coordinator attended any Instructor updates?

COURSE FOCUSED FUNCTIONS

Item 3 c. Is there evidence of a process in place for issuing cards for a two-year period?

Training Center Manager (TCM) automatically generates a 2-year expiration by calculating forward from the date of the course. It also prints the expiration in the AHA format of MM/YYYY. Unless one manually alters the print template right before printing, the software will not allow a poorly printed expiration on an AHA card. It also lines up the template for perfect printing on the AHA 2 to a sheet mailer or the 3 to a sheet card pages.

Item 3 e. Can the TC demonstrate that it issues the cards within 30 days of receipt of paperwork?

Training Center Manager (TCM) will keep track of the CARD PRINTED date for each student. After printing the cards, on the CERTIFICATE PRINTER page, click the CONFIRM PRINTING button – this will add the date of card issuance to the student’s record.

Item 3 f. Can the TC demonstrate that cards are competed correctly?

Training Center Manager (TCM) automatically lines up the template for perfect printing on the AHA 2 to a sheet mailer or the 3 to a sheet card pages. It also prints the expiration in the AHA format of MM/YYYY. The software will not allow a poorly printed expiration on an AHA card unless there is an incomplete or missing field. A final print preview allows the user to see what will be printed before sending the information to the printer so as to make sure there are no missing fields.

Item 5 c. Is there evidence that the course/Instructor evaluation tool is summarized?

Item 5 d. Is a summary of course/Instructor evaluations maintained in course files and individual evaluations maintained for those with potential issues/problems?

Training Center Quality Manager (TCQM) can create a printed course evaluation report for a course, showing the average of each quantitative score, plus all the comments placed in the feedback section of the course. This summary can be printed and attached to the course paperwork. When an instructor’s evaluations suggest a problem (“Bob was terrible”) an individual instructor quality report can be generated and placed in the student file.

Item 5 e. Are individual instructors evaluated? Is there evidence that the TC used the information on the course/Instructor evaluation tool for improvement?

Training Center Quality Manager (TCQM) can create a printed individual evaluation report for an instructor. The use of these evaluations as outlined in our downloadable QA template will allow you to demonstrate the a system is in place for improving instructors who need remediation. You should also document and keep actual events in the instructor’s paper file.

Item 5 e. Are individual instructors evaluated? Is there evidence that the overall TC program administration has been evaluated?

Training Center Quality Manager (TCQM) can create a printed course evaluation report for a course. By including questions on the evaluation that deal with the quality of materials, time frame, etc, you can also evaluate the overall program. You can also look to the data collected from miscellaneous comment boxes such as COMMENTS: or HOW WOULD YOU IMPROVE THIS COURSE? TCQM will allow you to generate reports for these fields, and those can be used in your QI program.

Item 6 e. Is there evidence that course exams are issued to students and proctored?

Training Center Manager (TCM) will keep student scores in each student’s profile for that course. Those scores will be printed on the course roster.

Item 7 a. Does the TC use rosters with AHA guidelines for all courses?

Training Center Manager (TCM) will print a course roster for any course you enter into the software. We took painstaking time to create a roster that addresses the AHA’s audit items. You can see a sample of this roster here.

Item 7 b. Is there evidence that rosters are used for every class?

Training Center Manager (TCM) will generate a course roster for any course you enter into the software. Simply print it and attach it to the roster.

Item 7 c. Are all the areas of the roster completed?

Training Center Manager (TCM) will print a course roster for any course you enter into the software. All areas of the roster are automatically filled in, unless they are left blank in the actual program.

Item 7-1 a. Are all the following components included on the roster: Name of the organization?

Automatically printed on the roster.

Item 7-1 b. Are all the following components included on the roster: Type of course?

Automatically printed on the roster.

Item 7-1 c. Are all the following components included on the roster: Instructors listed and their status or position?

Automatically printed on the roster (status is added from the TITLE field in the INSTRUCTOR PROFILE in versions 3.1 and after)

Item 7-1 c. Are all the following components included on the roster: Was a physician instructor available (ACLS/PALS only)?

Automatically printed on the roster (status is added from the TITLE field in the INSTRUCTOR PROFILE in versions 3.1 and after. MD/DO title will identify physicians)

Item 7-1 d. Are all the following components included on the roster: Number of participants?

Automatically printed on the roster – use PASS as the student’s STATUS.

Item 7-1 d. Are all the following components included on the roster: Number of participants remediated?

Automatically printed on the roster – use PASS – Remediated as the student’s STATUS.

Item 7-1 e. Are all the following components included on the roster: Number of participants remediated?

Automatically printed on the roster – use INCOMPLETE as the student’s STATUS.

Item 7-1 g. Are all the following components included on the roster: Instructor-student-manikin ratio?

Automatically printed on the roster – number of students and manikins, and instructor list at course.

Item 7-1 h. Are all the following components included on the roster: Total hours of instruction?

Automatically printed on the roster – Start time and finish.

Item 7-1 i. Are all the following components included on the roster: Signed by Lead Instructor or Course Director?

Automatically printed on the roster is a statement that the course was conducted according to AHA guidelines. A signature spot for the responsible party is provided.

Item 7-1 g. Are all the following components included on the roster: Test Scores?

Automatically printed on the roster – this item is optional, but included on the roster.

INSTRUCTOR FOCUSED FUNCTIONS

Item 1-1 Each TC must maintain a current file on Instructors/TCF in all disciplines. Is there evidence of a file for each Instructor/TCF member?

TCM keeps information about instructors in a complete instructor profile. This can be printed on demand. In Version 3.1 and after, a batch print of all instructors can be printed at once.

Item 1-1 a Each TC must maintain a current file on Instructors/TCF in all disciplines. Is there evidence of a file for each Instructor/TCF member?

TCM keeps information about instructors in a complete instructor profile. This can be printed on demand. You should also keep a paper file as a backup and for non-digital items.

Item 1-2 Each TC must maintain a current file on Instructors/TCF in all disciplines.

a. All files should be complete: Name?

TCM keeps this item in the INSTRUCTOR section of the ADMINISTRATION section.

b. All files should be complete: Job Status (MD, RN, EMT-P)?

TCM keeps this item in the INSTRUCTOR section of the ADMINISTRATION section.

c. All files should be complete: Mailing Address?

TCM keeps this item in the INSTRUCTOR section of the ADMINISTRATION section. It will also keep the optional email address and use it for communication.

d. All files should be complete: Phone Number?

TCM keeps this item in the INSTRUCTOR section of the ADMINISTRATION section.

f. All files should be complete: Initial recognition date?

TCM keeps this item in the INSTRUCTOR section of the ADMINISTRATION section. You can place it in the COMMENTS section of the record that keeps track of their instructorship.

g. All files should be complete: Renewal date?

TCM keeps this item in the INSTRUCTOR section of the ADMINISTRATION section. It will be searchable and you can see the expiration date of the instructor before you assign him/her to a course.

Item 2 a Is there evidence of teaching activity for TCF/Instructors?

TCM can generate printable activity reports for each instructor, including type of course, number of courses, and total students taught.

Item 3 a Is there evidence that the TC has conducted an adequate number of provider courses?

TCM can generate printable activity reports for the training center as a whole, including type of course, number of courses, and total students taught.

Item 3 b Is there evidence that the TC has conducted an adequate number of instructor courses?

TCM can generate printable activity reports for the training center as a whole, including type of course, number of courses, and total students taught.

Item 4 Is there evidence that the TC updated instructors/TCF with the latest information on: AHA courses? Science Guidelines? Policies and Procedures? Training Bulletins?