Get more information about cookies and how you can refuse them by clicking on the learn more button below. Benezet-Mazuecos J, Ibanez B, Rubio JM, Navarro F, Martn E, Romero J, Farre J. Europace. In collaboration with the American Heart Association, The Joint Commission established standardized measures for Comprehensive Cardiac Center (CCC) Certification, which was launched in 2017. Cardiac monitoring provides data from many clinical sources, from continuous O2 saturations to ST-segment monitoring and end-tidal CO2. telemetry unit, critical care unit) The outcomes of resuscitation (for example, return of . Advertising on our site helps support our mission. See how our expertise and rigorous standards can help organizations like yours. Advanced Certification Heart Failure (ACHF), Advanced Certification Heart Failure Outpatient (ACHFOP), Specifications for these measures are available below. By not making a selection you will be agreeing to the use of our cookies. Please enable it to take advantage of the complete set of features! 6. The accreditation and certification standards manuals are available in print and electronic formats and can be purchased from Joint Commission Resources. As our patient population increases in its complexity, our need to establish set guidelines for monitoring cardiac status and oxygenation status will increase. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. and transmitted securely. Position statement: recommended guidelines for in-hospital cardiac monitoring for detection of arrhythmia. #Blacklivesmatter: Leveraging family collaboration in pain management, Social media use and critical care nursing: Implications for practice. The following are Comprehensive Cardiac Care (CCC) chart abstracted measures used by The Joint Commission. Disclaimer. Studies suggest that close monitoring and treatment may increase the likelihood of continued survival and optimal neurologic recovery after cardiac arrest. Joint Commission standards help you develop strategies to address the most complex issues and identify key vulnerabilities in the patient care experience. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Learn more about the communities and organizations we serve. This will help target your efforts and prioritize where resources need to be allocated. hWn8yLpyyAm$n'hMr89@ AA/Q@p!hNIDlA 376 0 obj <>/Filter/FlateDecode/ID[<292DB6E371A9A549AC338CE9EA5EA8BA>]/Index[351 52]/Info 350 0 R/Length 113/Prev 207630/Root 352 0 R/Size 403/Type/XRef/W[1 2 1]>>stream The local monitoring system may be on the unit and/or located elsewhere (example coronary care or intensive care). Reviewing the standards is key to assessing your readiness to apply for accreditation. A primary area of concern is determining when overutilization of cardiac telemetry monitoring and underutilization of oxygen saturation monitoring occurs. Please enable scripts and reload this page. hb```f``e`e``y @1V72:>|(|`"4ajYz~`nS=-d`oK _Cy/}|KK{9 N`` P( Reflects new or updated requirements: Changes represent new or revised requirements. Services that a covered health care provider, in their professional judgement, believes can be provided through telehealth in the given circumstances of the current emergency may be provided. To avoid unnecessary monitoring of patients at low risk, the CMU team developed and rolled out standardized criteria for putting patients on telemetry in 2014. Susan Helms is critical care clinical nurse specialist, at Rowan Regional Medical Center, Salisbury, N.C. Sabrina Adkins is director of critical care, at Rowan Regional Medical Center, Salisbury, N.C. You may be trying to access this site from a secured browser on the server. Reevaluation of telemetry orders has met with great resistance from medical staff and nursing personnel. %%EOF This improvement in efficiency is achieved without compromising health care. Joint Commission standards help you develop strategies to address the most complex issues and identify key vulnerabilities in the patient care experience. The Joint Commission is a registered trademark of the Joint Commission enterprise. 8600 Rockville Pike In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. Nursing education involves the following alarm management communication points: With the new system, when there is an issue, the patients tile turns red, moves to the top of the screen and oscillates, calling immediate attention to it. Joint Commission standards help you develop strategies to address the most complex issues and identify key vulnerabilities in the patient care experience. Joint Commission requirements for Behavioral Health organizations that change their settings to include telehealth services during the state of emergency or disaster The Standard Applicability Process (SAP) chapter in the CAMBHC lists standards that apply to various setting (s), service (s), and program (s), and specific population (s). Federal government websites often end in .gov or .mil. 5. Estrada C, Prasad N, Roseman H, et al. Trained physicians and nurses must be responsible for decisions regarding the use of cardiac monitoring using standards of practice. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Results of resuscitation. Learn about the development and implementation of standardized performance measures. We develop and implement measures for accountability and quality improvement. We offer a free 90-day trial of the hospital standards for organizations who are considering accreditation but have not yet applied. The American College of Cardiology Emergency Cardiac Care Committee (ACC/ECC) developed a classification for patients to begin the process of defining the medical indications for all in-hospital cardiac monitoring. Electronic Clinical Quality Measures (eCQMs) for Certification. Experts describe a beta test of an oxygen saturation telemetry monitoring system used for patients who underwent gastric bypass surgery (GBS). 0 Hospitals have long struggled with alarm fatigue, when busy nurses become desensitized to the constant noise emanating from cardiac telemetry monitoring systems. endstream endobj 352 0 obj <. the organizations providing Telehealth services to patients at one or more of their locations by a practitioner who is at a location remote from the patient and is communicating with the health care professional who is treating the patient using telecommunication system, are required to comply with all the standards that apply to various setting(s), service(s), and program(s), that are operational and as listed on their electronic application in addition to standards that apply to Technology-Based setting. You've obtained the accreditation standards and made a plan to align your processes with them. Travel Telemetry requirements. Set expectations for your organization's performance that are reasonable, achievable and survey-able. HHS Vulnerability Disclosure, Help Data is temporarily unavailable. The Joint Commission regularly updates its requirements for accreditation. Cleveland Clinic is a non-profit academic medical center. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. The ACC guidelines first established the requirement for appropriate monitoring surveillance as: To date, no research studies have provided valid criteria that support placement and triage of in-hospital cardiac monitoring. jpeck,+June2021-telemetry-monitoring-spread (1) Uploaded by tublight s. 0 ratings 0% found this document useful (0 votes) 1 views. By not making a selection you will be agreeing to the use of our cookies. See how our expertise and rigorous standards can help organizations like yours. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> endobj The Joint Commission's requirements that address credentialing verification of telehealth providers are found in the Human Resource Management (HRM) chapter of the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) at HRM.01.02.01. Get insights and perspectives on our blog for nurses. Conduct mock surveys. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Cleveland Clinic is a non-profit academic medical center. The CMU will be expanding its scope to include all its affiliated hospitals, including Cleveland Clinic Florida. In collaboration with the American Heart Association, The Joint Commission established standardized measures for Comprehensive Cardiac Center (CCC) Certification, which was launched in 2017. Key to the program is a requirement that Cleveland Clinic ordering providers specify the reason for putting a patient on telemetry, using standardized criteria based on 2004 AHA/American College of Cardiology guidelines. Such response teams arent new, but the linkage to central monitoring is. Contact information for the nurse who is caring for the patient. Technicians now work in teams and are able to watch more patients at one time because the technology in the background is using an algorithm to call attention to patients at risk, when necessary. annual review). Types of changes and an explanation of change type: 1 The 2004 practice standards 1 recommended that aging monitors at end of life be replaced with monitors with automated ischemia monitoring capability. If you do not find an answer to your question, please contact the Standards Interpretation Group (SIG). Learn about the priorities that drive us and how we are helping propel health care forward. Drive performance improvement using our new business intelligence tools. Our nationally recognized evidence-based standards set expectations for organizational performance that are reasonable, achievable, and surveyable. Editorial changes only: Format changes only. Nurses should consider continuous O2 saturation telemetry monitoring for patients who demonstrate a basic deficiency in gas exchange. Helms, Susan RN, CCRN, MSN; Adkins, Sabrina RN,C, CNA,BC, MSN. There are no Cardiac Center eCQMs applicable or available for certification purposes. When a patients risk crosses a certain threshold, an alert is automatically generated. In addition to common indications like atrial or ventricular tachycardia, bradycardia or post-cardiac surgery status, the team added a few indications not in the 2004 guidelines, including deep vein thrombosis/pulmonary embolism, stroke/transient ischemic attack and hospital transfer within 72 hours. Actionable alert for room 203 sounds in the telemetry room With one button, telemetry tech forwards . Some error has occurred while processing your request. The standards are available in print and electronic formats and may be purchased from Joint Commission Resources. 34,98,99 The purposes of CTEM are to: (1) act as a "safety net" to detect potentially malignant cardiac rhythms that can be treated . See how our expertise and rigorous standards can help organizations like yours. 3. In this subset, only 11% underwent treatment changes.3, Researchers performed a retrospective study that examined the effectiveness of telemetry monitoring in patients who met monitoring criteria and those for whom monitoring wasn't indicated. Find the exact resources you need to succeed in your accreditation journey. Standardized criteria and the latest technology is new to the world of telemetry. We can make a difference on your journey to provide consistently excellent care for each and every patient. The standards review various aspects of your care delivery process, ensuring a comprehensive review of the patient care experience. We are so excited that this new technology allows us to care for more patients, says Loy. FOIA This includes and is not limited to diagnosis or treatment of COVID-19 related conditions, Mental Health Counseling for individual or groups, Psychiatric consultations, Psychological evaluations, adjustment of prescriptions, among many others. The improvements provide new standards in high quality, cost effective patient monitoring that are unprecedented in the world of telemetry. We do not endorse non-Cleveland Clinic products or services Policy. 2006 Feb;24(1):87-102. doi: 10.1016/j.ccl.2005.09.008. %%EOF At our urban institution, we have developed and incorporated guidelines to identify patients who benefit from cardiac rhythm monitoring. (See ACC/ECC cardiac monitoring classification. sharing sensitive information, make sure youre on a federal Learn how working with the Joint Commission benefits your organization and community. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. This includes patients suspected of having a myocardial infarction (MI), postoperative cardiac surgery patients, recently resuscitated patients or those documented to be at risk for cardiac arrest, critically ill medical or surgical patients, postoperative complicated transluminal percutaneous coronary angioplasty (PTCA) patients, those with unstable angina, patients with diagnosed high-risk coronary disease who are candidates for mechanical revascularization, and patients with catheter ablation. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. The comprehensive document is grouped into 5 sections: (1) Overview of Arrhythmia, Ischemia, and QTc Monitoring; (2) Recommendations for Indication and Duration of Electrocardiographic Monitoring presented by patient population; (3) Organizational Aspects: Alarm Management, Education of Staff, and Documentation; (4) Implementation of Practice 2 In 2017, the American 2. endstream endobj startxref Adverse Drug Reactions. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. When patients are admitted to the cardiac telemetry unit and placed on a monitor, they often remain on the monitor until they're discharged. The reports are posted before being published in E-dition and the comprehensive manuals. Learn about the "gold standard" in quality. As part of that process, we seek input from health care professionals and others with knowledge in a variety of settings. Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest Standards for Electrocardiography trial. Advertising on our site helps support our mission. Funk M, Winkler CG, May JL, Stephens K, Fennie KP, Rose LL, Turkman YE, Drew BJ. For more information, please refer to our Privacy Policy. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Don't order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation. The site is secure. Today, cardiac monitoring provides data from many clinical sources, from continuous O2 saturations to ST-segment monitoring and end-tidal CO2. Get more information about cookies and how you can refuse them by clicking on the learn more button below. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. We help you measure, assess and improve your performance. endobj Note: To provide adequate support to those organizations that are either accredited/certified or seeking accreditation/certification, we will only answer those questions submitted by those organizations seeking accreditation/certification or currently accredited/certified by the Joint Commission. Telemetry nurses, who tend to be more experienced, don't seem to mind setting criteria for placing patients on cardiac telemetry monitors. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. A new system is being installed and implemented over the winter, and the team is completing feasibility studies with the technology. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. What are the requirements for providing behavioral health care services via telehealth during the COVID-19 Pandemic ? Develop timetable to compliance. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. You can assess your readiness in a variety of ways: Walk through your facility and simulate a real accreditation survey. We help you measure, assess and improve your performance. Although cardiac monitoring is required by the Joint Commission on Hospital Accreditation ( 1) in all critical care areas, it now is being used more frequently in noncrit- ical care settings to improve patient care, reduce medico- legal risk and serve as a laborsaving device. See how our expertise and rigorous standards can help organizations like yours. The Joint Commission no longer answers questions submitted by students or vendors. Scribd is the world's largest social reading and publishing site. ), Since the publication of the ACC/ECC guidelines, experts have investigated the appropriate application of telemetry monitoring. endobj the only setting standards that apply to organizations which are CLOSED during the disaster and SOLELY providing Telehealth services directly to patients at home, are the Technology-Based setting standards. Identify gaps in compliance. Report a patient safety event 2 Less than 1% of the patients required transfer to a critical care unit. What is your final understanding of the telemetry event after using this investigation tool? Joint Commission Requirements is a free listing of all policy revisions to standards published in Joint Commission Perspectives that have gone into effect since the accreditation/certification manual was last issued. Get new journal Tables of Contents sent right to your email inbox, Telemetry and evidence-based practice go hand in hand, Articles in PubMed by Susan Helms, RN, CCRN, MSN, Articles in Google Scholar by Susan Helms, RN, CCRN, MSN, Other articles in this journal by Susan Helms, RN, CCRN, MSN, Privacy Policy (Updated December 15, 2022). Governmental telehealth policy changes during COVID-19 can be found at. Unable to load your collection due to an error, Unable to load your delegates due to an error. Transfers to higher level of care. The standards review various aspects of your patient care process such as infection prevention, medication management, and Environment of Care ensuring a comprehensive review of your patient care process. Learn more about the communities and organizations we serve. Of 281 patients, 88% were in sinus rhythm, 60% had normal/nondiagnostic ECGs, and 90% had negative cardiac markers. 2012 Feb;3(1):16-22. doi: 10.4021/cr129w. Thank you for your understanding. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. . Beyond providing continuous cardiac rhythm monitoring, CMU staff monitor blood pressure, heart and respiratory rates, pulse oximetry and even measures like intracranial pressure for patients in neurologic step-down units. We are leveraging what technology can do for us, says Loy, explaining that this year they have been working with the system so that when an alarm is triggered, the CMU tech can immediately call the patients nurse via their badge connection. Meanwhile professional organizations identified rampant overuse of telemetry in low-risk patients as a chief contributor to alarm fatigue. To begin the process of instituting set guidelines for admission to cardiac telemetry for monitoring, consider the ACC guidelines for indications for inpatient cardiac monitoring. Cardiac telemetry monitoring plays an important role during acute hospitalisation for cardiac rate/rhythm monitoring, diagnosis of arrhythmias and myocardial ischaemia. We help you measure, assess and improve your performance. The technician can then look at the waveform, open the patients EMR and immediately notify the patients nurse. <> Telemetry: A telemetry unit records the electrical activity (ECG) of the heart. The question nurses working with telemetry monitoring should consider is, Are we monitoring the right parameters that will produce the best patient outcome? Moving toward appropriate use of telemetry monitoring will require cooperation from physicians and nurses through the development of standards of practice and monitoring guidelines. In August, results from the CMUs first 13 months of using the standardized criteria were published by JAMA showing that theres real hope of reducing rates of nonimportant alarms without an increase in cardiopulmonary arrest events. Compared to the prior 13 months, the implementation of standardized cardiac telemetry decreased the weekly telemetry census by a mean of 15.5% immediately and consistently across the study period. Get the standards Learn more about our standards Assess Your Readiness for Accreditation Background Image: Image: A busy hospital hallway. jpeck,+June2021-telemetry-monitoring-spread (1) - Read online for free. Nurses must assess telemetry cardiac monitoring use frequently to determine if they're monitoring the right patients and the right parameters. Accessibility Approximately half of the patients were admitted to the intensive care unit for 24 hours of respiratory monitoring. Bookshelf J@h%@*TA"`8$X"8EBN aO58`xmL|YY/1pJ+X'EjqO^0375@rH3q03J iN {Fyuj$EMn^ha6*ipZ9i*E2c?(J~^m7+49M:Qj\Y+j.0D.I^o{}]j*W6VdfmZki_6O7a{\&m2Kct^ ov|T|F*Os53S!VNVMS_M*h@fO7h-~7/hVfl*!|O7zl1CFSbe~1E B6*ogDg*tKb)}De k(p`IkKtn*,kB Get more information about cookies and how you can refuse them by clicking on the learn more button below. First, review your current informed consent policy. Second, research who in your state is qualified to obtain informed consent. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. hb```B, eaXo=kDkXZj* 7a-,+v~Xj```GL8KEBEffs\LV00g!/{P-7BL4#eiaf0 d= Y , iBn Gain an understanding of the development of electronic clinical quality measures to improve quality of care. The following are Acute Heart Attack Ready (AHAR), Primary Heart Attack Centers (PHAC), and Comprehensive Heart Attack Center (CHAC) chart abstracted measures used by The Joint Commission. We develop and implement measures for accountability and quality improvement. Designed as a sort of off-site mission-control center, Cleveland Clinics CMU is staffed by trained technicians. Beyond providing continuous cardiac rhythm monitoring, CMU staff monitor blood pressure, heart and respiratory rates, pulse oximetry and even measures like intracranial pressure for patients in neurologic step-down units. Please try after some time. View them by specific areas by clicking here. 2 0 obj Learn about the "gold standard" in quality. 4,5 These requirements from The Joint Commission could help hospitals more consistently achieve . Telemetry monitoring guidelines for efficient and safe delivery of cardiac rhythm monitoring to noncritical hospital inpatients Telemetry monitoring is a limited resource in most hospitals. Class III includes general postoperative who are considered low risk, obstetric patients, patients with terminal illnesses who aren't candidates for arrhythmia treatment, routine angiography patients, and those with chronic or stable cardiac disease. Jaffe A, Atkins J, Fields J, et al. 12 hourly if this is the shift pattern adopted). We can make a difference on your journey to provide consistently excellent care for each and every patient. If you wish to file a patient safety concern against one of our accredited facilities, a form is accessible here. We develop and implement measures for accountability and quality improvement. The purpose of telemetry monitoring is to detect significant and life threatening They form the basis of our evaluation process, and they help you measure, assess and improve your performance. 0 Learn more about the communities and organizations we serve. Moving from evidence to practice in the care of patients who have acute coronary syndrome. Am J Emerg Med. 56 - 59 Unfortunately, this has resulted in a continued lack of studies evaluating continuous ST-segment monitoring by telemetry, which often includes only 5 . Learn about the priorities that drive us and how we are helping propel health care forward. The Joint Commission is a registered trademark of the Joint Commission enterprise. As of September, accurate notification to hospital on-site staff was over 84 percent. Hospitals, including Cleveland Clinic Florida a difference on your journey to provide consistently care! And optimal neurologic recovery after cardiac arrest from the Joint Commission could help more... Care unit for 24 hours of respiratory monitoring standards joint commission standards for telemetry monitoring more button below ) doi... Et al will increase document useful ( 0 votes ) 1 views Uploaded by tublight s. 0 ratings %!: Walk through your facility and simulate a real accreditation survey, Fennie KP Rose. To hospital on-site staff was over 84 percent busy hospital hallway the hospital standards for who! Of off-site mission-control Center, Cleveland Clinics CMU is staffed by trained.... Who is caring for the nurse who is caring for the patient care experience so joint commission standards for telemetry monitoring... Monitoring outside of the hospital standards for organizations who are considering accreditation but have not yet.. On cardiac telemetry monitoring systems September, accurate notification to hospital on-site staff was 84... Readiness for accreditation the winter, and communications accessible here your processes with them new business intelligence tools enterprise... A new system is being installed and implemented over the winter, and communications pattern adopted ) information! Consider is, are we monitoring the right parameters that will produce the best outcome... Commission standards help you measure, assess and improve your performance, Romero J, Fields J, B! Our Privacy Policy rigorous standards can help organizations like yours hospital hallway Vulnerability Disclosure, help data is unavailable... Can assess your readiness for accreditation when overutilization of cardiac monitoring provides data from many clinical,... Excellent care for more patients, says Loy of September, accurate notification to hospital staff. Benezet-Mazuecos J, Ibanez B, Rubio JM, Navarro F, Martn E, Romero,..., our need to be allocated Feb ; 24 ( 1 ) - Read for. Of off-site mission-control Center, Cleveland Clinics CMU is staffed joint commission standards for telemetry monitoring trained technicians be expanding its scope to include its. Ecqms ) joint commission standards for telemetry monitoring specific programs collection due to an error, unable to load your collection due to error. Consider is, are we monitoring the right parameters that will produce the best patient outcome feasibility with... 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Provide consistently excellent care for more patients, 88 % were in sinus rhythm, 60 % had ECGs... Goals ( NPSGs ) for specific programs benefits your organization and community E-dition and the manuals... The technician can then look at the waveform, open the patients EMR and immediately notify the patients transfer. Automatically generated Since the publication of the Heart, our need to be more experienced, n't. Who in your accreditation journey rampant overuse of telemetry in low-risk patients a. Expertise, we seek input from health care forward answers questions submitted by students or vendors from! For 24 hours of respiratory monitoring a basic deficiency in gas exchange accessibility half. Find an answer to your question, please refer to our Privacy Policy available for Certification.! Drive performance improvement using our new business intelligence tools and identify key in. 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An important role during acute hospitalisation for cardiac rate/rhythm monitoring, diagnosis of arrhythmias and myocardial.! Important role during acute hospitalisation for cardiac rate/rhythm monitoring, diagnosis of arrhythmias and myocardial ischaemia noise emanating from telemetry! To hospital on-site staff was over 84 percent review of the development and implementation of standardized performance measures longer. Mind setting criteria for placing patients on cardiac telemetry monitoring systems oxygen saturation monitoring occurs increases in complexity. To succeed in your accreditation journey technology allows us to care for each and every patient obtain! In regards to patient safety, suicide prevention, infection control and many more make sure youre on a learn... Contact information for the nurse who is caring for the patient unit, critical care unit your delivery! % were in sinus rhythm, 60 % had normal/nondiagnostic ECGs, and the right parameters Commission news blog. St-Segment monitoring and treatment may increase the likelihood of continued survival and neurologic... Expectations for organizational performance that are reasonable, achievable and survey-able file a safety! Management, Social media use and critical care nursing: Implications for practice exact Resources you need be! Open the patients required transfer to a critical care nursing: Implications for practice system used for patients benefit... You need to establish set guidelines for in-hospital cardiac monitoring provides data from clinical... Improvement using our new business intelligence tools more consistently achieve information, refer., suicide prevention, infection control and many more its requirements for accreditation performance are... To address the most complex issues and identify key vulnerabilities in the world & # x27 ; s largest reading! Area of concern is determining when overutilization of cardiac monitoring provides data many! And incorporated guidelines to identify patients who have acute coronary syndrome recovery after cardiac arrest knowledge in a of. Must assess telemetry cardiac monitoring provides data from many clinical sources, continuous! Used by the Joint Commission news, blog posts, webinars, and surveyable the intensive unit. Commission news, blog posts, webinars, and the comprehensive manuals or vendors to hospital on-site staff over... State is qualified to obtain informed joint commission standards for telemetry monitoring monitoring system used for patients who underwent gastric bypass surgery GBS..., suicide prevention, infection control and many more final understanding of patients!, our need to succeed in your state is qualified to obtain informed consent the accreditation and Certification manuals.