Policies & Procedures

The purpose of ICCPR’s program certification scheme is to recognize cardiac rehabilitation (CR) programs in low-resource settings (includes in high-income countries, as defined in ICRR’s protocol available here) who meet a minimum quality standard with regard to program structure, processes and patient outcomes. The program certification is a peer-reviewed process designed to review CR programs for adherence to quality standards of the ICCPR also recognized other professional societies.

ICCPR Program Certification is an option to programs participating in ICCPR’s International Cardiac Rehab Registry (ICRR). Upon payment of the fee, if the below quality standards are met, CR programs will be ICCPR-certified for 3 full calendar years from the date of certification issue. Programs will receive an electronic dated certification certificate to print and post. Their program will be listed on ICCPR’s website, and the news will be shared on ICCPR’s social media platforms. They may also use the ICCPR certification logo (to be provided) on their website(s) (if applicable) denoting they are an “ICCPR-quality program”. Certified programs will also be provided sample social media posts and email templates to share the news of their successful certification. We are also available to support press releases.

Processes for re-certification are outlined below.

GOVERNANCE AND RESPONSIBILITY:

ICCPR’s program certification is governed by a committee of 3-8 members representing the variety of disciplines delivering CR, from around the world. At least 1 member of ICCPR Executive and ICRR’s Steering Committee shall serve. The committee shall report to ICCPR Executive. The terms of reference are available here.

Note that this process involves analysis of provided data that cannot be directly verified as well as program observation at generally one point in time. Therefore, ICCPR provides no guarantee of service quality. Moreover, ICCPR holds no legal responsibility for patient care, malpractice, innocent accidents or negligence. The applying program agrees to indemnify and hold the ICCPR harmless against any claims, deeds, suits, actions, proceedings, recovery warranties or representations. It is understood that the warranties, representations and indemnification will survive in perpetuity. Applicant programs should understand and comply with healthcare regulations and requirements in their jurisdiction.

For questions about program certification, contact globalcardiacrehab@gmail.com.

REQUIREMENTS:

1.  Your CR program meets the inclusion criteria for the ICRR (i.e., phase II outpatient program, in a low-resource setting, offering at least initial assessment, structured exercise [supervised or unsupervised] and at least one other strategy to control risk factors) as per the protocol found here. Note that home-based programs are eligible.

2. Pay application fee (amount below).

3. Preferably your country is represented on ICCPR council through an association or “friend” member (see list here); if not at time of application you will be asked if there is a relevant professional association that may wish to consider joining ICCPR or if not, whether you or a colleague would be interested in being a “friend” of ICCPR, as per our terms). The purpose is to formalize communication with ICCPR throughout the duration of the term your program may be certified, and to promote currency in best practices as espoused by ICCPR.

4. At least one member of your CR program staff has their ICCPR Cardiac Rehab Foundations Certification (CRFC; click here).

5. Your program has / is participating in the ICCPR’s International Cardiac Rehab Registry (ICRR; if not, you can sign up by completing the online survey here)

a. Programs must not have outstanding data quality or completeness issues raised by the ICRR.

b. Post-program / progress data must be provided for a minimum of 4 months as well as post-program /progress data on at least 60 consecutive consenting patients submitted  (regardless of program completion / dropout).

6. Participation in a minimum 2-hour virtual site visit with ICCPR Program Certification assessor(s), where facilities and services can be observed, using a tablet or laptop for mobility and screen size; mobile phones are insufficient. You will need high-speed, wireless internet at your centre. Your device requires a functioning video camera (external USB web cam or integrated), and should be fully charged at the time of the site visit. You will need to be in a fairly quiet space throughout the duration of the virtual site visit. Ensure good sound though the microphone and speaker. The device should be mobile such as on a cart on wheels, so we can have a tour of the gym and facilities as applicable (sound on one device only if applicable to mitigate echo or audio feedback). It is preferable all your staff are present, but a minimum of 2 different disciplines are required on-site. The site visit will be arranged during your center hours of operation, so we can also potentially interact with willing patients. You will also need to be able to share your screen so we can see patient education materials etc., and be ready to talk about some random registry patient IDs (anonymously), so have your charts handy.

Note the certification assessment is generally conducted in English, and thus all materials should be provided in English (or the assessors will use an online translator if necessary). However, some assessors are proficient in other languages, so please let us know whether you would like us to determine if we can secure an assessor in another language for your assessment.

FEES:

The 2022 application fees for 3-year certification are as follows (in USD):

Country Income Classification*	Privately-Funded Program	Solely Publicly-Funded Program
Low-income	$300	$200
Middle-income	$500	$400
High-income	$800	$600

*Based on World Bank.

The re-attempt fee (where all materials / are not available during the site visit, or programs are close to meeting 70% of the quality standards) is 50% of the initial application fee, and the re-certification fee is 70% (valid also for 3 calendar years from date of re-certification).

The application, re-attempt and re-certification fees may be revised annually by the ICCPR Steering Committee (e.g., 3% increase / year). The fees cover the cost of administering the certification program (i.e., pending availability of funds and number of assessors, a stipend of $150USD is provided for each virtual site assessment upon completion of the certification process via Paypal), and registry maintenance; this is a not-for-profit initiative.

Unfortunately, it would be a rare circumstance where the fee could be reduced. Fees cannot be paid in installments. Fees will not be returned if a site visit does not proceed or if certification is not granted (but see re-attempt process and fee). Materials will not be considered until fees are received.

CR QUALITY STANDARDS:

The following quality standards were selected based on ICCPR’s consensus statement on CR delivery in low-resource (1,2), a review of CR quality indicators (3) , clinical practice guidelines (4), WHO’s Package of Rehabilitation Interventions for Ischemic Heart Disease (to be released), as well as recent EAPC standards and quality indicators (5,6). They were also informed by ICRR’s delphi process for variable selection and subsequent quality indicators (Chowdhury et al., Global Heart, 2022).

Quality standards will be reviewed at a regular interval by the ICCPR Program Certification committee, and may be revised based on evidence, among other considerations (e.g., applicability, verifiability of quality standards, commonality across low-resource settings).

“Patients” refers only to cardiac patients, as per ICRR inclusion criteria stated in the ICRR protocol found here.

To be recognized by ICCPR, programs must meet the 3 mandatory standards (*), and 70% of all standards.

Program-level / Structure & Process Indicators (assessed based on responses to ICRR on-boarding survey available here, as well as during site visit, or based on patient-level data entered into ICRR, as specified for each below)

1. *Comprehensive program, including (a) initial assessment, (b) structured exercise training (supervised or unsupervised) and (c) ≥1 other strategy to control CVD risk factors; evidenced based on program survey and during site visit (demonstration of at least one other component)

2. Multidisciplinary team (i.e., ≥2 different regulated professions available to support patients at least on a part-time or referral basis): evidenced based on program survey, provision of current job descriptions with regulatory body membership (or equivalent), and confirmed during site visit

3. *Cardiac emergency policies in place: evidenced based on program survey and site visit

4.  Assessment of the following CVD risk factor: tobacco use; evidenced based on program survey, responses in ICRR, and patient chart)

5.  Assessment of the following CVD risk factors: blood pressure; evidenced based on program survey, responses in ICRR, and patient chart)

Patient-level / Process & Outcome Indicators

(assessed based on ICRR data, and some confirmed during site visit)

6. Program completion rate: <50% of patients lost to follow-up / dropped out for non-clinical reasons other than return-to-work

7. *Mean peak METs increase of ≥.5 from pre to post-program, in 75% of program completers

8. Mean post-program quality of life score > pre-program score, in program completers

9. Mean minutes of moderate to vigorous-intensity activity per week post-program /progress ≥150, in program completers

10.  ≥70% of patients reporting yes they know what heart pills they should be taking post-program, in program completers that have coverage for medication

11.  ≥70% of patients reporting yes they know their cholesterol level and how to control it post-program, in program completers

12.  ≥70% of patients reporting yes they know how to follow a heart-healthy diet post-program, in program completers

13.  ≥70% of patients reporting yes they have been supported to get back to their important life roles post-program, in program completers

Note that ICRR-participating programs can download their own data to check whether they meet these standards. The ICRR Secretary can support this where programs are unclear. The ICRR secretary can also share ICRR Program Survey responses so programs can confirm information is up-to-date and whether relevant standards are met in advance of program application.

HOW TO APPLY & PROCESS TO CONFIRM ELIGIBILITY:

Applications are accepted at any time. Programs can expect the certification decision process to take approximately 3 months from receipt of application.

Ensure at all times that any patient information is not identifiable (i.e., black out name, date of birth, address etc.). Current information should be provided.

1.  Pay the applicable fee to https://www.paypal.com/paypalme/iccpr (programs having trouble paying via paypal can contact the ICCPR Treasurer at globalcardiacrehab@gmail.com)

2. Provide the below information and materials at this link https://yorkufoh.ca1.qualtrics.com/jfe/form/SV_0JPMyfAeXiArpZk:

(a) express your interest in applying. Provide your full name, the program/ institution name (including email for the program), program / institutional website if available) and country.

(b) attach a CRFC professional completion certificate for one of your team members (as per  https://globalcardiacrehab.com/Certification)

(c) confirm whether your country has a formal linkage to ICCPR (see https://globalcardiacrehab.com/Members and search for your country, and if not, suggestions on how this might be achieved);

(d) confirm that you meet program inclusion criteria from the registry protocol here https://globalcardiacrehab.com/resources/Documents/ICRR%20Benchmarking_Protocol_v4-2.pdf.

(e) provide at least 2 professions job descriptions and their regulatory college membership or equivalent (individuals who can be available during the site visit);

(f) specify program funding source (preferably providing evidence of no private funding if applicable), AND (g) confirming that the applicable fee has been paid.

Programs can describe any quality-related changes to the program that may have been made since completion of the ICRR on-boarding survey which is used to evaluate certification candidacy. They can also state the range of months of pre and post-program data they wish considered if they have engaged in quality improvement activities since joining the ICRR.

If you would like to request a virtual site assessment in a language other than English, please specify the language; we will see if we can identify a suitable site assessor (no guarantees).

3. ICRR Secretary will:

a. Confirm with ICCPR secretary payment was received, and if yes

b. Confirm all needed information is received. If not, the program will be contacted to secure it. If yes, the ICRR secretary will:

c.  review the ICRR data completeness report (should be minimal variables in red denoting <50% completion, and particularly at post-program assessment variable completion rate should not be lower than the average for all programs); annual assessment not applicable), and checking with the ICRR research sub-cttee co-chair and /or statistician for any outstanding data quality issues (e.g., based on audits of internal consistency of data, representativeness as per data quality policy here),

d.  and collate the number of participants with post-program / progress responses (in specified time frame if applicable as per 2a), and the range in number of months over which this is provided. 

i.  Programs may be asked to review data completeness or follow-up with further patients before the process proceeds

e.  If there are no data issues and the patient minimums are met, the ICRR secretary shall review responses to ICRR program survey (and any corresponding updates in application email), and document for which program-level quality standards the program meets or does not meet certification standards preliminarily in the Program Certification Assessment Form

i. If the program-level mandatory standards are not met, the ICRR secretary will inform the applying program the reason their application cannot proceed, providing 2 weeks for a response with reconsideration request. If no response is received the application will be considered denied and complete.

f. If the mandatory program-level standards appear to be met, the ICRR secretary will review the site’s ICRR patient-level data, and using pre-specified syntax, check whether each patient-level quality standard is met or not met, and report value

g. Then the ICRR secretary will send an email to the applicant, cc’ing the Certification Program committee co-chair for Assessment Oversight, confirming receipt of payment, and stating whether each quality standard is met, using the Program Certification Assessment form (pre-site visit column). Note it may be some weeks from application to receipt of email if all materials are received, as the program certification initial assessment unfolds through all steps as outlined above.

i.  If the 3 mandatory and 70% of the quality standards are met preliminarily, the ICRR secretary shall invite a virtual site Certification Assessor from ICRR Steering and sub-committees as well as ICCPR Program Certification committee members (consideration will be given to language as well as time zone, and any conflicts of interest will be ruled out including no assessors from the same country),  as recommended by the Program Certification Assessment Oversight co-Chair, and arrange a mutually-convenient time for the 2-hr site visit. A calendar invite shall be sent with meeting link for the program to test in advance (confirm with us all the technology requirements are met before the site visit).

 ii.  If 70% are not met, the program has up to 2 weeks to provide applicable documentation that program-level quality standards are currently met, and/or provide a quality improvement plan to meet the patient-level indicators with a request for reconsideration at a pre-specified future date (at no additional cost).

VIRTUAL SITE VISIT ASSESSMENT PROCEDURES:

Applicant sites eligible to proceed to site visit will be provided with details on how to prepare. A mutually-convenient time will be arranged during your business hours so as many of your staff (minimum 2 required on-site) and some patients are available to speak with the Assessor(s). Ensure all requirements under item 6 above are met prior to the start of the virtual site visit, and that the relevant parties are available. A 30-minute technical dress rehearsal will be arranged with the Secretary before the actual site assessment. As per the above requirements, at this time, we will confirm you are ready to proceed to the virtual site visit by observing you have the following capability: (1) good internet connection, visuals and sound for you, (2a) able to communicate with (i.e., see and hear) team members and (b) patients; (3) show us you can share your screen with charts and /or patient education materials; (4) capability to take us on a tour of your centre to show us the various aspects; and (5) we will give you a random patient registry ID# and ask you to pull their chart, show it, and verify some of their information. This will then ensure you are ready to proceed to the actual site visit. If the site visit cannot be completed, the re-attempt fee shall be charged before re-scheduling. 

Where possible, the Program Certification Secretary shall attend the site assessment with the named Assessor.

During the site visit, while maintaining patient confidentiality, you will be asked to show the Certification assessor the following aspects of your program:

1. Show chart of randomly selected patient(s) from registry (site assessor to state registry IDs during site visit, and confirm correct patient chart pulled based on sex, age and initial assessment date), stored securely, documenting:

a. Initial assessment (e.g., history, risk; quality standard 1)

b. the risk factors of tobacco use and blood pressure (quality standard 4,5), and

c.  exercise prescription (quality standard 1)

2. Show how other components of your CR program are offered (in addition to exercise at least 1 must be offered of the following: patient education [e.g., show materials], risk factor modification [e.g., show charting of cardiac medications], behavior change counselling [e.g., show charting of diet recommendations, tobacco cessation intervention] or stress management / psychosocial [e.g., show relaxation techniques recommended to patients]) (quality standard 1)

3. Introduce us to 2 members of the team of different disciplines (can include applicant; corresponding to role descriptions provided at time of application), who will describe their clinical roles in the program (if the other person cannot be available, the site visit will need to be rescheduled upon payment of the re-attempt fee) (quality standard 2)

4.  Show the policy / procedure binder / manual for handling cardiac emergencies, and summarize to Assessor (note: staff may be queried on scenarios); Show the means on-site to summon assistance in case of emergency to start life support (latter not applicable to fully remote programs) (quality standard 3)

5. Show a patient functional capacity test, or if not possible, where / how performed at your program (can be virtual with patient with consent) (quality standard 7)

6.  Show a patient education session (could be 1-1, virtual and/or group), or secure consent from a patient to speak with the site Assessor about their education received (e.g., about medications, lipids, diet, psychosocial). (quality standard 10-13)

The site assessor may request additional information or documentation be provided after the virtual site visit if meeting of certain quality standards is unclear. In the case where there are some outstanding questions after the visit leading the Assessor(s) to have difficulty in making the certification recommendation, the ICCPR Program Certification committee may be consulted and/or a 2nd evaluation with a different Assessor may be arranged (no fee).

After the Site Visit:

The site assessor will complete the site visit column of the Program Certification Assessment form, and tally whether the 3 mandatory standards as well as the minimum % of standards has been met or not. Within 2 weeks of the site visit, a recommended decision to certify or not shall be communicated to the Steering Committee co-chair, and where not, what potential there might be to meet some of the standards and re-attempt.

A co-chair shall review the materials, and consult with the steering committee where warranted, before rendering a final decision. The program will be provided results for each quality standard by the Secretary via email within 4 weeks of the site visit, and informed whether they have earned ICCPR certification or not. Some commentary may or may not be provided around program quality.

All programs are invited to engage with ICRR’s user sub-committee in quality improvement activities where they are interested in addressing unmet quality standards. Contact us to be part of our “community of practice” at iccpr.icrr@gmail.com.

Where certification requirements are met:

Programs meeting requirements can then market themselves as “ICCPR-certified”, and will receive their Certification certificate and other supporting marketing materials electronically to use as desired. Your name and that of your program will be added to ICCPR’s website for the duration of the certification term, and this will also be shared on ICCPR’s social media channels. You will also be listed in ICCPR Program Certification reports. You may be contacted by ICRR’s user sub-committee with an invitation to share best practices with other programs in areas where you program performs at very high quality (e.g., documents, webinar).  

Certified programs are expected to at least maintain their practices throughout the certification term. ICCPR may conduct periodic audits at any time during the certification period to ensure that the standards are still being met. This may include a site visit or a request for submission of materials related to certification standards.

Where certification requirements are not met:

Unfortunately, the fee is not returned if the program is not successful in meeting certification requirements.

Programs that are close to meeting the 70% standard and it is perceived they could potentially meet the standard can re-attempt to meet additional standards they could not when they have made the necessary improvements / remediation by emailing  iccpr.icrr@gmail.com & globalcardiacrehab@gmail.com, and providing the applicable documentation or once a mutually-agreed number of new patients is contributed to the registry such that new data entered subsequent to changes made following the site visit could be analyzed by the Secretary to determine whether some unmet standards are since met (note: another site visit may be required depending on the quality standard in question). Re-attempts can be made up to one year from the site visit. Again, ICRR’s user sub-committee is here to support you in your quality improvement efforts to achieve certification, and the Secretary can support you by answering questions around what documentation could be provided to document meeting specific standards. Once the re-attempt fee outlined above is paid, applicable materials will be considered by the site assessor and a co-chair, and a decision (or request for further information) provided within 3 weeks.  

Programs wishing to re-butt negative decisions may contact globalcardiacrehab@gmail.com with the request and rationale (provide any supporting documentation; e.g., a certain standard is not relevant to their low-resource setting). The ICCPR Program Certification Steering Committee will review the correspondence as well as the Program Certification Assessment form for the site, and may correspond with the site assessor. They will either request further information or investigate before holding a vote, or render a decision based on majority vote within 4 weeks. A rationale supporting the reconsideration decision may or may not be provided. There is no cost for this process.

Note ICCPR will maintain the confidentiality of all applying programs, including results of the assessment. In future, reports on the certification program, descriptive statistics regarding program application success rates overall and proportion meeting each standard will be reported in aggregate only, with no program identifiable (or even country in those with few programs to maintain privacy).

RE-CERTIFICATION:

Re-certification every 3 years of certified programs is optional, and can be requested an unlimited number of times. Re-certification does not require current active participation in ICRR. Note there may have been some changes to the process or standards, and programs will be expected to meet the policies in effect at the time of re-certification. All mandatory standards must be met for re-certification.

The ICRR Secretary shall be in touch 6 months prior to the 3-year anniversary of certification. It is the program’s responsibility to be aware of their certification expiration date, and meet the application deadline for re-certification regardless of whether expiration reminders from ICCPR have been received.

Interested programs are asked to pay the re-certification fee (https://www.paypal.com/paypalme/iccpr), reply requesting initiation of the re-certification process, report any changes in program delivery (including location, institutional moves, primary CR program contact information) since the last certification, complete the provided survey with detail regarding delivery of each quality standard (including provision of documents), and work with the ICRR secretary to arrange a virtual site visit in some instances.

Programs that do not complete and meet the re-certification process requirements by the 3-year anniversary will be removed from ICCPR’s website. They will also be instructed to remove the ICCPR certificate, logo and associated certification marketing from their institutional materials; The program shall confirm this with ICCPR via email. The program may still undergo the re-certification process to reinstate program certification at any time (i.e., they do not have to follow the initial process).

References

1. Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell NRC, Derman W, et al. Cardiac rehabilitation delivery model for low-resource settings: An International Council of Cardiovascular Prevention and Rehabilitation consensus statement. Progress in Cardiovascular Diseases. 2016;59(3):1–20.

2. Grace SL, Turk-Adawi KI, Contractor A, Atrey A, Campbell N, Derman W, et al. Cardiac rehabilitation delivery model for low-resource settings. Heart. 2016;102(18):1449–55.

3. Moghei M, Oh P, Chessex C, Grace SL. Cardiac Rehabilitation Quality Improvement: A Narrative Review. Journal of Cardiopulmonary Rehabilitation and Prevention. 2019;39(4):226–34.

4. Mehra VM, Gaalema DE, Pakosh M, Grace SL. Systematic review of cardiac rehabilitation guidelines: Quality and scope. European journal of preventive cardiology. 2020 Jun 4;27(9):912–28.

5. Abreu A, Frederix I, Dendale P, Janssen A, Doherty P, Piepoli MF, Völler H; Secondary Prevention and Rehabilitation Section of EAPC, Davos CH. Standardization and quality improvement of secondary prevention through cardiovascular rehabilitation programmes in Europe: The avenue towards EAPC accreditation programme: A position statement of the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology (EAPC). European Journal of Preventive Cardiology. 2020 Jun 1:2047487320924912. doi: 10.1177/2047487320924912. Epub ahead of print.

6. Aktaa S, Gencer B, Arbelo E, Davos CH, Désormais I, Hollander M, Abreu A, Ambrosetti M, Bäck M, Carballo D, Crawford C, Deaton C, Dendale P, Eijsvogels TMH, Galbraith M, Piepoli MF, Salzwedel A, Smulders Y, Wilhelm M, Biondi-Zoccai G, Mach F, Visseren FLJ, Gale CP. European Society of Cardiology Quality Indicators for Cardiovascular Disease Prevention: developed by the Working Group for Cardiovascular Disease Prevention Quality Indicators in collaboration with the European Association for Preventive Cardiology of the European Society of Cardiology. European Journal of Preventive Cardiology. 2021 Oct 23:zwab160. doi: 10.1093/eurjpc/zwab160. Epub ahead of print.

Members of Steering Committee

ROLE	NAME	REGION
Chair	Sherry Grace	Americas
Co-Chair - Assmt Oversight	Emma Thomas	Western-Pacific
Secretary	Carol Tran	Americas
Treasurer	Jonathan David	Americas
Vice-Chair	Aashish Contractor	South-East Asia
Other representation	Diann Gaalema	Americas
Other representation	Won-Seok Kim	Western-Pacific
Acting Assmt. Oversight Lead	Jon Gallagher	Europe
ICRR Quality Improvement Liaison	Abraham Babu	South-East Asia

ICCPR-Certified Programs

Tabba Heart Institute, Pakistan

CardioFit, Mexico

Hamad Medical Corporation, Qatar

Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Iran