Development and Evaluation of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) Program Certification for Low-Resource Settings

Figures & data

Table 1 ICCPR Program Certification Quality Standards, and Pilot Program Assessment Results, N=5

	Quality Standard^‖ (Type^†)	Source(s)**	Site 1		Site 2		Site 3		Site 4		Site 5
			Value	Met Standard?	Value	Met Standard?	Value	Met Standard?	Value	Met Standard?	Value	Met Standard?
1*	Comprehensive program (≥3/10 components^⇨) (S)	Program survey Q26; corroborate d in site visit	8	Y	8	Y	8	Y	8	Y	8	Y
2	Multidisciplinary team (≥2/14 types^∞) (S)	Program survey Q21; corroborate d in site visit	8	Y	10	Y	7	Y	8	Y	6	Y
3*	Cardiac emergencies policy (S)	Program survey Q23; corroborate d in site visit	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
4	Assessment of risk factors: tobacco (P)	Responses in ICRR V22; corroborate d by Program survey Q25 and site visit	149 (100%) patients	Y	486 (100%) patients	Y	94 (100%) patients	Y	184 (100%) patients	Y	90 (100%) patients	Y
5	Assessment of risk factors: blood pressure (P)	Responses in ICRR V22; corroborate d by Program survey Q25 and site visit	149 (100%) patien ts	Y	483 (100%) patients	Y	94 (100%) patients	Y	184 (100%) patients	Y	89 (100%) patients	Y
6	Program completion rate (P)	Responses in ICRR V22	108 (81.2%)	Y	124 (36.3%)	N	93 (100%)	Y	92 (71.3%)	Y	62 (77.5%)	Y
7*	Peak MET increase ≥.5^§ (O)	Responses in ICRR V11; corroborate d in site visit	3.7 ± 1.9	Y	0.9 ± 1.2	Y	1.8 ± 1.1	Y	0.8 ± 0.9	Y	0.3 ± 0.3	N
8	QoL increase from pre to post-program^‡§ (O)	Responses in ICRR V18	1.3 ± 1.1	Y	2.3 ± 0.9	Y	1.6 ± 1.5	Y	8.5 ± 1.3	Y	2.1 ± 1.0	Y
9	Mins. MVPA ≥150/wk. post- program^§ (O)	Responses in ICRR V21	350.4 ± 168.8	Y	305.4 ± 89.9	Y	126.0 ± 19.6	Y	251.26 ± 141.3	Y	207.5 ± 62.9	Y
10	Knowledge – medications^§ (O)	Responses in ICRR V23; corroborate d in site visit	2 (100%)	Y	123 (100%)	Y	92 (100%)	Y	88 (100%)	Y	57 (91.9%)	Y
11	Knowledge – lipids^§ (O)	Responses in ICRR V25; corroborate d in site visit	2 (100%)	Y	122 (100%)	Y	92 (100%)	Y	88 (100%)	Y	57 (91.9%)	Y
12	Knowledge – diet^§ (O)	Responses in ICRR V25; corroborate d in site visit	104 (96.3%)	Y	122 (100%)	Y	92 (100%)	Y	88 (100%)	Y	62 (100%)	Y
13	Knowledge- return to life roles^§ (O)	Responses in ICRR V25; corroborate d in site visit	107 (99.1%)	Y	120 (100%)	Y	92 (100%)	Y	120 (100%)	Y	62 (100%)	Y
	Total		13 (100%)	Y	12 (92.5%)	Y	13 (100%)	Y	12 (92.5%)	Y	12 (92.5%)	Y

Notes: ^‖operationalization of each standard, including any exclusion criteria for each (eg, coverage for medication), are shown at: https://globalcardiacrehab.com/Program-Certification under “CR Quality Standards” sub-section. *Mandatory standard. ^‡Scored out of 10 at the pre-CR and post-CR assessments. ^§In program completers only. ^□Initial assessment, exercise training, patient education, nutrition counselling, tobacco cessation, stress management, medication prescription / titration, vocational counselling, psychosocial counselling, post-program re-assessment. ^∞Physician (cardiology, physiatry, internal medicine, psychiatry, other), nurse / nurse-practitioner, exercise specialist, physiotherapist, psychologist, social worker, dietitian, pharmacist, occupational therapist, community health worker, administrative assistant. Note that these disciplines are not necessarily working full-time with the CR program. **Q, question from ICRR program survey; V, variable from data dictionary entered into ICRR for each patient, operationalized as shown at: https://globalcardiacrehab.com/ICRR-Variables-and-Data-Dictionary(22. Values presented as n (%; patients for standards 5–13) or mean ± standard deviation.

Abbreviations: ^†S, structure, P, process, O, outcome; Y, yes; N, no; ICRR, International Cardiac Rehabilitation Registry; QoL, quality of life; MVPA, moderate or vigorous-intensity physical activity; METs, metabolic equivalents of task; ICCPR, International Council of Cardiovascular Prevention and Rehabilitation; Mins, minutes; wk, week.

Figure 1 ICCPR Program Certification process.

Note: Reproduced from International Council of Cardiovascular Prevention and Rehabilitation (ICCPR). Copyright 2010. Available from https://globalcardiacrehab.com/Program-Certification. Accessed October 31, 2023.²³

Abbreviation: ICCPR, International Council of Cardiovascular Prevention and Rehabilitation.

Table 2 Characteristics of ICRR-Participating Pilot Cardiac Rehabilitation (CR) Programs, N=5

	n (%) or Mean ± SD
Type of Institution*
Referral / tertiary / academic site	4 (80%)
Private hospital	2 (40%)
Outside of a hospital	1 (20%)
Funding for Program*
Patient	4 (80%)
Government	1 (20%)
Other	1 (20%)
Disciplines on CR Team*
Administrative assistant	5 (100%)
Physiotherapist	4 (80%)
Any other type of exercise specialist	4 (80%)
Nurse	3 (60%)
Any physician	2 (40%)
Other	1 (20%)
Core Components Offered*†
Patient education	5 (100%)
Resistance training	5 (100%)
Nutrition counselling	5 (100%)
Tobacco cessation sessions/ intervention	5 (100%)
Stress management / relaxation	5 (100%)
Prescription / titration of cardiac medications	4 (80%)
Other‡	4 (80%)
Program duration (weeks)	7.40 ± 2.97
Remote delivery available	5 (100%)
New patients served per month	18.33 ± 5.77

Notes: *More than one response could apply to each site. ^†Participating sites must offer initial assessment and structured, aerobic exercise (supervised or unsupervised) hence they are not listed. They also must offer at least one other component. ^‡See list of components in footnote of Table 1 (eg, vocational counselling).

Abbreviations: SD, standard deviation; ICRR, International Cardiac Rehabilitation Registry.

Figure 2 Map depicting cardiac rehabilitation programs which participated in pilot testing of ICCPR’s Program Certification.

Note: All sites were ultimately certified.

Abbreviation: ICCPR, International Council of Cardiovascular Prevention and Rehabilitation.

Table 3 Focus Group Participant Characteristics

Participant Identification Number	Sex	Profession / Role
1	F	RN
2	F	Administrative secretary of CR program
3	F	PT
4	F	PT
5	F	Occupational therapist
6	M	MD/ Director of CR center
7	M	MD, Sports medicine specialist/ Head of CR center
8	M	Occupational therapy supervisor
9	F	Senior rehabilitation specialist
10	F	Assistant manager of CR program
11	F	Dietitian
12	F	Deputy general manager of CR program
13	F	Program Director

Abbreviations: M, male; F, female; MD, medical doctor; PT, physiotherapist; CR, cardiac rehabilitation; RN, registered nurse.

Table 4 Four Major Themes Regarding ICCPR’s Program Certification, with Illustrative Quotes by Sub-Theme

Theme	Subtheme	Illustrative Quote (ID#)
Motivation, benefits	Showcase quality at international calibre, pride	“If we are certified, then it adds value to what we are already doing. I mean, whatever practices we benchmark, getting to learn from the registry. And again putting it out saying, okay, this is what exactly it is and let the numbers speak for themselves” – (3) “Having national certification really implies administrative, managerial and assistance processes that entail a lot of work; recognition is of great satisfaction. That is why, according to the new national registry of cardiac rehabilitation programs in our country, only a third of the registered centers are certified by our Society. You can imagine then that aspiring to be recognized now by the international authority of ICCPR is still a major challenge, but also an achievement of great proportions for all of us” – (6) “We want to improve the quality of the treatment and care which we provided to the patient through this certification. We are able to improve the standard which were the, you know, criteria of the international society” – (9) “Some standards, some benchmarks, we need just to see ourselves … where we are, where we are standing. So, this opportunity gave us a lot to improve… to check ourselves, and to motivate more and more-- not only for ourselves, but our team members also want some international certification like ICCPR” – (10) “Then once you, any program who got the certificate, definitely it increased their prestige. It increased their status, and increased their value. Because getting any international certification, it means a lot” – (12) “Individual [ICCPR] provider certification was great already, but the program certification gave us more confidence to deliver this cardiac quality service to our patients”. – (8)
	Promotes program with patients, institutional leadership and policy-makers	“This achievement within my union of cardiac rehabilitators, surprised everyone and generated congratulatory reactions and great recognition, both among health professionals of our community and in social media” – (6) “We have even placed the certificate in a very visible place in our institution. We have placed that certificate on our social media, and even in a newspaper advertisement we have shared our certification. Because now it’s a source of pride for us too, that we are the only one [in our country] who is certified by any international body, and working within the international standards”. – (12) “We have placed the certificate in our offices as well our waiting area-- in the prominent spaces of our institution” – (12) “We have given this information about the certification to the newspaper on World Heart Day, and we have also placed this information on our website. We are planning to print on our stationary too” – (12) “Our certificate, yeah, we shared it with the rest of the staff of the department; they were so happy about it. We printed it out. And we took a photo with the rest of the department. Yeah and we shared it in our social media. We even published it on our website” – (2) “We’re still taking pictures with the CEOs and the people and everyone’s like, oh my God, you get the certificate, let’s have a picture”. – (13) “We are planning to put the certification logo in our welcome letter for the patient upon joining” – (2) “We were very happy because it’s a hard process, you know, to achieve this; it’s also very meaningful for us, and we shared this with all our community. I think maybe an opportunity here is to inform the Presidents of the national cardiac rehabilitation societies when we get certified. We shared this achievement with all the Society members…. It was received with a lot of joy and congratulations” – (6)
	Lead to provision of program resources	“Before we were certified we were struggling to expand our services in many hospitals and all over the country because we are the first cardiac rehabilitation program. After the certification, there was a huge celebration, with the happy news coming from our Minister, the Minister of Health herself” – (13) “They are all saying we’re going to expand our Center. And we think that the cardiac rehabilitation certification by ICCPR has a lot of responsibility for this”. – (6) “Everything flipped. Like, we were struggling to have space and stuff. And [once certified] everyone looked at us and said ‘whatever you need, we’re going to give you’. We were struggling for 10 years and then just like that, in one month our life has changed” – (13)
		“We did have the funds in order to expand, but we lacked proof of quality. So, with this certification, everyone thinks and sees our program as a very high-standard, qualified program. And so yes, now we will give you what you want in order to expand, and to achieve all the beautiful things” – (13) “We’re going to also capitalize on this. We are going to expand our center in the South, and we think that certification by ICCPR has a lot to do with this” – (6)
Logistics	Communication with ICCPR was clear, responsive, timely, and helpful to get through the process	“All the experience communicating about all the program certification-- The online application-- I support it. Everything. I think it’s okay” – (6) “With the application process, I didn’t find any difficulty. The [ICCPR] team was very much supportive” – (12) “We all are convinced with the assessment, that all assessors have done a very fair assessment, and in fact supported us in in a lot of ways” – (12) “The communication and the help from ICCPR has been very helpful and smooth; even being in different time zones, the [ICCPR] team was very helpful” – (4) “We really received support and good comments also about our site” - (6)
	Cost, including for re-certification	“I think the costs are reasonable… it’s the work that it means for being certified; there’s a lot of work and maybe people are [balancing] other priorities; that’s the reality, but not costs. I think that is not the main reason here – it’s the work” – (6) “From our side, I think we will definitely we will [apply for re- certification in three years]” – (13) “I think it will give us more confidence you know, when it comes to our patients that we are certified internationally. So I think it would be good to continue the certification after three years” – (2)
	Site visit	“Nothing of that sort [being judged]. In fact, the assessors were very neutral during the virtual assessment” – (3) “There weren’t any biases. And as far as the confidentiality was concerned, they were very clear that they didn’t want to know the names of the patients, so that was good”. – (3) “We had an experience with a JCI audit in our hospital, and we didn’t expect that it would be as at par with ICCPR’s. As well, it was very detailed” – (2) “It was fair. They were very clear that it was meant to benchmark the practices, and imbibe certain best practices” – (3) “The [internet] connection during the virtual as a site, it is very important. And some of the team were a bit shy to be on the camera. We were happy with the questions because we got to show genuinely who we are and our every day work” – (2)
Standards and their assessment	Discussion of finding the right balance between ensuring process is feasible for low-resource sites to participate, but also need to have rigor to ensure quality	“It should be hard in some sense, because there needs to be criteria. But the work in the database and the [virtual] examination. It was a lot be ensure everything is fulfilled” – (6) “The people are paying from their own pocket, so our dropout rate is increasing day-by-day” – (12) “At the beginning we had difficulty following all the requirements. Actually we even got lost sometimes, in following up, even in the registry. I think I would suggest, to make it much easier probably, you could come up with a book, a guideline, or something like that”. – (2) “It was a quite in-depth audit. I was quite impressed that each and every component and aspect was investigated thoroughly” – (12) “…being the part of the registry added a lot of burden, in terms of manpower, finances and all that. It is really hard for me to have a approval from my administration for establishing and managing this registry because it costs a lot” – (12) “Being certificated or evaluated by you for being certificated, it’s something like being judged. In fact, I think this is necessary, because in some things we maybe are doing wrong; something’s wrong and we have to correct it” – (6) “Trying to make it more feasible for every [program] here… because there are a lot of benefits” – (6)
	Degree of difficulty of standards	“It was not difficult to meet all those standards except the the process outcome standard #6, which was about cholesterol. We are not asking our patients to have a cholesterol check regularly [because of the fee]. So the question is always about this standard; We are always low” – (12) “We think the peak METs increase of 0.5 from pre to post program is too low and should be changed” – (7) “It’s difficult sometimes to achieve all the criteria. But I think we really feel good, and we perceive that procedures and the way the standards were assessed were appropriate” – (6)
Areas for improvement	Website organization	“Improve the line spacing so that the text does not appear to be too near with each other for ease of reading. And also another one is like, if it appears more appealing on the main page, like upon opening the website, I think like a photo or something like that will be more appealing than seeing all the text; Like, when you see all the text, oh, which one I will read or something like that” – (2) ”It’s difficult. We are running all the time with a lot of stuff here, and maybe to simplify the information it would be better for us” – (6) “Add testimonials from the sites who are certified. So put my experience with the process or maybe how certification has helped me. So insights from those who have done it, that you know you could reach out to too, because it becomes a different scenario when you are on to the other side” – (3)
	Other	“I think it would be also good to inform the program that they can apply for certification [when they start with the registry] instead of doing it in the middle, like after five months or something like that. I think it could have supported more preparation” – (2) “We would not able to pay for the certification process because of the Paypal issue. So some options [for forms] of payment can be explored for these developing countries” – (12) “We got the soft copy of the certificate, and we got it printed …. But you know, it was asked by our administration that it would be more valuable if they would send a hard copy directly to us” - (12)

Abbreviations: ICCPR, International Council of Cardiovascular Prevention and Rehabilitation; METs, metabolic equivalents of task; JCI, Joint Commission International.

International Council of Cardiovascular Prevention and Rehabilitation. ICCPR Program Certification. 2010. Available from https://globalcardiacrehab.com/Program-Certification. Accessed May 25, 2023.

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