Author + information
- Published online May 11, 2020.
- George P. Rodgers, MD, FACC, Chair, Steering Committee,
- Jane A. Linderbaum, MS, CNP-BC, AACC, Co-Chair, Steering Committee,
- Dorothy D. Pearson, PA-C, AACC, Co-Chair, Steering Committee,
- Susan M. Fernandes, LPD, PA-C, Steering Committee Member,
- Susan D. Housholder-Hughes, DNP, ACNS-BC, ANP-BC, FACC, Steering Committee Member and
- Lisa A. Mendes, MD, FACC, Steering Committee Member
- Nancy C. Berg, MA, ANP-BC, AACC, Committee Member,
- Jennifer Day, FNP-C, Committee Member,
- David Drajpuch, ACNP-BC, CRNP, FNP-BC, MSN, Committee Member,
- Blair Erb Jr., MD, FACC, Committee Member,
- Marci Farquhar-Snow, MN, CCRN, CMC, CNS, ACNP-BC, AACC, Committee Member,
- Heather Johnson, MPAS, PA-C, Committee Member,
- Patricia Keegan, DNP, NP-C, AACC, Committee Member,
- Christine Kindler, PA-C, Committee Member,
- Rhonda Larsen, MHS, PA-C, Committee Member,
- Viet T. Le, MPAS, PA-C, AACC, Committee Member,
- Michelle J. Nickolaus, MSN, CRNP, ACNP-BC, CCRN, AACC, Committee Member,
- Celeste M. Phillips, MS, RN-C, ANP, AACC, Committee Member,
- Laura Ross, MS, PA-C, AACC, Committee Member,
- Sherrie R. Webb, PA-C, Committee Member and
- Erica S. Zado, PA-C, Committee Member
- ACC Competency Statement
- cardiovascular medicine
- clinical competency
- interpersonal and communication skills
- medical knowledge
- patient care and procedural skills
- practice-based learning and improvement
- systems-based practice
- team-based care
ACC Competency Management Committee
James A. Arrighi, MD, FACC, Chair
Lisa A. Mendes, MD, FACC, Co-Chair
Jesse E. Adams iii, MD, FACC∗
John E. Brush, Jr, MD, FACC∗
G. William Dec, Jr, MD, FACC
Ali Denktas, MD, FACC
Susan M. Fernandes, LPD, PA-C
Sanjeev A. Francis, MD, FACC
Rosario Freeman, MD, MS, FACC∗
Rebecca T. Hahn, MD, FACC
Jonathan L. Halperin, MD, FACC†
Susan D. Housholder-Hughes, DNP, ACNS-BC, ANP-BC, FACC
Sadiya S. Khan, MD, FACC
Kyle Klarich, MD, FACC
C. Huie Lin, MD, PhD, FACC
Joseph E. Marine, MD, FACC
Shannon McConnaughey, MD
John A. McPherson, MD, FACC∗
Khusrow Niazi, MBBS, FACC
Thomas Ryan, MD, FACC
Michael A. Solomon, MD, FACC
Robert L. Spicer, MD, FACC
Marty Tam, MD∗
Andrew Wang, MD, FACC, FAHA
Gaby Weissman, MD, FACC
Howard H. Weitz, MD, MACP, FACC
Eric S. Williams, MD, MACC‡
Table of Contents
1. Introduction 2486
1.1. Document Development Process 2486
1.1.1. Writing Committee Organization 2486
1.1.2. Document Development and Approval 2486
1.2. Background and Scope 2486
1.2.1. Cardiovascular NP and PA Competencies 2487
Table 1. Competency Framework for Nurse Practitioners and Physician Assistants in Adult Cardiovascular Medicine 2487
1.2.2. Assessment Tools 2488
Table 2 ACGME Core Competencies 2487
1.2.3. Research and Scholarly Activity 2488
2. Clinical Competencies 2488
Table 3. Core Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2488
Table 4. Acute Coronary Syndromes Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2490
Table 5. Adult Congenital Heart Disease Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2492
Table 6. Ambulatory and Consultative Care Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2494
Table 7. Cardiac Arrhythmias and Electrophysiology Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2496
Table 8. Cardiovascular Disease Prevention Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2498
Table 9. Critical Care Cardiology Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2501
Table 10. Heart Failure Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2503
Table 11. Pericardial Disease Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2505
Table 12. Stable Ischemic Heart Disease Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2506
Table 13. Valvular Heart Disease Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2508
Table 14. Vascular Medicine Competencies for Cardiovascular Nurse Practitioners and Physician Assistants 2509
Author Relationships with Industry and Other Entities (Relevant) 2512
Peer Reviewer Information 2514
Since the 1995 publication of its Core Cardiovascular Training Statement (COCATS) (1), the American College of Cardiology (ACC) has played a central role in defining the knowledge, experiences, skills, and behaviors expected of all clinical cardiologists upon completion of training. Subsequent updates have incorporated major advances and revisions—both in content and structure—including a further move toward competency-based training, and the use of the 6-domain competency structure promulgated by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, and endorsed by the American Board of Internal Medicine. A similar structure has been used by the ACC to describe the aligned general cardiology lifelong learning competencies that all practicing cardiologists are expected to maintain. Many hospital systems also now use the 6-domain structure as part of medical staff privileging and peer-review professional competence assessments.
The ACC Competency Management Committee oversees development of competency statements for cardiovascular specialists covering the entire career spectrum. In 2016, the ACC’s Cardiovascular Team Council approached the Competency Management Committee to develop a competency statement for members of the cardiovascular care team. One impetus for this request was the 2015 ACC Health Policy Statement on Cardiovascular Team-Based Care and the Role of Advanced Practice Providers (2) that highlighted the importance of team-based delivery of cardiovascular care and advocated for development of a nationally-recognized set of core competencies. The statement emphasized the important collaboration between cardiologists, nurse practitioners (NPs), physician assistants (PAs), and other cardiovascular team members in the care of patients. Also noted was the lack of formal postgraduate training programs for NPs and PAs such that most cardiovascular knowledge and skills are learned through practice experience from more experienced and tenured clinicians on the team. To fill this educational gap, the Cardiovascular Team Section Leadership Council requested that the Competency Management Committee commission a competency statement. This resulting document describes the key anticipated competencies for cardiovascular NPs and PAs, including those in general cardiovascular practices and those in focused areas of cardiovascular medicine. It also identifies aspects of cardiovascular medicine that exceed core expectations and may be maintained or achieved by some specialized NPs and PAs, depending on their expertise, skills, practice agreements, and licensure. This document is not intended to describe independent practice for a particular discipline or outline training standards. Rather, it is intended to delineate those competencies relevant to services that cardiovascular NPs and PAs provide to patients within the care delivery system of a cardiovascular practice.
A key feature of competency-based training and performance is an outcome-based evaluation system. All ACC competence and training statements, therefore, include examples of tools that can be used to assess achievement of the individual components of competency (see Section 1.2.2.). Recommendations in these statements are based on available evidence and, where evidence is lacking, reflect the consensus of expert opinion. The writing committees reflect the diversity of cardiovascular medicine, including content experts, general cardiology and sub-subspecialty practitioners in both academic and private practice settings, and early, mid-, and later-career representatives. All documents are subject to rigorous peer review and public comment.
The work of the writing committee was supported exclusively by the ACC without commercial support. Writing committee members volunteered their time to this effort. Conference calls of the writing committee were confidential, and only committee members attended. To avoid actual, potential, or perceived conflict of interest resulting from relationships with industry or other entities (RWI), writing committee members and peer reviewers were required to disclose all current healthcare-related relationships. The ACC Competency Management Committee determined that RWI are not relevant to the creation of a general cardiology competence statement but provided employment and affiliation information for authors and peer reviewers in Appendixes 1 and 2, respectively, along with disclosure reporting categories. To ensure transparency, comprehensive healthcare-related disclosure information, for authors and peer reviewers has been posted online. Disclosure information for the ACC Competency Management Committee is available online, online, as is the ACC disclosure policy for document development.
James A. Arrighi, MD, FACC
Chair, ACC Competency Management Committee
Lisa A. Mendes, MD, FACC
Co-Chair, ACC Competency Management Committee
1.1 Document Development Process
1.1.1 Writing Committee Organization
The writing committee consisted of a broad range of members selected by the ACC, including an equal number of cardiovascular NPs and PAs with expertise in the following clinical areas: acute coronary syndromes, adult congenital heart disease, ambulatory and consultative care cardiology, cardiac arrhythmias and electrophysiology, cardiovascular disease prevention, critical care cardiology, heart failure, pericardial disease, stable ischemic heart disease, valvular heart disease, and vascular medicine. Committee members represented a diversity of geographic location; urban, suburban, and rural practice settings; academic and community-based practice settings; institution size; gender; ethnicity; and stage in career (early, mid, and later), as well as those who exemplified practice acumen and team model care expertise. Although no members participated in a formal representational role from other professional societies, the writing committee is composed of authors who are engaged in NP, PA, and cardiovascular specialty organizations. In addition to the NP and PA members of the committee, 3 cardiologists with expertise in team model care and competency development participated in the writing, review, and revision of the document. The writing committee met the College’s disclosure requirements for RWI as described in the Preamble.
1.1.2 Document Development and Approval
The steering committee convened to plan the writing effort, determine the document framework, and initiate preliminary competency table development and project plans. Authors were then selected to address the criteria specified in Section 1.1.1. The writing committee convened by conference call and e-mail to finalize the document outline, develop the initial draft, revise the draft based on committee feedback, and ultimately approve the document for external peer review.
The document was reviewed by 4 official representatives from the ACC and 25 reviewers representing the following organizations: the Accreditation Review Commission on Education for the Physician Assistant, American Academy of Physician Assistants, American Association of Heart Failure Nurses, American Association of Nurse Practitioners, American Heart Association, American Nurses Credentialing Center, Association of Physician Assistants in Cardiology, Heart Failure Society of America, Heart Rhythm Society, National Organization of Nurse Practitioner Faculties, Physician Assistant Education Association, Preventive Cardiovascular Nurses Association, and the Society for Cardiovascular Angiography and Interventions. In addition, 56 content reviewers participated in peer review representing cardiologists, NPs, and PAs with expertise in the clinical topics addressed in this document as well as diversity across stage in career, practice setting, and geographic location, resulting in over 1,000 peer review comments. The list of peer reviewers, employment information, and affiliations for the review process is included in Appendix 2. The document was simultaneously posted for public comment from September 9, 2019, to September 30, 2019, resulting in 185 additional comments. The writing committee reviewed and addressed all comments. A member of the ACC Competency Management Committee served as lead reviewer to ensure a fair and balanced peer review resolution process. Both the writing committee and the ACC Competency Management Committee approved the final document to be sent for organizational approval. The ACC approved the document for publication with endorsement from the American Academy of Physician Assistants, American Association of Heart Failure Nurses, American Association of Nurse Practitioners, American Heart Association, American Nurses Credentialing Center, Association of Physician Assistants in Cardiology, Heart Rhythm Society, Physician Assistant Education Association, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and The National Organization of Nurse Practitioner Faculties. This document is considered current until the ACC Competency Management Committee revises or withdraws it from publication.
1.2 Background and Scope
NPs and PAs are integral members of the cardiovascular care team in diagnosis and management of patients with cardiovascular disease, both in general and specialty cardiovascular practices. Prerequisite education, training, experience, and demonstrated competency provide a foundation to function in a collaborative team environment with significant autonomy, extending the capabilities of the general or subspecialty cardiologist and the entire cardiovascular team. When practicing at the full scope of education, training, and licensure, NPs and PAs improve access to care and provide comprehensive clinical care, including diagnosis, management, test ordering and interpretation, procedure participation, patient education, and care coordination. Most clinical care teams that utilize NPs and PAs report enhanced practice performance, physician efficiency, revenue generation, improved clinical outcomes, and enhanced patient satisfaction (2–9).
Model cardiovascular teams are composed of members including but not limited to cardiologists, NPs, PAs, behavioral scientists, cardiovascular technologists, clinical nurse specialists, data/informatics professionals, exercise physiologists, genetic counselors, nurses, occupational therapists, pharmacists, physical therapists, registered dieticians, and social workers. High-performing cardiovascular care teams aspire for each member to practice at the top of his or her education, training, licensure, and experience with clearly defined roles. This document identifies competencies for the NP and PA members of the cardiovascular care team.
The overarching goal in competency statements is to provide a framework by which educational initiatives and clinical competencies can be coordinated to improve the overall delivery of care to cardiovascular patients. This competency document identifies the knowledge and skills important for NPs and PAs working in general cardiovascular medicine and cardiac subspecialty areas, thereby assisting NPs and PAs in identifying learning needs and opportunities for professional growth. It also helps to increase awareness of the roles that NPs and PAs have within the cardiovascular team. Such efforts will promote and enhance collaborative, high-quality, patient-centered care teams.
Acquisition of the competencies described in this document can come from a variety of sources, including learning from more experienced cardiovascular care team members, educational programs, workshops, and self-directed reading and study. The general cardiovascular competencies for NPs and PAs provide a foundation for practice, given individual learning needs, practice setting, and baseline knowledge. However, after months and years of clinical experience, one would anticipate aspirational development into deeper knowledge and specialty skills based on practice area and model.
It is important to recognize that some NPs and PAs acquire exceptional clinical acumen and a high level of expertise and technical proficiency in advanced skills such as emergency response systems, inserting temporary pacemakers, and performing pericardiocentesis, depending on their level of experience and training, state licensure, and institutional privileging. This document does not delineate these highly specialized competencies but rather focuses on the NP and PA competencies that typically apply in most practice settings.
1.2.1 Cardiovascular NP and PA Competencies
The cardiovascular competencies, organized in a topic format, identify the competencies for clinical cardiovascular NPs and PAs, as well as aspects of cardiovascular medicine that exceed core expectations and may be maintained or achieved by some cardiovascular NPs and PAs depending on their background and practice focus (see Table 1). Given the document design, the competencies that define an individual’s practice may overlap with multiple topic areas even for highly specialized practitioners.
The competencies for cardiovascular NPs and PAs are organized using the 6 domains promulgated by Accreditation Council for Graduate Medical Education/American Board of Medical Specialties and endorsed by American Board of Internal Medicine (see Table 2) to align with ACC’s physician-based competencies. Core competencies that pertain to all clinical areas, describing competencies for systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism, are found in Table 3. Tables 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 encompass the medical knowledge and patient care and procedural skill competencies related to the 11 clinical areas identified in Table 1. These competencies are unique to each of the clinical areas identified in Table 1.
18.104.22.168 Distinction Between Competencies Generally Expected of All Cardiovascular NPs and PAs and Those Based on the Focus of Practice
All tables distinguish competencies generally expected of all cardiovascular NPs and PAs (left column) from those generally expected of selected cardiovascular NPs and PAs based on background, specialized knowledge, skills, experience, and practice focus (right column). Therefore, the left column reflects the competencies expected of most NPs and PAs practicing within adult cardiovascular medicine. It is anticipated, however, that not all cardiovascular NPs and PAs will acquire or retain all core left-column competencies, due to differences in training and prolonged time and experience in practice-focused specialization.
1.2.2 Assessment Tools
There are several ways cardiovascular NPs and PAs can maintain competency and expand lifelong learning in practice (ensuring currency with the evolving art and science of the field) and assess their own professional needs for education and performance improvement. Objective evaluation of clinical competence in the practice setting can be challenging and sometimes overlooked. Clinical competencies for NPs and PAs are designed to promote a framework for educational initiatives and practice performance. These competencies may be assessed by the review of one’s individual practice, by review of hospital data, or through performance assessments or practice improvement initiatives. Continuing education for NPs and PAs is important for ensuring high-quality care, fostering practice collaboration, sharing best practices, and providing an opportunity for self-assessment and reflection. For procedural or diagnostic laboratory activities, assessment tools may include registry and/or hospital data, appropriate use criteria, and metrics developed by professional organizations. Patient surveys and multisource (360˚) evaluations in hospital or practice environments can provide information about outcomes, communication skills, and professionalism.
1.2.3 Research and Scholarly Activity
The topic areas in Table 1 define the clinical competencies for practicing cardiovascular NPs and PAs. Scholarly activity and clinical research are also important in lifelong learning and professional competency. All cardiovascular NPs and PAs should have the skills to assess new research findings and appropriately incorporate new diagnostic and treatment modalities in patient care. A scholarly approach to literature review is required to evaluate evidence, address clinical questions, and enhance outcomes. Knowledge should be maintained and enhanced through regular review of journals and other sources of reliable information and through participation in scholarly scientific meetings, continuing professional education activities, and professional congresses. Review and referral of patients for consideration and participation in clinical trials should be considered for both academic and nonacademic clinicians, including cardiologists, NPs, and PAs.
President and Staff
Richard J. Kovacs, MD, FACC, President
Timothy W. Attebery, DSc, MBA, FACHE, Chief Executive Officer
Janice Sibley, MS, Executive Vice President, Education and Publishing
Robyn Snyder, BA, Senior Director, Core Education Division Services and Activities
Dawn R. Phoubandith, MSW, Team Leader, Competencies and Educational Gaps
Kelli C. Bohannon, Associate Director, Member Strategy
Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing
Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—2020 ACC Clinical Competencies for Nurse Practitioners and Physician Assistants in Adult Cardiovascular Medicine
Appendix 2 Peer Reviewer Information—2020 ACC Clinical Competencies for Nurse Practitioners and Physician Assistants in Adult Cardiovascular Medicine
Appendix 3 Abbreviations
ACC = American College of Cardiology
ECG = electrocardiography
NP = nurse practitioner
NSTE-ACS = non–ST-elevation acute coronary syndrome
PA = physician assistant
STEMI = ST-elevation myocardial infarction
↵∗ Former Competency Management Committee member; member during this writing effort.
↵† Former Competency Management Committee co-chair, co-chair during this writing effort.
↵‡ Former Competency Management Committee chair, chair during this writing effort.
Endorsed by the American Academy of Physician Assistants, American Association of Heart Failure Nurses, American Association of Nurse Practitioners, American Heart Association, American Nurses Credentialing Center, Association of Physician Assistants in Cardiology, Heart Rhythm Society, Physician Assistant Education Association, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and The National Organization of Nurse Practitioner Faculties
The American College of Cardiology Lifelong Learning Oversight Committee approved this document in January 2020. The American Association of Heart Failure Nurses, Association of Physician Assistants in Cardiology, Heart Rhythm Society, Preventive Cardiovascular Nurses Association, and Society for Cardiovascular Angiography and Interventions endorsed the document in February 2020. The American Academy of Physician Assistants, American Association of Nurse Practitioners, American Heart Association, Physician Assistant Education Association, and The National Organization of Nurse Practitioner Faculties endorsed the document in March 2020. The American Nurses Credentialing Center endorsed the document in April 2020. For the purpose of transparency, disclosure information for the Lifelong Learning Oversight Committee is available at http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/clinical-document-approval.
The American College of Cardiology requests that this document be cited as follows: Rodgers GP, Linderbaum JA, Pearson DD, Fernandes SM, Housholder-Hughes SD, Mendes LA, Berg NC, Day J, Drajpuch D, Erb B Jr, Farquhar-Snow M, Johnson H, Keegan P, Kindler C, Larsen R, Le VT, Nickolaus MJ, Phillips CM, Ross L, Webb SR, Zado ES. 2020 ACC clinical competencies for nurse practitioners and physician assistants in adult cardiovascular medicine: a report of the ACC Competency Management Committee. J Am Coll Cardiol 2020;75:2483–2517.
Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), American Academy of Physician Assistants (www.aapa.org), American Association of Heart Failure Nurses (www.aahfn.org), American Association of Nurse Practitioners (www.aanp.org), American Heart Association (www.heart.org), Association of Physician Assistants in Cardiology (www.cardiologypa.org), Heart Rhythm Society (www.hrsonline.org), Physician Assistant Education Association (www.paeaonline.org), Preventive Cardiovascular Nurses Association (www.pcna.net), Society for Cardiovascular Angiography and Interventions (www.scai.org), and The National Organization of Nurse Practitioner Faculties (www.nonpf.org). For copies of this document, please contact Elsevier Inc. Reprint Department via fax (212-633-3820) or e-mail ( ).
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- 2020 American College of Cardiology Foundation
- Halperin J.L.,
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- American Association of Nurse Practitioners
- American Nursing Association
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- American Academy of PAs Research Department
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- ACC Competency Management Committee
- Table of Contents
- 1 Introduction
- 2 Clinical Competencies
- President and Staff
- Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—2020 ACC Clinical Competencies for Nurse Practitioners and Physician Assistants in Adult Cardiovascular Medicine
- Appendix 2 Peer Reviewer Information—2020 ACC Clinical Competencies for Nurse Practitioners and Physician Assistants in Adult Cardiovascular Medicine
- Appendix 3 Abbreviations