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Section 1: Program and Organization


		1.	What was your ECLS Program’s volume of patients in the following categories for the last 3 complete years?
		2.	Does your ECLS Program have the following critical roles defined? Please check the appropriate box below: (1.2)
		3.	Does your ECLS Program have access to physicians, nurses, and related clinical/non-clinical personnel in necessary service lines & ancillary support? Please indicate below: (1.3) Specialties with Patient Population Designation
		Not Population-Specific
		4.	Does your ECLS Program have access to the following services to support clinical care? Please indicate the services which are available to at your Institution below: (1.4)
		5.	Does your ECLS Program have direct access to necessary backup components of ECMO circuits? Please indicate the backup components that are available to your ECLS program below: (1.5.1)
		6.	If ECLS modes other than ECMO are provided at your institution, does your ECLS Program have direct access to necessary backup components? Please indicate below: (1.5.2)
		7.	Does your ECLS Program have access to an Institution-wide supply chain system for access to equipment, disposables, and necessary items for patient care? (1.5.3)
		8.	Is your Institution (or members of your ECLS staff) a member of one or more regional, national, or international organizations related to ECLS care? Membership in ELSO is not compulsory but is highly recommended. (1.6)
		9.	Does your Institution comply with the following standards as it relates to supporting and regulating the ECLS Program? (1.7)
		10.	Does your ECLS Program collaborate with relevant medical societies, consortia, and other organizations that support safe patient care? (1.8)
		11.	Does your ECLS Program consult and collaborate with peer and/or neighboring ECLS centers regarding individual cases and/or best practices for patient management? (1.9)

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Section 2: ECLS Team Leadership and Composition


		1.	Does your ECLS Program have the role and responsibilities of the ECLS Specialist clearly defined? (2.3)
		Patient Population 2.	Do all ECMO team members go through the same training program, regardless of patient population (Adult/Pediatric/Neonatal)? (2.4.1)
		ECMO-Specific Training (Q3-6) 3.	Do ALL of your ECLS Program staff participate in required didactic, simulation, AND proctored clinical hours to learn and maintain clinical skills specific to ECMO care? (2.4.1)
		A)	Where does your team receive didactic training? (ex: lecture, eLearning, or similar)
		B)	Does your didactic training contain the required learning sections & meet ELSO’s learning objectives for Didactic Training? (2.4.2)
		A)	Where does your team receive simulation training? (ex: wet lab or other structured practical training)
		B)	Does your simulation training contain the required simulations & meet ELSO’s learning objectives for Simulation Training? (2.4.3)
		5.	Do all ECLS Specialists within your Program participate in adequate ECMO Proctored Clinical Hours during onboarding to the ECLS program? (2.4.4
		6.	Do ECLS Specialists within your Program participate in sufficient ECMO clinical care and/or additional simulation training to maintain clinical skills? (2.4.5)
		Neonatal Patients ECMO-Specific Training (Q3-6) 3.	Do ALL of your ECLS Program staff participate in required didactic, simulation, AND proctored clinical hours to learn and maintain clinical skills specific to ECMO care? (2.4.1)
		A) Neonatal Patients	Where does your team receive didactic training? (ex: lecture, eLearning, or similar)
		B) Neonatal Patients	Does your didactic training contain the required learning sections & meet ELSO’s learning objectives for Didactic Training? (2.4.2)
		A) Neonatal Patients	Where does your team receive simulation training? (ex: wet lab or other structured practical training)
		B) Neonatal Patients	Does your simulation training contain the required simulations & meet ELSO’s learning objectives for Simulation Training? (2.4.3)
		5. Neonatal Patients	Do all ECLS Specialists within your Program participate in adequate ECMO Proctored Clinical Hours during onboarding to the ECLS program? (2.4.4)
		6. Neonatal Patients	Do ECLS Specialists within your Program participate in sufficient ECMO clinical care and/or additional simulation training to maintain clinical skills? (2.4.5)
		Pediatric Patients ECMO-Specific Training (Q3-6) 3.	Do ALL of your ECLS Program staff participate in required didactic, simulation, AND proctored clinical hours to learn and maintain clinical skills specific to ECMO care? (2.4.1)
		A) Pediatric Patients	Where does your team receive didactic training? (ex: lecture, eLearning, or similar)
		B) Pediatric Patients	Does your didactic training contain the required learning sections & meet ELSO’s learning objectives for Didactic Training? (2.4.2)
		A) Pediatric Patients	Where does your team receive simulation training? (ex: wet lab or other structured practical training)
		B) Pediatric Patients	Does your simulation training contain the required simulations & meet ELSO’s learning objectives for Simulation Training? (2.4.3)
		5. Pediatric Patients	Do all ECLS Specialists within your Program participate in adequate ECMO Proctored Clinical Hours during onboarding to the ECLS program? (2.4.4)
		6. Pediatric Patients	Do ECLS Specialists within your Program participate in sufficient ECMO clinical care and/or additional simulation training to maintain clinical skills? (2.4.5)
		Adult Patients ECMO-Specific Training (Q3-6) 3.	Do ALL of your ECLS Program staff participate in required didactic, simulation, AND proctored clinical hours to learn and maintain clinical skills specific to ECMO care? (2.4.1)
		A) Adult Patients	Where does your team receive didactic training? (ex: lecture, eLearning, or similar)
		B) Adult Patients	Does your didactic training contain the required learning sections & meet ELSO’s learning objectives for Didactic Training? (2.4.2)
		A) Adult Patients	Where does your team receive simulation training? (ex: wet lab or other structured practical training)
		B) Adult Patients	Does your simulation training contain the required simulations & meet ELSO’s learning objectives for Simulation Training? (2.4.3)
		5. Adult Patients	Do all ECLS Specialists within your Program participate in adequate ECMO Proctored Clinical Hours during onboarding to the ECLS program? (2.4.4)
		6. Adult Patients	Do ECLS Specialists within your Program participate in sufficient ECMO clinical care and/or additional simulation training to maintain clinical skills? (2.4.5)
		Training Specific to ECLS Modes Other Than ECMO 7.	If ECLS modes other than ECMO are provided at your institution, does your ECLS Program provide training on the specific protocols and policies related to each additional ECLS mode offered? (2.5)
		The Proceeding Questions in This Section Apply to the Entire ECLS Program 8.	Does your Institution maintain standardized policies and procedures for granting care privileges at the Institution? (2.6)
		9.	Does your Institution adapt or modify any credentialing policies or procedures to grant ECLS care privileges at the Institution? (2.6.1)
		10.	Does your Institution maintain specific policies or procedures for granting care privileges for each mode of ECLS offered at the Institution? (2.6.2)
		11.	11. Have at least 50% of your ECLS care staff completed (or are in progress of completing) one of the many individual ECLS certifications that exist? (E-AEC, E-NPEC, CES-A, CES-P, etc.) (2.7)
		12.	Does your ECLS Program meet the required minimum staffing ratios? Please indicate so by checking the staffing ratios maintained by your institution below: (2.8.1)
		13.	Does your ECLS Program have a well-defined staffing model for ECLS care including clear roles and responsibilities for each team member? (2.8.1.5)
		14.	Can your Institution and ECLS Program flex ECLS capacity models to reflect current patient volume, projected need, and anticipated volume in times of emergency? (2.9)

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Section 3: Care Protocols


		1.	Does your Institution maintain clearly defined policies related to ECLS care decisions? A full ECLS policy contains the following elements: Cannulation ECLS Management Weaning from ECLS, AND Discontinuing ECLS related to end-of-life decision making. (3.2)
		2.	Does your Institution maintain clearly defined policies related to patient consultation and selection for ECLS care? (3.3)
		3.	Does your Institution maintain clearly defined policies for ECLS cannulation? Please indicate so by checking the following boxes next to the defined policy: (3.4)
		4.	Does your Institution maintain protocols for ECLS patient management that reference consensus documents and/or peer-reviewed research which are subject to periodic review? Please indicate so by checking the following boxes next to the defined policy: (3.5)
		5.	If ECLS modes other than ECMO are provided at your institution, does your ECLS maintain clinical protocols specific to these additional modes of ECLS? Please indicate so by checking the appropriate box below: (3.6)
		6.	Does your ECLS Program perform Extracorporeal Cardiopulmonary Resuscitation (ECPR) and meet the additional requirements necessary to safely provide ECPR care? (3.7)
		7.	Does your ECLS Program perform or participate in any type of in-hospital or out-of-hospital ECLS Transport? Please indicate so by checking the following types of ECLS Transport below: (3.8)
		8.	Has your ECLS Program made any changes to your Institution’s established medical records process to accommodate ECLS care? (3.9)
		9.	Does your Institution maintain an ECLS-specific Infection Control policy? (3.10)
		10.	Has your ECLS Program made any changes to your Institution’s Patient Rights & Responsibilities policy specific to ECLS care? (3.11)
		11.	Does your ECLS Program make resources available for patients, families, and caretakers of ECLS patients including adequate psychological and social work support? (3.12)
		12.	Does your ECLS Program and Institution maintain well-defined procedures and protocols concerning patient follow-up care post-discharge? (3.13)

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Section 4: Case Review & Process Improvement


		1.	Does your ECLS Program participate in continuous improvement efforts including case review, process improvement, and quality initiatives? (4.2)
		2.	Does your Institution have a clearly defined policy and process for reporting near misses, adverse events, and medical errors? (4.3)
		3.	Does your ECLS Program utilize clinical data to inform internal quality improvement initiatives and/or contribute to a registry? (4.4)
		4.	Does your Institution have a clearly defined Whistleblower Policy and are all ECLS team members aware of this policy? (4.6)
		5.	Does your ECLS Program test and implement new technologies in the clinical environment as a part of research programs, device development, or to update existing clinical practice? (4.7)
		6.	If research is a core activity of your Institution, does your ECLS Program make use of shared site research programs to participate in and facilitate research operations? (4.8)

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Section 5: Contribution to an ECLS Registry - ELSO or others


		1.	Does your ECLS Program actively contribute to an ECLS Registry? Note: Participation in the ELSO Registry is not mandatory, but the ECLS Registry must meet the criteria in the Center Certification Standards. (5.1)
		2.	Does your Institution maintain data privacy and protection policies surrounding patient data and participation in registries? (5.2)

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Verification of Standards Compliance

Attest with signature below, the following:

The Applicant and ECLS Program have read and understood the standards as outlined within the ECLS Center Certification Standards document.
The ECLS Program has aligned their clinical ECLS practice with the relevant ELSO guidelines, peer-reviewed research, commonly accepted standards and/or thinking for:
- Organization and development of an ECLS program.
- Provision of ECLS care services.
- Case review and process improvement as they relate to ECLS patient care.
The information contained in this Application and submitted as an attachment is truthful, complete, and provided in the spirit of full disclosure as part of an ECLS Center Certification Process.
Any purposeful dishonesty, misrepresentation, misleading answers, or other forms of mistruth may result in the denial of certification at ELSO’s discretion.

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