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Primary Stroke Center Certification

M.J. Hampel

The Joint Commission

October 30, 2007

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“…the process of applying for disease-specific certification is one important way Bay Medical has moved forward with three important goals: creating high-quality clinical programs; improving its clinical reputation among prospective patients; and fostering teamwork among physicians, hospital employees, and management.”

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Today’s Topics

Certification and recertification processStandardized set of performance

measuresWhat’s happening in the Great Lakes

region

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Accreditation vs. Certification

Accreditation Surveys– Organization-wide evaluation of care

processes and functions

Certification Reviews– Product or service specific evaluation

of care and outcomes

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Primary Stroke Center Certification

Our first “advanced” certification programCollaborative effort with American Stroke

Association Launched December 2003Over 400 certified in 43 states Leading states: Florida and California

(25% of certified Primary Stroke Centers are in these two states)

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Primary Stroke Center Evaluation

Quality & Safety of Stroke Care

JC DSC Standards + BAC Recommendations

Standardized Measure SetASA or equivalent evidence-based guidelines

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Core Program Components

Disease-SpecificCare

Certification

Guidelines

Standards

Measures

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Disease-Specific Care Standards

Program ManagementDelivering or Facilitating Clinical CareSupporting Self-ManagementClinical Information ManagementPerformance Improvement and

Measurement

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Brain Attack Coalition Recommendations

Hospital and Administrative SupportAcute Stroke TeamWritten Care ProtocolsEmergency Medical SystemsEmergency DepartmentStroke UnitNeurosurgical ServicesNeuroimaging Laboratory ServicesOutcomes/Quality ImprovementEducational Programs

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Disease-Specific Care2008 National Patient Safety Goals

• Improve the accuracy of patient identification• Improve the effectiveness of communication among

caregivers• Reduce the risk of health care-associated infections• Accurately and completely reconcile medications across

the continuum of cares• Reduce the risk of patient harm resulting from falls• Reduce the risk of influenza and pneumococcal disease

in institutionalized older adults• Encourage patients’ active involvement in their own care

as a patient safety strategy.

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Core Program Components

Disease-SpecificCare

Certification

Guidelines

Standards

Measures

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Primary Stroke Center Clinical Practice Guidelines

Patient care must be based on guidelines/evidence-based practice

Review process includes– Assessment of implementation of CPGs– Rationale for selection and modification

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Core Program Components

Disease-SpecificCare

Certification

Guidelines

Standards

Measures

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Primary Stroke Center Standardized Measure Set

DVT Prophylaxis Discharged on Antithrombotics Patients with Atrial Fibrillation Receiving

Anticoagulation Therapy Thrombolytic Therapy Administered Antithrombotic Therapy by End of Hospital Day

Two Discharged on Cholesterol Reducing Medication Dysphagia Screening Stroke Education Smoking Cessation/Advice/Counseling Assessed for Rehabilitation

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Stroke Performance Measurement Advisory Panel

Robert J. Adams, MD, MS Medical College of GeorgiaMark Alberts, MD

Northwestern University Lawrence M. Brass, MD Yale University School of MedicinePamela W. Duncan, PhD, FAPTA University of FloridaJudith Hinchey, MD New England Medical CenterKaren Johnston, MD University of Virginia Health SystemTimothy F. Kresowik, MD University of IowaJerod M. Loeb, PhD The Joint CommissionDavid Matcher, MD Duke Center for Clinical Health Policy Research

Rosemary Miller, RN, CCRC University of CincinnatiDavid Nilasena, MD, MSPH, MS Centers for Medicare and Medicaid Services Andrea R. Redman, PharmD, BCPS Mercer UniversityMarilyn N. Rymer, MD Saint Luke’s Hospital Stroke CenterLee H. Schwamm, MD Harvard Medical SchoolSusan R. Winkler, PharmD, BCPS University of Illinois at Chicago Medical CenterRichard Zorowitz, MD University of Pennsylvania

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Primary Stroke CenterPerformance Measures

Harmonized Performance Measure Set– Collect monthly data points on all 10

measures (effective 1-1-08)– Share 4 months worth of data at initial visit– Data Submission

–Annually for now–Quarterly once technological interface is

complete

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Primary Stroke CenterPerformance Measures

Harmonized stroke measures across three initiatives:– Joint Commission Standardized Measure

Set– CDC’s Coverdell Registry– ASA’s Get With the Guidelines - Stroke

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Primary Stroke CenterPerformance Measures

Value of aligning measures:– Ability to compare data across all registries– Ability to determine impact of certification

on stroke care– Limits the burden of data collection on

hospitals

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Primary Stroke CenterPerformance Measures: Resources

Stroke Performance Measurement Implementation Guide:

http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/stroke_pm_edition_2.htm

Free audio conference

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Certification Timelines by Month

-6 -4 -3 0 1 9 12 18 24

Submit Application

Review Scheduled

Onsite Review

Onsite Review

Certification Report Posted

Reminder letter for

Intracycle

Intracycle Report

Due90 DAY WINDOW

Re-application notification (rolling timeframe)

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The On-Site Evaluation

Patient-centered tracer activitiesEngaging practitionersEducativePreliminary report

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Challenges of Certification

Consistent implementation of Clinical Practice Guidelines

Evaluating patient perception of care quality

Performance Measurement:– Data collection– Maintaining the stroke log

National Patient Safety Goals

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Recertification

5-day notification of recertification visitsAnnual review of Clinical Practice

Guidelines2 years worth of performance

improvement data, analysis, and action

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What’s New?

Certification Extranet Page: – A secure section of our website designed

for individual healthcare organizations– Electronic information and

communication vehicle – Accessible only with log-in ID and

password

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What’s New?

Disease-Specific Care Certification Manual, 3rd edition available October 2007

2008 National Patient Safety Goals2008 Certification Decision RulesAll certification outcomes to be posted

on Quality Check (January 2008)

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Certified Primary Stroke Centers

1-3 4-6 7-9 10-19 >3020 - 30

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Certified PSCs in the Great Lakes Region

Illinois 19

Indiana 9

Michigan 19

Minnesota 8

Ohio 18

Wisconsin 14

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Why Get Certified?Structure clinical programs of excellenceImprove processes of careToot your horn to consumersEnhance your bottom line

– Attract more patients– Leverage certification as a tool in contract

negotiationsCulture change: communication, loyalty,

teamwork

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Questions?

M.J. Hampel

Senior Associate Director

Disease-Specific Care Certification

630.792.5720

mhampel@jointcommission.org