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DNV GL © 2013 SAFER, SMARTER, GREENER DNV GL © 2013
DNVGL Healthcare Comprehensive Stroke Center Certification Program
2nd Annual Stroke Center Certification Workshop November 6, 2014 Cathie Abrahamsen RN MSN
DNV GL © 2013
Disclosure
Employment
– Chief Standards and Program Development Officer for DNVGL
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DNV GL © 2013 Slide 3 23 December 2014
Integrity at the core
Independent foundation established in 1864 / In the US since 1898 150 year Anniversary 2014 Third Party Evaluation and Assessment with a focus of managing risk as
our core Vision: “Global Impact for Sustainable Future” Purpose: “Safeguarding Life, Property and the Environment” Accreditation Organization with deeming authority approved by CMS
DNV GL © 2013
DNVHC Comprehensive Stroke Center Certification Primary Stroke Center Certification
November 2009 Comprehensive Stroke Center Certification
September 2012
DNV GL © 2013
DNVHC Comprehensive Stroke Center Certification
Basic Premises of the DNV GL Certification Program We are partners with the centers to assure the best health care
possible.
We believe you are the experts in the care you are giving and we are the third eye that will listen, ask questions, discuss and verify.
Certification is not accreditation, but a highly evolved, specialty clinical care within an accredited facility so focus on the expertise is key.
Be thoughtful and reasonable Be inclusive, not exclusive.
Find a reason to say yes. Always keep the patient in mind.
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DNV GL © 2013
DNVHC Comprehensive Stroke Center Certification
Comprehensive Stroke Center Eligibility Criteria Current Hospital Accreditation,
– does NOT have to be DNV accredited – host hospital must be Medicare Certified Hospital – State or
Accredited by one of the approved accreditation organizations with deeming authority.
– does not require non DNV hospitals to be ISO certified if they have a functional equivalent process in place within the host hospital
DNV GL © 2013
DNVHC Comprehensive Stroke Center Certification
Must be able to show compliance with primary as well as Comprehensive Stroke Center standards during the survey process Must be part of a data registry
– If in a hospital system, may participate in the system data if there is comparative data reports
Must be involved in some IRB research
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DNV GL © 2013
Comprehensive Stroke Centers Criteria
Volume Requirements Greater than or equal to 20 SAH patients per year
Greater than or equal to 10 clippings/coilings
Greater than or equal to 25 tPA
Each neurosurgeon should participate in greater than or equal to 10 surgical intervention cases per year.
Lower volume centers can have excellent outcomes
High volume centers are not assured of excellent outcomes
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DNV GL © 2013
Comprehensive Stroke Center Certification Process
Surveys will be planned and announced – 30 days notice
Notice to give an opportunity to have the stroke team leaders present
Survey activity emphasis on stroke services such as: – Data review for trending, analysis and use of data
– Development of protocols based on national guidelines (Brain Attack Coalition, American Heart/ Stroke etc.)
– Capabilities for diagnostic and treatment of stroke patients
– Competence and engagement of care providers
– Timelines for response, turn around for labs and imaging
– Physical rehabilitation evaluation and therapy Initiation
– tPA within specified timeframes
Areas included in the assessment are those involved with stroke (e.g. ED, ICU, Stroke Unit, Interventional and surgical areas), additional areas related to the PSC/CSC will also reviewed.
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Comprehensive Stroke Centers
CSC survey is every year at this time on site
May go with a model of every other year on site survey with the alternate GAP year
Proposal is to look at :
– Previous findings and corrective actions report
– Review of data
– Focus Subject which would be a pre determined focus on one subject for either all of CSCs or the individual focus of the stroke center
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DNV GL © 2013
DNVHC Comprehensive Stroke Center Certification
Surveyor Enhancement Licensed physician or nurse Stroke education every year Add current stroke coordinators as surveyors
–Current working experts –Opportunity to network with other program coordinators –Opportunity for inclusion in review of requirements on an
on-going basis –Potential to see other programs
DNV GL © 2013
DNVHC Comprehensive Stroke Center Certification
Survey is over two days
Starts with an overview from the Stroke center leadership
Both surveyors usually visit the emergency room
Technical advisors tend to focus on the stroke clinical aspects
DNV clinical surveyor focus is on supportive services
– Credentialing
– Competency
– Rehab
– Radiology
• Both will do chart review and quality sessions
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Scope of the CSC Components
Leadership and Management of the Comprehensive Stroke Center Staff (Competency/Qualifications/Evaluation) Staffing Management Policies/Procedures Pre hospital Process Stroke Pathway (Protocol) Emergency Department (Initial Assessment and Treatment) Stroke Unit Visit (ICU or other Respective Unit) Medication Management Quality Management System/Monitoring, Measuring and Analysis Rehabilitative Services Medical Records Physical Environment
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Staff (Competence / Qualifications) Qualifications for those involved with Stroke Care
– Job descriptions
– Licensure, experience, etc.
– Education (specific for care of stroke patients)
– Stroke Team
– Nursing staff not assigned to the Stroke Team need education on accessing the Stroke Team / care of stroke patients
– Orientation (specific regarding CSC, Stroke Team, Stroke Protocols)
Defined the criteria and qualifications required for designation of qualified practitioners, professionals and other personnel as a Stroke Team – Neurologist or Neurosurgeon – Physician with expertise in cerebrovascular disease – Other qualified professionals – Emergency department personnel and emergency medical services – Nursing Staff Radiology Technologists (MRI/CT) – Rehabilitation Therapists Case Manager / Social Worker
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Specific requirements for CSC – Stroke Team
The Stroke Team shall be comprised of personnel that may be employed, contracted or otherwise available in some manner to the CSC to encompass the following areas of expertise: neurologists and neurosurgeons (senior-level resident), board certified or eligible; surgeons
with expertise performing carotid endarterectomy (CEA)
diagnostic radiologists/ rad techs(including MRI and CT technologists)
physicians with expertise in interventional endovascular neuroradiology procedures and techniques
physicians with expertise in critical care or neurointensive care
Emergency department personnel and emergency medical services (EMS)
Nursing staff trained in the care of acute stroke patients
Advanced practice nurses (APNs)
Rehabilitation therapists with expertise in treatment of acute stroke patients
case manager or social worker
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Stroke Protocol
References used to develop the protocol will include those prepared by the Brain Attack Coalition, American Stroke Association, American Heart Association, and others recognized professional organizations for the care of stroke patients Shared this protocol with emergency department practitioners, EMS
providers and ICU and/or Stroke Unit Review/Update (as necessary) at least annually The Stroke Protocol defines: Evaluation and management of the acute stroke patient. Physicians (as a part of the Stroke Team) have knowledge and expertise
in the diagnosis and treatment of cerebrovascular disease. Written documentation with evidence of neurosurgical coverage or
protocol for transfer to an appropriate facility. Ensuring access to neurological expertise when required.
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Specific requirements for CSC
Early implementation of stroke protocol and notification to the Stroke Team upon entry to the ED or prior upon notification from EMS personnel. • Evaluation and management of the acute stroke patient; A log documenting call times, response times, patient
diagnoses, treatments and outcomes will be kept and used for quality improvement projects. The CSC shall have the facilities and appropriate qualified
neurosurgical staff within a minimum of two hours when determined to be immediately needed by the patient. For decision to transfer due to periodic gaps in Neurosurgical or
Endovascular coverage that the CSC will promptly make both referring PSC’s and EMS aware of the situation.
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Diagnostic Tests
Magnetic Resonance Imaging (MRI) and computed tomography (CT) available
– OR referral protocol in place to identify a facility nearby
Brain imaging studies are interpreted by a physician with expertise in reading CT or MRI studies
Documentation indicating that on a 24/7 basis, acute stroke patients have a diagnostic brain image completed within 20 minutes of being ordered and results reported to or reviewed by a member of the stroke team within 45 minutes of it being ordered
Initial lab / imaging tests are availability on site 24/7 and:
– lab tests are reporting in less than 45 minutes from being ordered?
– perform an ECG and chest x-ray within the same time frame as laboratory testing
– Blood Glucose essential
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Specific requirements for CSC - Services
Endovascular Services will be provided for the treatment of cerebrovascular diseases.
– microsurgical clipping and coiling must be available
– ability to perform intracranial angioplasty or IA infusions of vasodilators is recommended. If therapy cannot be provided, protocols for the rapid transfer of patients is required
Surgical interventional services will be available for management of stroke patients.
– neurosurgical expertise must be available 24/7
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Emergency Department
Effective system in place for communicating with inbound Emergency Medical System for activation of the acute stroke team
Emergency Department practitioners clearly demonstrate the recognition, assessment, and management of acute stroke complications
CSC collaborate with ED personnel, emergency physicians and nurses, and stroke professionals to identify capabilities to improve facilitation with EMS responders for triage and transport of acute stroke patients
CSC offer EMS providers the opportunity to participate in education and training programs offered by the PSC
DTN time within 60 min or less for 50% of eligible patients during the first 3 to 4.5 hours of care, including thrombolytic therapy for patients
Indications and contraindications for the use of IV thrombolytic therapy
Consents need to follow policy of the state or hospital
– New wording in standards treat consent as like CPR, standard of care
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Specific requirements for CSC – Rehab Services
Rehabilitation services should be implemented as soon as possible. Mobilization of the stroke survivor and resumption of self-care activities should occur as soon as medically feasible. Both inpatient and outpatient rehabilitation programs can improve outcomes and prevent deterioration.
Stroke rehabilitation shall focus on
– training for maximum recovery,
– prevents and treats comorbid conditions,
– enhance psychosocial coping,
– promote integration into the community,
– prevent recurrent strokes and other vascular events, and
– enhance quality of life.
DNV GL © 2013
DNV Comprehensive Stroke Program Update
Comprehensive Metrics Update Required metrics are 1,2,3,4,5,7,8,9,12,13,15,18,19,23. Metric 18 added for Jan 2015
Will require addition of metric 18, starting Jan 1
– Metric 18 Complication rates for aneurysm coiling and clipping
– Complications will be defined to include death, stroke or bleeds
Metric 12 delineated further and there will now be a 12a and 12b which will be requiring a separation of the documentation of the ICH and SAH severity scores rather than the sum, remove the AVM references and delineate the severity scales as the Hunt and Hess scale or the World Federation of Neurological Surgeons Scale for SAH patients and the ICH score for ICH patients.
23 December 2014 Private and confidential
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DNVGL Stroke Program Top Five Findings for CSC 2014
PC.4 Monitoring of vital signs after tPA PC.6 Defining members of stroke team PC.4 Consents PC.7 Plan of care (Patient education) PC.6 Protocols
• Update issue with EHR/paper
23 December 2014 Private and confidential
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DNV GL © 2013
DNV GL © 2013
SAFER, SMARTER, GREENER
www.dnvaccreditation.com
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Patrick (Pat) Horine, CEO [email protected] 513-388-4888
Cathie Abrahamsen RN MSN CEO [email protected] (847) 359-5231