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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