M.J. Hampel
The Joint Commission
October 30, 2007
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Primary Stroke Center
Certification
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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.”
Today’s Topics
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Certification and recertification process
Standardized set of performance
measures
What’s happening in the Great Lakes
region
Accreditation vs. Certification
Accreditation Surveys
– Organization-wide evaluation of care
processes and functions
– Product or service specific evaluation
of care and outcomes
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Certification Reviews
Our first “advanced” certification program
Collaborative effort with American Stroke
Association
Launched December 2003
Over 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 Certification
Primary Stroke Center Evaluation
JC DSC Standards + BAC Recommendations
ASA or equivalent
evidence-based guidelines
Standardized Measure Set
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Quality & Safety
of Stroke Care
Core Program Components
Standards
Guidelines
Measures
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Disease-Specific
Care
Certification
Program Management
Delivering or Facilitating Clinical Care
Supporting Self-Management
Clinical Information Management
Performance Improvement and
Measurement
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Disease-Specific Care Standards
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Hospital and Administrative Support
Acute Stroke Team
Written Care Protocols
Emergency Medical Systems
Emergency Department
Stroke Unit
Neurosurgical Services
Neuroimaging
Laboratory Services
Outcomes/Quality Improvement
Educational Programs
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Brain Attack Coalition
Recommendations
•
•
•
•
•
•
•
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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Disease-Specific Care
2008 National Patient Safety Goals
Core Program Components
Standards
Guidelines
Measures
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Disease-Specific
Care
Certification
Primary Stroke Center
Clinical Practice Guidelines
Patient care must be based on
guidelines/evidence-based practice
Review process includes
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– Assessment of implementation of CPGs
– Rationale for selection and modification
Core Program Components
Standards
Guidelines
Measures
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Disease-Specific
Care
Certification
 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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Primary Stroke Center
Standardized Measure Set
Robert J. Adams, MD, MS
Medical College of Georgia
Mark Alberts, MD
Northwestern University
Lawrence M. Brass, MD
Yale University School of Medicine
Pamela W. Duncan, PhD, FAPTA
University of Florida
Judith Hinchey, MD
New England Medical Center
Karen Johnston, MD
University of Virginia Health System
Timothy F. Kresowik, MD
University of Iowa
Jerod M. Loeb, PhD
The Joint Commission
David Matcher, MD
Duke Center for Clinical Health Policy
Research
Rosemary Miller, RN, CCRC
University of Cincinnati
David Nilasena, MD, MSPH, MS
Centers for Medicare and Medicaid
Services
Andrea R. Redman, PharmD, BCPS
Mercer University
Marilyn N. Rymer, MD
Saint Luke’s Hospital Stroke Center
Lee H. Schwamm, MD
Harvard Medical School
Susan R. Winkler, PharmD, BCPS
University of Illinois at Chicago
Medical Center
Richard Zorowitz, MD
University of Pennsylvania
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Stroke Performance Measurement
Advisory Panel
Primary Stroke Center
Performance Measures
– 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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Harmonized Performance Measure Set
Primary Stroke Center
Performance Measures
Harmonized stroke measures across
three initiatives:
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– Joint Commission Standardized Measure
Set
– CDC’s Coverdell Registry
– ASA’s Get With the Guidelines - Stroke
Primary Stroke Center
Performance Measures
Value of aligning measures:
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– Ability to compare data across all registries
– Ability to determine impact of certification
on stroke care
– Limits the burden of data collection on
hospitals
Primary Stroke Center
Performance Measures: Resources
Stroke Performance Measurement
Implementation Guide:
http://www.jointcommission.org/CertificationPr
ograms/PrimaryStrokeCenters/stroke_pm_edit
ion_2.htm
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Free audio conference
Certification Timelines by Month
Submit
Application
Intracycle
Report
Due
Onsite
Review
Onsite
Review
90 DAY WINDOW
-4 -3
0
1
Review
Scheduled
Certification
Report Posted
9
Reminder
letter for
Intracycle
12
18
24
Re-application
notification (rolling
timeframe)
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The On-Site Evaluation
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Patient-centered tracer activities
Engaging practitioners
Educative
Preliminary report
Challenges of Certification
– Data collection
– Maintaining the stroke log
National Patient Safety Goals
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Consistent implementation of Clinical
Practice Guidelines
Evaluating patient perception of care
quality
Performance Measurement:
Recertification
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5-day notification of recertification visits
Annual review of Clinical Practice
Guidelines
2 years worth of performance
improvement data, analysis, and action
What’s New?
Certification Extranet Page:
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– 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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Disease-Specific Care Certification
Manual, 3rd edition available October
2007
2008 National Patient Safety Goals
2008 Certification Decision Rules
All certification outcomes to be posted
on Quality Check (January 2008)
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What’s New?
1-3
4-6
7-9
10-19
20 - 30
>30
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Certified Primary Stroke Centers
Certified PSCs in the Great Lakes
Region
Illinois
19
Indiana
9
Minnesota
19
8
Ohio
18
Wisconsin
14
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Michigan
Structure clinical programs of excellence
Improve processes of care
Toot your horn to consumers
Enhance your bottom line
– Attract more patients
– Leverage certification as a tool in
contract negotiations
Culture change: communication, loyalty,
teamwork
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Why Get Certified?
Questions?
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M.J. Hampel
Senior Associate Director
Disease-Specific Care Certification
630.792.5720
mhampel@jointcommission.org