HFAP Stroke Certification 19 th Annual Stroke Belt Consortium February, 2014 Therese (Tess) Poland Terms Terms Certification Benefits of Certification HFAP Stroke Certification What s Around the Turnpike Policy Implications i 1
Terms Designation is operational & political Attestationt ti is the issuance of a report on subject matter that is the responsibility of another party (with & without validation) Certification involves an onsite audit by an external e organization, a o of the hospitals as performance against established criteria OK? TX SRC Free standing children's MO 4- Levels AR LA SRC? MS TN Stroke Center IN KY AL SRC GA SC 4 Levels 4 Levels FL VA 4- Levels NC 2
ST Level EMS By- Pass Desig Attest & Application Data Task Force Provider Leg AL C P & R Yes Voluntary Yes Yes PHDSPTF TJC? HJR 32 AR Yes Data List Register GA P & R Yes Yes IN C & P No List?Des SRC /w Survey Register/ GWTG PCR PCR AASCTF TJC Ref Bill 326 AHA Task Force SPTF TJC Open TJC HFAP KY P No GWTG KHDSP+Q TJC Ref LA 4 Levels Standards No Yes SRC No Survey GWTG LERN SB59 IC 25-22.5 Enacted Policy LERN+Q TJC Only Supported MS C P & R. Voluntary NA GWTG TFHDSP TJC Only HB 759 SB 2314 NC P & R Yes List PCR JWHDSP+Q All Bill 456 SC 4 Levels Yes GWTG SSCAC+Q TJC/Equiv A62, R81, S588 TN C & P No GWTG TSSCTF+Q TJC Only Bill 4011 VA 4 Levels Yes Des & List CHQI VSSTF+Q TJC DNV Enacted FL TX C & P Standards CP & R Standards Yes No Des & List 2yrs Attest /w Certification LoA?Survey GWTG Yes HDSP RAC Regional Advisory Councils State/ TJC/Equiv TJC/Apply Enacted HB2344 SB1687 Attestation Challenges for self attestation / internal audit: Stroke Coordinator is most likely to complete the attestation documents because they are the holder of information. Familiarity enables cultural bias and reduces objectivity Responses are limited by the respondents knowledge / interpretation of the question / standard Specialty program requires specialty knowledge, if attestation is completed by someone other than the stroke coordinator, information may be limited by the respondents scope 3
Certification Provides Objective assessment Promotes understanding of expectations to customer Builds confidence in hospital regarding compliance with requirements Deficiencies may be deemed critical which may revoke certification Provides accountability Compliance monitoring Corrective action follow-up Sub-audits at various stages in cycle Benefits of Certification Organize hospital delivery structures towards advanced levels of treatment Improves patient outcomes & LOS Improves coordination of care Reduces the burden of long-term costs associated with poor outcomes Potential to improve reimbursement rates Boosts staff morale and reduce turn-over 4
Certification Incentives US Center for Medicare and Medicaid Services: implementation of stroke measures Pay for Participation Pay for Performance Organized stroke care reduces risk: 14% Death 18% Death or institutionalized care 18% Death or dependency Gorelick, P.B. (2012). Primary and Comprehensive Stroke Centers History, Value and Certification Criteria, Journal of Stroke. 15 (2) 78-89. HFAP Stroke Certification Comprehensive Stroke Centers Primary Stroke Centers Stroke Ready Centers 5
What sets HFAP Apart? HFAP clinicians provide bi-weekly teleconferencing with clinical staff to assist with implementation and standards interpretation The organization receives a copy of the complete standards manual, which includes scoring procedure used by surveyors Three-year certification with an mid-cycle review One price inclusive of all costs over the three year period 6
Customers Perspective Surveyor was attentive to every detail. Excellent insight into our challenges. Very positive. It was clear HFAP surveyors wanted our Stroke Program to "shine" and offered helpful suggestions to reach our goals. The surveyors' approach was nonthreatening and collegial, staff who were interviewed felt at ease, it was a great learning experience! Respectful of staff, courteous, friendly. Listen well. Provides helpful suggestions and applauds our hard work and efforts. Customers Perspective As my new role as Stroke Coordinator this was a wonderful experience working with the surveyors. They were very knowledgeable about the stroke process and offered improvements as needed to the stroke program. I do believe that HFAP does force us to continually re-examine our programming g and does improve the quality of stroke care in our facilities/communities. 7
What's Happening Around The Turnpike? Legislative change and impact on hospitals EMS bypass State attestation State Agency Handoff Accreditation Certification Policy Implications Designation through self evaluation / attestation without an on-site validation Sustainability of funding for state attestation Value-Based Purchasing impact on CAHs and small rural hospitals as Potential financial penalties associated with inadequate measure performance 8
Questions Therese Poland (RN, BSN, MSN) Quality and Certification Healthcare Facilities Accreditation Program e: tpoland@hfap.org p: 312-202-8076 www.hfap.org Healthcare Facilities Accreditation Program @HFAPquality References Higashida, R., Alberts, M.J., Alexander, D.A., Crocco, T.J., Demaerschalk, B.M., Derdeyn, C.P., Goldstein, L.B., Jauch, E.C., Mayer, S.A., Meltzer, N.M., Peterson, E.D., Rosenwasser, R.H., Saver, J.L., Schwamm, L., Summers, D., Wechsler, L. and Wood,.P. (2013). Interactions Within Stroke Systems of Care: A Policy Statement From the American Heart Association/American Stroke Association. Stroke, 44:00-00. Simons, R. & Kilpatrick, A. (2002). Assuring Optimal Trauma Care: The Role of the Trauma Center Accreditation, Trauma and Critical Care. 45 (4) 288-295. Gorelick, P.B. (2012). Primary and Comprehensive Stroke Centers History, Value and Certification Criteria, Journal of Stroke. 15 (2) 78-89. Castka, P. (2013). Audit and Certification: What Do Users Expect? Study conducted by the Q21 Research Group, University of Canterbury and Joint Accreditation Systems Australia and New Zealand (JAS-ANZ). Hunter, R.M., Davie, C., Rudd, K., Thompson, A., Walker, H., Thomson, N., Mountford, J., Schwamm, L., Deanfield, J. Thompson, K., Dewan, B., Mistry, M., Quoraishi, S. & Morris, S. (2013). Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model. PLOS ONE, 8 (8) e70420, 1-9. 9