The Joint Commission American Heart Association American Stroke Association CERTIFICATION Meets standards for Comprehensive Stroke Center Comprehensive Stroke Center (CSC) Certification Quick Guide Your inside track for applying, on-site process checklists, helpful tips, and more. Copyright 2016 The Joint Commission. 1
2015 Checklist for applying for CSC Current Volumes 20 SAH by aneurysm per year 15 endovascular coiling or surgical clippings per year for aneurysm 25 IV thrombolytics eligible patients per year (50 over 2 years) IV thrombolytics ordered & monitored via telemedicine at another hospital is acceptable IV thrombolytics administered at outside hospital and transferred to CSC site is acceptable Documents to Prepare Prior to the On-site Review: Provide a list of all stroke patients currently admitted o Submit a separate list for each category: (SAH, Ischemic, IV thrombolytics, etc.) o Include the admission date for each patient, include the diagnosis, MD, gender, location, stroke related treatments if possible (IV thrombolytics, IR, surgery) 2
o If you do not have an admitted stroke patient in that category at the time of review, please be prepared to submit a list of closed record patients from that category for the previous 90 days to 4 months for a random selection by the reviewers. Provide a printed copy of job descriptions for the stroke coordinator and medical director. o Assure responsibilities as they relate to the stroke program are clearly defined. Provide 2 copies of the stroke alert process for your facility. o Be prepared to discuss your stroke alert process for emergency and inpatients. Provide copies of the on-call schedules for 3 months for neurosurgeons and IR physicians. Provide copies of all Clinical Practice Guidelines (CPGs) for all types of stroke patients Provide copies of all order sets for all types of stroke patients Provide transfer policies/procedures Provide a copy of a patient information manual for stroke. 3
Key Areas for Review and Discussion Advanced Imaging Available: o Carotid duplex ultrasound o Extracranial ultrasonography o Transcranial Doppler o TEE and TTE available Available on-site 24/7: o Catheter angiography o CT angiography o MR angiography (MRA) o MRI with diffusion NICU Staffing Dedicated Neuro-intensive care beds 24/7 on-site LIP s with neurovascular training (APN, PA, N-Intensivists, Fellows, Residents) Neuro Surgery: Neuro surgery must be able to demonstrate the ability to care for two complex stroke patients at one time with appropriate providers Be prepared to discuss and document your neurosurgical coverage including on call and back up on call MDs and staff for 24/7 coverage. 4
Interventional Radiology: IR must be able to demonstrate the ability to care for two complex stroke patients at one time with appropriate providers. Be prepared to discuss and document your IR coverage including on call and back up on call MD s and staff for 24/7 coverage Stroke Research Active IRB s Currently enrolling patients Opening Conference Assure attendance of representatives from all areas that support the program including: leadership, all departments who provide care to stroke patients, EMS and, if possible, physicians that represent all specialties (i.e. IR, Neurosurgery, NICU, ED and the Program Medical Director.) In your presentation to the reviewer, focus on providing an overview of your stroke program. Please keep your presentation to approximately 45-50 minutes. Areas to consider including: o Mission o Target population (including unusual populations) 5
o Volumes for each type of stroke patient o Emergency Department annual volume o Annual IV thrombolytics volume o Annual clipping/coiling volume o Identify your core stroke team members o Reporting structure for Stroke Program Coordinator and Medical Director o Model of care (ED, ICU, Stroke Unit) o Neurologists and Neurosurgeons who participate in the program o Stroke alert processes o Rapid response team members, if you utilize such a team o Telemedicine as appropriate o Dashboard metric overview for key areas, such as door to needle, door to procedure, and door to CT (remember you have a full data session later in the day to share all data) o Volume for drip and ship patients received from other facilities o Designated stroke inpatient beds o Inpatient services available to stroke patients 6
o EMS system overview, relationship, transfer policies (into stroke facility) o Community education o Total number of stroke patients who are delivered to your organization by car versus EMS o EMS Structure (regionalized, coalition, municipal, volunteer, paid on call) o Your hospital s interface with EMS, including provision of stroke education and input into their protocols o Method in which you provide performance improvement data to EMS o Education requirements for staff in the ED, ICU and Stroke Unit (hours, type) o Multi-disciplinary team planning (rounds, team planning meetings, etc.) o Functions of key committees or teams: stroke team, peer review sessions, data management o Get With the Guidelines - Stroke Performance Awards, if applicable 7
Comprehensive Stroke Center Review Agenda Day One Reviewers arrive at 7:30 a.m. 8:00 a.m. - 9:30 a.m. Opening conference and Orientation to the program 9:30 a.m. - 10:00 a.m. Reviewer Planning Session (Reviewer will need this time to review your documents so please provide privacy) 10:00 a.m. - 12:30 p.m. Patient Tracers (open records and closed records as needed) 12:30 p.m. - 1:00 p.m. Lunch 1:00 p.m. - 3:30 p.m. Continue Patient Tracers 3:30 p.m. - 4:30 p.m. Reviewer Summary/Optional Special Issue Resolution Day Two 8:00 a.m. - 8:30 a.m. Daily briefing and a review of the previous days findings 8:30 a.m. - 10:30 a.m. Continue Patient and staff Tracers 10:30 a.m. - 12:30 p.m. Data Management Tracer 12:30 p.m. - 1:00 p.m. Lunch 8
Comprehensive Stroke Center Review Agenda Day Two (cont d) 1:00 p.m. - 3:00 p.m. Credentialing and Privileging and competency session. (note the Reviewers may each review one area at the same time. Assure your staff are able to cover both areas during this time). 3:00 p.m. - 4:00 p.m. Report Preparation. Special Issue Resolution If needed. 4:00 p.m. - 4:30 p.m. Program Exit Final Report to Your Organization Departments that will be involved: (Physicians, Clinical staff, and Support Staff) ED, NICU, overflow ICU, Step Down units OT/PT/Speech/Pharmacy CT/MRI IR suite EMS Human Resources Medical staff Data abstractors Laboratory Leadership Case Managers Care Coordinators Social Workers Quality/Patient Safety representative 9
Patient Tracers Designate an area out of the arena for the reviewer to interview staff (conference room, class room or break room, etc.) Introduce the Reviewer to the Director/ Manager, Charge RN on the unit so they know they are present. RN should be ready to start the tracer when the Reviewer arrives All staff on the unit should be able to speak to their stroke orientation and ongoing stroke education As available, additional staff should join the group: pharmacy, OT, PT, Speech, physicians, APN, dietary, social workers, case managers, lab, palliative care and others Staff should be prepared to speak to their formal processes for care and multi-disciplinary care practices Patient assessments and re-assessments will be a focus Patient procedures and hand off communication processes are reviewed Records in which patients received IV thrombolytics will be reviewed for timely neuro checks and vital signs Patients who have undergone interventional procedures will be a focused area for review 10
Patients who have undergone neurosurgery will be a focus for review. All staff should be able to speak to performance improvement processes Individualized patient goal setting will be reviewed Behavior modification for risk factors will be reviewed Stroke alert processes will be discussed Patient and caregiver education processes will be discussed Assessing the patient s ability and willingness to learn will be discussed Preparing the patient and caregiver for discharge procedures should be clearly documented and will be discussed Follow-up care coordination when the patient returns to their own community or to your health care organization for care after discharge is explored throughout the tracers. 11
Emergency Department Topics for Discussion: Assure staff are able to address the following items: Be prepared to discuss the EMS structure for your community Discussion regarding neuro coverage for all patients who present to the ED Stroke alert process for EMS calls Radio communications Processes for rapid efficient management of the patient with other internal and external resources (EMS, CT, MRI, lab, etc). Who makes the decision to give IV thrombolytics? (Rapid Response team, neurologist, ED MD) Discussion regarding IV thrombolytics: inclusion and exclusion criteria, weights, mixing, provision, monitoring, consents, calculations, documentation, results of CT, etc. (MD, nursing, pharmacy involvement in the process) On-call schedule accessibility Reviewers will trace the patient from the perspective of the walk in patient and the patient delivered via EMS EMS discussions will take place if EMS personnel are in the ED Use of NIHSS (NIH Stroke Scale) Be prepared to discuss telemedicine practices, as appropriate Education of staff re: stroke, (NIHSS, Dysphagia screens, administration of IV thrombolytics) 12
Use of Clinical Practice Guidelines (CPGs) Use of order sets On-call schedule accessibility for neurologists for IA procedures Accessibility for neurosurgeons Current resources available to staff Processes will be reviewed, including transitions of care (CT, ICU, Stroke Unit, procedures) Post Hospital Care Coordination Follow up phone calls (home/ transfers) Involvement of case managers/social workers Physical Therapy involvement Occupational Therapy involvement Speech Therapy Involvement Review of all information gathered from phone calls/transfers must be utilized to drive a dynamic change in the program. Prepare to speak to this process. Multi-disciplinary teams should be able to discuss intervention and involvement of the teams into the patients plan of care, teaching, goal setting with the patient/family, assuring the goals are individualized to meet the needs of the patient. o Discussion of risk factors and strategies for modifications. o Discussion of support services: dietary, activity, medications, follow up appointments and other self-support requirements. 13
Data Management System Tracer: Powerpoint presentation with ALL data collected as it relates to your stroke program. This is the best method for The Joint Commission to view your data. Method allows for all team members to see and discuss the same data points at the same time. Assure reports have date range and N noted with volumes. Tracer will start with a discussion of how you utilize the data you collect in your hospital to improve your program. Prepare to speak to how you collect, analyze and share data to make improvements in your program on a continuous basis. All clinical staff should be able to speak to performance data and how it is shared with them. The staff who abstract, collect and analyze the data should attend the session. Attendees from across the hospital who are involved in the collection or interpretation of the data should attend the session. Include your patient satisfaction data in this session 14
Present all core measures Data on the administration of IV thrombolytics within 60 minutes should be included Share all data collected for your program (this should indicate how you are interested in improving different aspects of your program) Prepare questions for the reviewer on how to improve your data collection methods, changing your measures, areas to focus on, etc. (ask about Best Practices seen in other Comprehensive Stroke Centers) Credentialing and Privileging and the Peer Review Discussion System Tracer: Peer Review Discussion is included in this session. Plan to have a MD attend (this could be the Stroke Medical Director, CMO, or VPMA) This discussion will include the number and types of patients selected to review via your peer review process. Sampling versus 100 percent of cases. Criteria should be clear and should not just include outliers. 15
The Licensed Independent Practitioners (LIPs) for stroke need to meet on a routine basis to discuss the provision of stroke care (monthly, quarterly, etc.) provided to patients at the health care organization. LIPs include Medical Director, neurologists, neurosurgeons, ED MD, APNs, intensivists, etc. The records must be reviewed by the team as a matter of peer review and not based only on outliers. Cases can be sampled in large volume organizations. Medical Directors should not be reviewing their own cases The process for resolving identified issues should be clear including the peer review process route and the areas identified for further review (process or practitioner issues) Medical Staff: Assure all physicians are credentialed for procedures they complete and all files are up to date. o Provide access to MD licensure, DEA as appropriate, original appointment and re-appointment to the medical staff, MD onboarding / orientation activities, copies of all credentialing files, OPPE/ FPPE files accessible. 16
Peer Review Process: Standardized and established multi-disciplinary LIP peer review team that meets on a routine basis to review the care provided to stroke patients who meet the HCO s established identified patient populations. o Review of care for all stroke patients with ischemic, hemorrhagic, and complex stroke patient care is reviewed. Significant issues identified with care provided to patients or a practitioner should follow the established peer review process and if significant issues identified, these may be referred up to and through established MEC rules/regulations. On-boarding of new MDs will be discussed Discussion regarding how the facility verifies credentials for new practitioners Credentialing and Privileging documents for LIP files: MD and APN license Current DEA Appointment and re-appointment to the medical staff 8 hours of stroke education for all core stroke team members. This can be in any format (paper or computer). If a journal article, please include in APA format with journal, pages, title, hour verification, date, and any other identifying information. 17
Competency System Tracer: Staff identified through tracers (open and closed records) Assure that HR and managers know what is kept in each other s files. Prepare to share education related to stroke for all categories of staff who provide stroke care. o All core stroke team members o RN, technicians, case workers, social workers, pharmacists, OT, PT, speech, and others o For all core stroke team members evidence of 8 hours of stroke education annually. Documents: Provide copies of the following: o job description for all staff identified by the Reviewers whose files will be reviewed, o provide evidence of orientation in the area of stroke for all staff, o provide documentation of ongoing stroke education for all staff in appropriate areas (ICU, ED, stroke unit for NIHSS, dysphagia screening, IV thrombolytics, etc.), copies of current licensure or certification, and a copy of the staff member s most recent performance evaluation. 18
o License / certificate per job description o Copies of all education records related to stroke per organization hour/course requirement The reviewer will review education on a rolling annual basis o Copies of certificates (BLS, ACLS, PALS, etc.) and degrees per job description o Orientation checklist Education for staff who work in specialty areas (ED, ICU, stroke unit) should include documentation of education in NIHSS, dysphagia screening, IV thrombolytics administration per the HCO s requirements. 19
Closing Conference: The organization can select who they want to attend the closing conference You will be able to print the preliminary report once it is published The reviewer will discuss the results of the review The reviewer will share if they identified any best practices while at your organization and indicate how you can submit them to The Joint Commission s Leading Practice Library Tips for our Customers The stoke coordinator should be available to accompany the reviewer for the on-site event. The medical director should be available to respond to reviewer s questions as needed during the onsite event. Be prepared to discuss how you care for two stroke cases at one time (ER/ ICU/IR/ neurosurgery) All staff should be prepared to discuss their stroke education on a yearly basis: o Physicians (ED, ICU, Neuro, IR) o Other staff (ED, ICU, step down units, IR, etc), 20
o OT/PT/Speech/Case Managers, if they are part of the core stroke team Be prepared to speak about how you assure the EMS provider transporting the patient has the level of expertise to assure that the level of care is not decreasing during transport, especially with patients provided IV thrombolytics or with a hemorrhagic stroke Assure staff can speak about how the CSC works with the Acute Stroke Ready Hospital or Primary Stroke Center to coordinate the care of the patient. Be prepared to discuss how the CSC interacts with these entities to assure the transfer of patients is completed in a well coordinated manner. A discussion regarding the health care organization s formulary will be discussed If your hospital has a stroke alert occurring while the reviewer is on-site, please notify the reviewer for an opportunity to observe o All staff should be able to demonstrate to the reviewer how they find CPG s and additional resources in their department (electronically and printed as applicable). o Short term and long term goals must be documented in the MR after clinical rounding. 21
o Documentation in the MR should demonstrate the patient is involved in goal setting. o Patient / care giver education regarding stroke care should be readily visible in every chart. o Assure your CMIP data is up to date o Provide for two teams with scribes and your observers. o Limit the number of staff accompanying the reviewers for your staff s comfort. o Assure a staff member comfortable with the EMR in open and closed records is available during open and closed chart reviews. o Assure all staff who support the stroke program minimally attend the opening and closing conferences 22
Value for you as our Customer: We are committed to assuring that subject matter experts review your program. Our reviewers currently work in the area of stroke in a health care organization. This assures that they are current, contemporary and relevant when reviewing your program. Our reviewers consists of Stroke Neurologists, Advanced Practice Nurses, Clinical Nurse Specialists, and Master s Prepared Stroke Program Coordinators Reviewers will make the review process as transparent as possible No surprises at the end of the review. If we identify an issue, we will point it out to you immediately and provide an opportunity for you to address the situation. We will acknowledge staff for their contributions to the process and the program. Collaboration, engagement and sharing of best practices allows you to continually improve your program and assure it is dynamic to meet the needs of a continually changing health care environment. If we identify leading practices, we will present this information to your team at the closing conference. 23
Improvements in our programs are made based on customer feedback. Please consider the opportunity to complete the Customer Value Assessment and the reviewer evaluation. The Joint Commission is committed to you as our customer. We will review all feedback and, as appropriate, share it with the reviewer. Your feedback also allows us the opportunity to assure that we are being consistent among the team of reviewers when we review your program. Thank you for choosing The Joint Commission for all of your program certification needs. We appreciate the opportunity to work with you to provide high quality patient care to your patients. The Joint Commission: Helping Health Care Organizations Help Patients The Joint Commission Advanced Certification for Comprehensive Stroke Center program was developed in collaboration with the American Heart Association/American Stroke Association. 24
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