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“…the process of applying for disease-specific certification is one
“…the process of applying for disease-specific certification is one
Primary Stroke Center Certification
Primary Stroke Center Certification
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Primary Stroke Center Certification

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1Primary Stroke Center Certification. 16MD University of Virginia Health System
M.J. Hampel The Joint Commission October Timothy F. Kresowik, MD University of Iowa
30, 2007. use these colors. Jerod M. Loeb, PhD The Joint Commission
2“…the process of applying for David Matcher, MD Duke Center for Clinical
disease-specific certification is one Health Policy Research. Rosemary Miller,
important way Bay Medical has moved RN, CCRC University of Cincinnati David
forward with three important goals: Nilasena, MD, MSPH, MS Centers for
creating high-quality clinical programs; Medicare and Medicaid Services Andrea R.
improving its clinical reputation among Redman, PharmD, BCPS Mercer University
prospective patients; and fostering Marilyn N. Rymer, MD Saint Luke’s Hospital
teamwork among physicians, hospital Stroke Center Lee H. Schwamm, MD Harvard
employees, and management.”. Medical School Susan R. Winkler, PharmD,
3Today’s Topics. Certification and BCPS University of Illinois at Chicago
recertification process Standardized set Medical Center Richard Zorowitz, MD
of performance measures What’s happening University of Pennsylvania.
in the Great Lakes region. 17Primary Stroke Center Performance
4Accreditation vs. Certification. Measures. Harmonized Performance Measure
Accreditation Surveys Organization-wide Set Collect monthly data points on all 10
evaluation of care processes and functions measures (effective 1-1-08) Share 4 months
Certification Reviews Product or service worth of data at initial visit Data
specific evaluation of care and outcomes. Submission Annually for now Quarterly once
5Primary Stroke Center Certification. technological interface is complete.
Our first “advanced” certification program 18Primary Stroke Center Performance
Collaborative effort with American Stroke Measures. Harmonized stroke measures
Association Launched December 2003 Over across three initiatives: Joint Commission
400 certified in 43 states Leading states: Standardized Measure Set CDC’s Coverdell
Florida and California (25% of certified Registry ASA’s Get With the Guidelines -
Primary Stroke Centers are in these two Stroke.
states). 19Primary Stroke Center Performance
6Primary Stroke Center Evaluation. Measures. Value of aligning measures:
Quality & Safety of Stroke Care. JC Ability to compare data across all
DSC Standards + BAC Recommendations. ASA registries Ability to determine impact of
or equivalent evidence-based guidelines. certification on stroke care Limits the
Standardized Measure Set. burden of data collection on hospitals.
7Core Program Components. Standards. 20Primary Stroke Center Performance
Guidelines. Measures. Disease-Specific Measures: Resources. Stroke Performance
Care Certification. Measurement Implementation Guide:
8Disease-Specific Care Standards. http://www.jointcommission.org/Certificati
Program Management Delivering or nPrograms/PrimaryStrokeCenters/stroke_pm_e
Facilitating Clinical Care Supporting ition_2.htm Free audio conference.
Self-Management Clinical Information 21Certification Timelines by Month.
Management Performance Improvement and Intracycle Report Due. Submit Application.
Measurement. Onsite Review. Onsite Review. -6 -4 -3 0 1
9 9 12 18 24. Review Scheduled. Reminder
10Brain Attack Coalition letter for Intracycle. Re-application
Recommendations. Hospital and notification (rolling timeframe).
Administrative Support Acute Stroke Team Certification Report Posted. 90 DAY
Written Care Protocols Emergency Medical WINDOW.
Systems Emergency Department Stroke Unit 22The On-Site Evaluation.
Neurosurgical Services Neuroimaging Patient-centered tracer activities
Laboratory Services Outcomes/Quality Engaging practitioners Educative
Improvement Educational Programs. Preliminary report.
11Disease-Specific Care 2008 National 23Challenges of Certification.
Patient Safety Goals. Improve the accuracy Consistent implementation of Clinical
of patient identification Improve the Practice Guidelines Evaluating patient
effectiveness of communication among perception of care quality Performance
caregivers Reduce the risk of health Measurement: Data collection Maintaining
care-associated infections Accurately and the stroke log National Patient Safety
completely reconcile medications across Goals.
the continuum of cares Reduce the risk of 24Recertification. 5-day notification of
patient harm resulting from falls Reduce recertification visits Annual review of
the risk of influenza and pneumococcal Clinical Practice Guidelines 2 years worth
disease in institutionalized older adults of performance improvement data, analysis,
Encourage patients’ active involvement in and action.
their own care as a patient safety 25What’s New? Certification Extranet
strategy. Page: A secure section of our website
12Core Program Components. Standards. designed for individual healthcare
Guidelines. Measures. Disease-Specific organizations Electronic information and
Care Certification. communication vehicle Accessible only with
13Primary Stroke Center Clinical log-in ID and password.
Practice Guidelines. Patient care must be 26
based on guidelines/evidence-based 27
practice Review process includes 28What’s New? Disease-Specific Care
Assessment of implementation of CPGs Certification Manual, 3rd edition
Rationale for selection and modification. available October 2007 2008 National
14Core Program Components. Standards. Patient Safety Goals 2008 Certification
Guidelines. Measures. Disease-Specific Decision Rules All certification outcomes
Care Certification. to be posted on Quality Check (January
15Primary Stroke Center Standardized 2008).
Measure Set. DVT Prophylaxis Discharged on 29Certified Primary Stroke Centers. 4-6.
Antithrombotics Patients with Atrial 20 - 30. 1-3. 7-9. 10-19. >30.
Fibrillation Receiving Anticoagulation 30Certified PSCs in the Great Lakes
Therapy Thrombolytic Therapy Administered Region. Illinois. 19. Indiana. 9.
Antithrombotic Therapy by End of Hospital Michigan. 19. Minnesota. 8. Ohio. 18.
Day Two Discharged on Cholesterol Reducing Wisconsin. 14.
Medication Dysphagia Screening Stroke 31Why Get Certified? Structure clinical
Education Smoking programs of excellence Improve processes
Cessation/Advice/Counseling Assessed for of care Toot your horn to consumers
Rehabilitation. Enhance your bottom line Attract more
16Stroke Performance Measurement patients Leverage certification as a tool
Advisory Panel. Robert J. Adams, MD, MS in contract negotiations Culture change:
Medical College of Georgia Mark Alberts, communication, loyalty, teamwork.
MD Northwestern University Lawrence M. 32Questions? M.J. Hampel Senior
Brass, MD Yale University School of Associate Director Disease-Specific Care
Medicine Pamela W. Duncan, PhD, FAPTA Certification 630.792.5720
University of Florida Judith Hinchey, MD mhampel@jointcommission.org.
New England Medical Center Karen Johnston,
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Primary Stroke Center Certification

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