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Primary Stroke Center Certification
Primary Stroke Center Certification
the process of applying for disease-specific certification is one
the process of applying for disease-specific certification is one
Todays Topics
Todays Topics
Accreditation vs
Accreditation vs
Primary Stroke Center Certification
Primary Stroke Center Certification
Primary Stroke Center Evaluation
Primary Stroke Center Evaluation
Core Program Components
Core Program Components
Disease-Specific Care Standards
Disease-Specific Care Standards
Primary Stroke Center Certification
Primary Stroke Center Certification
Brain Attack Coalition Recommendations
Brain Attack Coalition Recommendations
Disease-Specific Care 2008 National Patient Safety Goals
Disease-Specific Care 2008 National Patient Safety Goals
Core Program Components
Core Program Components
Primary Stroke Center Clinical Practice Guidelines
Primary Stroke Center Clinical Practice Guidelines
Core Program Components
Core Program Components
Primary Stroke Center Standardized Measure Set
Primary Stroke Center Standardized Measure Set
Stroke Performance Measurement Advisory Panel
Stroke Performance Measurement Advisory Panel
Primary Stroke Center Performance Measures
Primary Stroke Center Performance Measures
Primary Stroke Center Performance Measures
Primary Stroke Center Performance Measures
Primary Stroke Center Performance Measures
Primary Stroke Center Performance Measures
Primary Stroke Center Performance Measures: Resources
Primary Stroke Center Performance Measures: Resources
Certification Timelines by Month
Certification Timelines by Month
The On-Site Evaluation
The On-Site Evaluation
Challenges of Certification
Challenges of Certification
Recertification
Recertification
Whats New
Whats New
Primary Stroke Center Certification
Primary Stroke Center Certification
Primary Stroke Center Certification
Primary Stroke Center Certification
Whats New
Whats New
Certified Primary Stroke Centers
Certified Primary Stroke Centers
Certified PSCs in the Great Lakes Region
Certified PSCs in the Great Lakes Region
Why Get Certified
Why Get Certified
Questions
Questions

: Primary Stroke Center Certification. : Onoma LLC. : Primary Stroke Center Certification.ppt. zip-: 1349 .

Primary Stroke Center Certification

Primary Stroke Center Certification.ppt
1 Primary Stroke Center Certification

Primary Stroke Center Certification

M.J. Hampel The Joint Commission October 30, 2007

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2 the process of applying for disease-specific certification is one

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.

3 Todays Topics

Todays Topics

Certification and recertification process Standardized set of performance measures Whats happening in the Great Lakes region

4 Accreditation vs

Accreditation vs

Certification

Accreditation Surveys Organization-wide evaluation of care processes and functions Certification Reviews Product or service specific evaluation of care and outcomes

5 Primary Stroke Center Certification

Primary Stroke Center Certification

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)

6 Primary Stroke Center Evaluation

Primary Stroke Center Evaluation

Quality & Safety of Stroke Care

JC DSC Standards + BAC Recommendations

ASA or equivalent evidence-based guidelines

Standardized Measure Set

7 Core Program Components

Core Program Components

Standards

Guidelines

Measures

Disease-Specific Care Certification

8 Disease-Specific Care Standards

Disease-Specific Care Standards

Program Management Delivering or Facilitating Clinical Care Supporting Self-Management Clinical Information Management Performance Improvement and Measurement

9 Primary Stroke Center Certification
10 Brain Attack Coalition Recommendations

Brain Attack Coalition Recommendations

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

11 Disease-Specific Care 2008 National Patient Safety Goals

Disease-Specific Care 2008 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.

12 Core Program Components

Core Program Components

Standards

Guidelines

Measures

Disease-Specific Care Certification

13 Primary Stroke Center Clinical Practice Guidelines

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

14 Core Program Components

Core Program Components

Standards

Guidelines

Measures

Disease-Specific Care Certification

15 Primary Stroke Center Standardized Measure Set

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

16 Stroke Performance Measurement Advisory Panel

Stroke Performance Measurement Advisory Panel

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 Lukes 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

17 Primary Stroke Center Performance Measures

Primary Stroke Center Performance 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

18 Primary Stroke Center Performance Measures

Primary Stroke Center Performance Measures

Harmonized stroke measures across three initiatives: Joint Commission Standardized Measure Set CDCs Coverdell Registry ASAs Get With the Guidelines - Stroke

19 Primary Stroke Center Performance Measures

Primary Stroke Center Performance 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

20 Primary Stroke Center Performance Measures: Resources

Primary Stroke Center Performance Measures: Resources

Stroke Performance Measurement Implementation Guide: http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/stroke_pm_edition_2.htm Free audio conference

21 Certification Timelines by Month

Certification Timelines by Month

Intracycle Report Due

Submit Application

Onsite Review

Onsite Review

-6 -4 -3 0 1 9 12 18 24

Review Scheduled

Reminder letter for Intracycle

Re-application notification (rolling timeframe)

Certification Report Posted

90 DAY WINDOW

22 The On-Site Evaluation

The On-Site Evaluation

Patient-centered tracer activities Engaging practitioners Educative Preliminary report

23 Challenges of Certification

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

24 Recertification

Recertification

5-day notification of recertification visits Annual review of Clinical Practice Guidelines 2 years worth of performance improvement data, analysis, and action

25 Whats New

Whats 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

26 Primary Stroke Center Certification
27 Primary Stroke Center Certification
28 Whats New

Whats New

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)

29 Certified Primary Stroke Centers

Certified Primary Stroke Centers

4-6

20 - 30

1-3

7-9

10-19

>30

30 Certified PSCs in the Great Lakes Region

Certified PSCs in the Great Lakes Region

Illinois

19

Indiana

9

Michigan

19

Minnesota

8

Ohio

18

Wisconsin

14

31 Why Get Certified

Why Get Certified

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

32 Questions

Questions

M.J. Hampel Senior Associate Director Disease-Specific Care Certification 630.792.5720 mhampel@jointcommission.org

Primary Stroke Center Certification
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