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Primary Stroke Center CertificationM.J. Hampel The Joint Commission October 30, 2007 use these colors |
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“…the process of applying for disease-specific certification is oneimportant 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.” |
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Today’s TopicsCertification and recertification process Standardized set of performance measures What’s happening in the Great Lakes region |
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Accreditation vsCertification Accreditation Surveys Organization-wide evaluation of care processes and functions Certification Reviews Product or service specific evaluation of care and outcomes |
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Primary Stroke Center CertificationOur 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 EvaluationQuality & Safety of Stroke Care JC DSC Standards + BAC Recommendations ASA or equivalent evidence-based guidelines Standardized Measure Set |
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Core Program ComponentsStandards Guidelines Measures Disease-Specific Care Certification |
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Disease-Specific Care StandardsProgram Management Delivering or Facilitating Clinical Care Supporting Self-Management Clinical Information Management Performance Improvement and Measurement |
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Brain Attack Coalition RecommendationsHospital 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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Disease-Specific Care 2008 National Patient Safety GoalsImprove 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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Core Program ComponentsStandards Guidelines Measures Disease-Specific Care Certification |
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Primary Stroke Center Clinical Practice GuidelinesPatient care must be based on guidelines/evidence-based practice Review process includes Assessment of implementation of CPGs Rationale for selection and modification |
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Core Program ComponentsStandards Guidelines Measures Disease-Specific Care Certification |
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Primary Stroke Center Standardized Measure SetDVT 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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Stroke Performance Measurement Advisory PanelRobert 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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Primary Stroke Center Performance MeasuresHarmonized 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 |
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Primary Stroke Center Performance MeasuresHarmonized stroke measures across three initiatives: Joint Commission Standardized Measure Set CDC’s Coverdell Registry ASA’s Get With the Guidelines - Stroke |
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Primary Stroke Center Performance MeasuresValue 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 |
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Primary Stroke Center Performance Measures: ResourcesStroke Performance Measurement Implementation Guide: http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/stroke_pm_edition_2.htm Free audio conference |
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Certification Timelines by MonthIntracycle 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 |
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The On-Site EvaluationPatient-centered tracer activities Engaging practitioners Educative Preliminary report |
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Challenges of CertificationConsistent implementation of Clinical Practice Guidelines Evaluating patient perception of care quality Performance Measurement: Data collection Maintaining the stroke log National Patient Safety Goals |
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Recertification5-day notification of recertification visits Annual review of Clinical Practice Guidelines 2 years worth of performance improvement data, analysis, and action |
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What’s NewCertification 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 |
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What’s NewDisease-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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Certified Primary Stroke Centers4-6 20 - 30 1-3 7-9 10-19 >30 |
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Certified PSCs in the Great Lakes RegionIllinois 19 Indiana 9 Michigan 19 Minnesota 8 Ohio 18 Wisconsin 14 |
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Why Get CertifiedStructure 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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QuestionsM.J. Hampel Senior Associate Director Disease-Specific Care Certification 630.792.5720 mhampel@jointcommission.org |
«Primary Stroke Center Certification» |
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