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Preparing for a Successful Stroke Center Certification

Erin Conahan, MSN,RN,ACNS-BC,CNRN,SCRN,PHRNJulie Fussner, BSN,RN,CPHQ,SCRN

Lynn Hundley, MSN,RN,APRN,CNRN,CCNS,ANVP-BCJeanie Luciano, MSN,CNRN,SCRN,CRNP,FAHA

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Disclosures

Erin Conahan- No actual or potential conflict of interest in relation to this presentation.Julie Fussner - No actual or potential conflict of interest in relation to this presentation.Lynn Hundley – Speaker bureau: Medtronic, modest Jeanie Luciano- No actual or potential conflict of interest in relation to this presentation.

Objective

Discuss the components for a successful stroke center certificationResourcesRecent themes with surveysOpen floor for questions/sharing

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Certifying Bodies for Stroke Certification

• Acute Stroke Ready

• Primary Stroke

• Thrombectomy Stroke

• Comprehensive Stroke

• Acute Stroke Ready

• Primary Stroke

• Comprehensive Stroke

• Stroke Ready

• Primary Stroke

• Comprehensive Stroke

Standards

Performance Measures

Practice Guidelines

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DNV GL Resources for Initial and Recertification • Use NIAHO hospital accreditation standards

• Incorporates requirements of the CMS Conditions of Participation for Hospitals (CoPs) and Guidelines of the Brain Attack Coalition and American Stroke Association.

• Stroke Care Certification brochure

• Standards Document includes:• Eligibility

• Surveyor Information Gathering and Investigation

• Program Management

• Quality Management

• Patient Care Services

• Medical and Nursing Staff

• Staffing Management

• Patient Rights

• Medical Records

• Physical Environment

Healthcare Facilities Accreditation Program • Initiated a Primary Stroke Certification program in 2006 using

recommendations from the Brain Attack Coalition as the foundation for its standards.

• Requires hospital accreditation through a CMS deeming authority entity

• Endorses the AHA GWTG tool for patient management and performance measure.

• Stroke Handbook• Certification Process

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Joint Commission Resources for Initial and Recertification • Stroke brochure

• Eligibility

• Key Requirements

• Comparison of certification

• Review Process Guide

• Certification Quick Guides • Planning Checklist

• Documents needed

• Webinars

• DSC Perspective Newsletter

Joint Commission Resources for Initial and Recertification

Standards

• Program Management

• Delivering or Facilitating Care

• Supporting Self Management

• Clinical Information Management

• Performance Management

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Joint Commission Resources for Initial and Recertification

Clinical Practice Guidelines

• Evidence based practice• Incorporate guidelines into tools / protocols/ order sets

Performance Measures

• ASR – NEW: 5 standardized (3 inpatient and 2 outpatient)

• PSC – 8 standardized

• TSC – 16 standardized• CSC – 16 standardized

Joint Commission Resources for Initial and Recertification Review Process Guide

• Organization Review Preparation

• Performance Measures

• Clinical Practice Guidelines• Agendas

• Description / details of each session on site

• Clinical Record Review Tool

• Human Resource Record Review Tool

• Intracycle Evaluation Process

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The SAFER Matrix• Deficiencies placed on matrix according to likelihood of

causing harm to patients, staff, or visitors and according to how widespread the problem is based upon observations

• As risk level increases placement moves from bottom left corner to upper right corner

• All cited deficiencies have a time frame of 60 days for corrective action

• Higher risk deficiencies require listing of leadership/administrator that will support and sustain the actions

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Most Frequently CitedCollected from Joint Commission top 5 and shared survey experiences

Assessments performed as ordered

• Vital signs, neuro checks, post-procedure checks

• Blood pressure• Multiple blood pressure goals in charts

• Titrating vasoactive medication to orders• Matching BP to titration at a moment in time

• Use of PRNs

*Normal Saline Flush after tPA

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Clinical Practice Guidelines

• Based upon most current evidence-based practice

• Demonstrated use in the EMR

• Order sets should reflect guidelines• Demonstrate individualization of order selection

• Allow standardization of care regardless of unit or service

• Staff know how to access

• Evaluated for relevance to target population• ED specific protocols

• Process for reviewing/updating and integrating into practice

Patient education

• Demonstrated throughout patient’s admission

• Individualized risk factor education • Beyond the required 5

• Specific to co-morbidity

• Direction how to incorporate into post-hospital life

• Inclusion of family/caregiver

• Not just nursing!

• CSC: carotid intervention…emergent and elective

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Plan of care based on patient’s assessed needs

• Individualized plan of care

• “Patient stated goals” reflected in EMR

• Resolution of problems

The program initiates, maintains, and makes accessible a medical record for every patient

• Documentation indicates the reason eligible patients did not receive acute stroke intervention

• Consents: completed to your hospital policy• Timing of H&P, pre-op clearance for elective procedures

• Process for obtaining EMS records documenting care provided to the patient during interfacility transport

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The program defines leadership roles

• Medical director• Contract or job description

• Stroke coordinator• Job description or role delineation

• Administrative support• Presence during survey

• Letter of support

• Organizational chart with stroke program personnel identified within

Practitioners are qualified and competent• Annual education hours as defined by the program

• New education• Education should be based on staff role

• NIHSS: trained vs certified

• Orientation: original orientation, orientation to stroke care

• BLS, ACLS, etc as specified in job requirements

• IR/OR staff training- devices (techs & nurses)

• CSC: competencies specific to Neuroscience ICU; physician & APP credentialing & delineation of privileges (DOPs)

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Patient satisfaction

• How are you measuring?• Think beyond HCAHPS

• How are you using this information to make changes in your program?

• Give examples during quality session

• CSC: Discharge phone calls

Website Resources:

• http://www.jointcommission.org

• http://dnvglhealthcare.com/certifications/stroke-certifications

• http://www.hfap.org/AccreditationPrograms/stroke.aspx

AANN: Stroke Listserv