1. © Copyright, The Joint Commission Primary Stroke Center Certification M.J. Hampel The Joint Commission October 30, 2007 use these colors

2. GLRSN - 2 © Copyright, The Joint Commission “…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. GLRSN - 3 © Copyright, The Joint Commission Today’s Topics  Certification and recertification process  Standardized set of performance measures  What’s happening in the Great Lakes region

4. GLRSN - 4 © Copyright, The Joint Commission 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. GLRSN - 5 © Copyright, The Joint Commission 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. GLRSN - 6 © Copyright, The Joint Commission Primary Stroke Center Evaluation Quality & Safety of Stroke Care JC DSC Standards + BAC Recommendations Standardized Measure SetASA or equivalent evidence-based guidelines

7. GLRSN - 7 © Copyright, The Joint Commission Core Program Components Disease-Specific Care Certification Guidelines Standards Measures

8. GLRSN - 8 © Copyright, The Joint Commission Disease-Specific Care Standards  Program Management  Delivering or Facilitating Clinical Care  Supporting Self-Management  Clinical Information Management  Performance Improvement and Measurement

9. GLRSN - 9 © Copyright, The Joint Commission

10. GLRSN - 10 © Copyright, The Joint Commission 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. GLRSN - 11 © Copyright, The Joint Commission 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. GLRSN - 12 © Copyright, The Joint Commission Core Program Components Disease-Specific Care Certification Guidelines Standards Measures

13. GLRSN - 13 © Copyright, The Joint Commission 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. GLRSN - 14 © Copyright, The Joint Commission Core Program Components Disease-Specific Care Certification Guidelines Standards Measures

15. GLRSN - 15 © Copyright, The Joint Commission 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. GLRSN - 16 © Copyright, The Joint Commission 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 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

17. GLRSN - 17 © Copyright, The Joint Commission 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. GLRSN - 18 © Copyright, The Joint Commission Primary Stroke Center Performance Measures  Harmonized stroke measures across three initiatives: –Joint Commission Standardized Measure Set –CDC’s Coverdell Registry –ASA’s Get With the Guidelines - Stroke

19. GLRSN - 19 © Copyright, The Joint Commission 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. GLRSN - 20 © Copyright, The Joint Commission Primary Stroke Center Performance Measures: Resources  Stroke Performance Measurement Implementation Guide: http://www.jointcommission.org/CertificationPr ograms/PrimaryStrokeCenters/stroke_pm_edit ion_2.htm  Free audio conference

21. GLRSN - 21 © Copyright, The Joint Commission Certification Timelines by Month -6 -4 -3 0 1 9 12 18 24 Submit Application Review Scheduled Onsite Review Onsite Review Certification Report Posted Reminder letter for Intracycle Intracycle Report Due 90 DAY WINDOW Re-application notification (rolling timeframe)

22. GLRSN - 22 © Copyright, The Joint Commission The On-Site Evaluation  Patient-centered tracer activities  Engaging practitioners  Educative  Preliminary report

23. GLRSN - 23 © Copyright, The Joint Commission 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. GLRSN - 24 © Copyright, The Joint Commission Recertification  5-day notification of recertification visits  Annual review of Clinical Practice Guidelines  2 years worth of performance improvement data, analysis, and action

25. GLRSN - 25 © Copyright, The Joint Commission What’s 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. GLRSN - 26 © Copyright, The Joint Commission

27. GLRSN - 27 © Copyright, The Joint Commission

28. GLRSN - 28 © Copyright, The Joint Commission What’s New?  Disease-Specific Care Certification Manual, 3 rd 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. GLRSN - 29 © Copyright, The Joint Commission Certified Primary Stroke Centers 1-3 4-6 7-910-19>30 20 - 30

30. GLRSN - 30 © Copyright, The Joint Commission Certified PSCs in the Great Lakes Region Illinois19 Indiana 9 Michigan19 Minnesota 8 Ohio18 Wisconsin14

31. GLRSN - 31 © Copyright, The Joint Commission 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. GLRSN - 32 © Copyright, The Joint Commission Questions ?  M.J. Hampel Senior Associate Director Disease-Specific Care Certification 630.792.5720 mhampel@jointcommission.org