Acute Stroke Ready Hospital Certification Program

Size: px
Start display at page:

Download "Acute Stroke Ready Hospital Certification Program"

Transcription

1 Ready-or-Not? Acute Stroke Ready Here We Come! Acute Stroke Ready Hospital Certification Program Kenny Barajas DNP, RN, CEN Disease Specific Care Reviewer-The Joint Commission April 28, 2017

2 Presenter Disclosure Statement ASRH, PSC and CSC Reviewer for The Joint Commission No Financial Disclosure

3 Mission The mission of The Joint Commission is to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

4 Objectives Understand the rationale for developing an acute stroke ready (ASRH) certification for the disease-specific care program Describe key features of the ASRH standards that might fit your organization Build a case for supporting this certification at your institution Lead the charge for incorporating the ASRH team with your collaborating PSC or CSC

5 History of Acute Stroke-Ready Hospitals (ASRH) On July 1, 2015, The Joint Commission in collaboration with the American Heart Association/American Stroke Association developed the Disease Specific Care Advanced Certification program for Acute Stroke Ready Hospitals (ASRH). Over the past ten years in the United States, using stroke centers to provide care for patients with an acute stroke has become a more frequent practice.

6 History of Acute Stroke-Ready Hospitals (ASRH) The Joint Commission provided two levels of stroke center certification primary stroke and comprehensive stroke. The literature indicated that many patients who have an acute stroke live in areas without ready access to a primary or comprehensive stroke center. In fact, at least 50% of the population in the United States lives more than 60 minutes away from a primary stroke center.

7 History of Acute Stroke-Ready Hospitals (ASRH) It is estimated that rural facilities have the capability to give t-pa, complete a CT scan and have Neuro expertise (maybe telemedicine) Less than 5% of patients receive t-pa Based on the literature it was identified that if a patient is greater than minutes away from PSC/CSC patients should go to the closest ASRH

8 History of Acute Stroke-Ready Hospitals (ASRH) Designed for the acute care and critical access hospital Should be rural and less than 100 beds No designated stroke beds Transfer agreements Telemedicine- how do you assess their competency? t-pa on formulary

9 Facts Acute Stroke Ready- 26 Primary Stroke Centers 1107 Comprehensive Stroke Centers 123

10 Disease-Specific Care Programs for Stroke

11 Why Acute Stroke Ready? The history of stroke center certification Serve the need of small and/or rural communities Suitable for small facilities to include free standing ED s Getting patients to the nearest stroke-ready facility in a timely manner Limited staffing and resources Capitalizing on EMS expertise and collaborative with PSCs and CSCs

12 Requirements Assessed at Application A relationship with local emergency management systems (EMS) that encourages training in field assessment tools and communication with the hospital prior to bringing a patient with a stroke to the emergency department Stroke protocols along with an acute stroke team, in order to expedite the assessment and treatment of a patient presenting with acute stroke symptoms

13 Requirements Assessed at Application The ability to perform diagnostic imaging and laboratory tests 24 hours a day, 7 days a week with results within 45 minutes of testing. Access to stroke expertise 24 hours a day, 7 days a week (in person or via telemedicine) and transfer agreements with facilities that provide primary or comprehensive stroke services. The ability to administer intravenous thrombolytics, if needed, prior to transferring the patient to a facility that provides primary or comprehensive stroke services.

14 Resources

15 Resources

16 Resources

17 Clinical Practice Guidelines Purpose: To describe appropriate care based on the best available scientific evidence and broad consensus; To reduce inappropriate variation in practice Where to locate Clinical Practice Guidelines:

18 ASRH Review Schedule 1 Reviewer Opening session Planning session Tracers Lunch Data Management Competency Credentialing and Privileges Issue resolution and report preparation 1630 Closing Note times are flexible based upon the necessary time to complete activities

19 Preparing for Your Site Visit Request assistance from your accreditation/quality department Utilize your resources Mirror tracer experience Increases staff comfort level in presenting patient case Inter-professional team discussion Individual role and communication as a team

20 Checklist for Day of Review List of all patients that are and were treated for a stroke (inpatients, hemorrhagic stroke, ischemic stroke, TIA, IV thrombolytics) currently and in the past 4-12 months. - List should include primary diagnosis, presentation date, transfer disposition, location in your facility, patient age, gender and ethnic origin Letter of support, charter or line item on a budget to demonstrate leadership support of the program. A copy of the stroke program s mission and scope of services. List of core stroke team members and their disciplines, roles, responsibilities.

21 Checklist for Day of Review Job description for Medical Director. Document listing ED staff who participated in stroke education in the past year. List of ED practitioners who are educated in the Acute Stroke Ready Hospital s stroke protocols. A copy of your stroke alert process for inpatients and outpatients (ED). Order sets and Clinical Practice Guidelines (CPG s). A copy of the patient education binder, pamphlet, folder, etc.

22 Key Focus Areas for Review Emergency Department EMS CT/MRI based on your model of care Pharmacy Laboratory Nursing staff Physical Therapy Occupational Therapy Speech Therapy Palliative Care/Hospice Case Managers Social Workers Data Collection Abstractors Medical Staff/Office Staff Practitioners including Stroke Medical Director and or CMO/VPMA Educators Unit Managers Human Resources Additional staff: leadership, regulatory, quality improvement staff, volunteers, dietary

23 Opening Session Highlights Attendance: Representatives from all areas that support the program All departments who provide care to stroke patients, EMS Stroke Medical Director and Stroke Coordinator Areas to consider including: Mission Target population (including unusual populations) Volumes for each type of stroke patient Emergency Department annual volume Annual IV thrombolytics volume Identify your core stroke team members Reporting structure for Medical Director Model of care in ED Neurologists who participate via telemedicine Stroke alert processes Rapid response team members, if you utilize such a team Telemedicine 60 minutes

24 Opening Session Highlights Dashboard metric overview for key areas Door to needle time, practitioner response time, number of times stroke team activated (remember you have a full data session later in the day to share all data) Volume for drip and ship patients transferred to other facilities Beds utilized for stroke patients EMS system overview, relationship, transfer policies out of stroke facility Total number of stroke patients who are delivered to your organization by car versus EMS EMS Structure (regionalized, coalition, municipal, volunteer, paid on call) Your hospital s interface with EMS, including provision of stroke education and input into their protocols Method in which you provide performance improvement data to EMS Education requirements for staff in the ED (hours, type) Multi-disciplinary team planning (rounds, team planning meetings, etc.) Functions of key committees or teams: stroke team, peer review sessions, data management Get With the Guidelines - Stroke Performance Awards, if applicable

25 Individual Tracers The RN assigned to the patient and someone who can navigate the EMR should be ready to start the tracer when the reviewer arrives All staff should be able to speak to their stroke orientation and on-going stroke education Staff should be prepared to speak to their formal processes for care and multi-disciplinary care practices Assessments and re-assessments will be a focus Patient procedures and hand off communication are reviewed Patients provided IV thrombolytics (neuro checks etc. will be reviewed for compliance with the facilities protocols.)

26 Indivudual Tracers All staff should be able to speak to: Performance improvement processes Individualized patient goal setting Behavior modification for risk factors Stroke alert process Patient and caregiver education Assessing the patient s ability and willingness to learn Preparing the patient and caregiver for discharge Follow-up care coordination when the patient returns to their own community or to your health care organization for care after discharge

27 Emergency Department Topics Discussion from the perspective of the walk in patient and the patient delivered via EMS Use of NIHSS (NIH Stroke Scale) Telemedicine practices, as appropriate Decision for IV thrombolytics (rapid response team/acute stroke team, neurologist, ED MD) Inclusion and exclusion criteria for IV thrombolytics IV thrombolytics: weights, mixing, provision, double checks, documentation

28 Emergency Department Topics Discussion regarding the administration of IV thrombolytics (including risks and benefits) as well as other treatment options with the patient, family/significant others Staff education re: stroke, (NIHSS, Dysphagia screens, administration of IV thrombolytics) Preparation for transfer of patient Use of Clinical Practice Guidelines (CPGs) Use of order sets Accessibility of neurology expertise Current resources available to staff

29 Emergency Department Topics The reviewer will speak to: Security Registration Nursing ED providers Pharmacy Lab CT tech Radiologist

30 Emergency Department Topics Transitions of care (CT, ICU, and inpatient beds) EMS provider transporting the patient has the level of expertise to assure that the level of care is not decreasing during transport, especially with patients provided IV thrombolytics or with a hemorrhagic stroke Assure staff can speak about how the ASRH works with the Primary Stroke Center or Comprehensive Stroke Center to coordinate the care of the patient Discuss how the ASRH interacts with these entities to assure the transfer of patients is completed in a well coordinated manner A discussion regarding the health care organization s formulary If your hospital has a stroke alert occurring while the reviewer is on-site, please notify the reviewer for an opportunity to observe

31 Data Session Powerpoint presentation with ALL data collected as it relates to your stroke program This is the best method for The Joint Commission to view your data Method allows for all team members to see and discuss the same data points at the same time Assure reports have date range and n noted with volumes Tracer will start with a discussion of how you utilize the data you collect in your hospital to improve your program

32 Data Session Prepare to speak to how you collect, analyze and share data to make improvements in your program on a continuous basis Attendees from across the hospital who are involved in the collection or interpretation of the data should attend the session Include your patient satisfaction data in this session Data on the administration of IV thrombolytics within 60 minutes should be included Share all data collected for your program (this should indicate how you are interested in improving different aspects of your program) Prepare questions for the reviewer on how to improve your data collection methods, changing your measures, areas to focus on, etc. (ask about Best Practices seen in other Acute Stroke Ready Hospitals)

33 Credentialing and Privileges- Peer Review Plan to have a MD attend (this could be the Stroke Medical Director, CMO, or VPMA) This discussion will include the number and types of patients selected to review via your peer review process Sampling versus 100 percent of cases Criteria should be clear and should not just include outliers.

34 Credentialing and Privileges The Licensed Independent Practitioners (LIPs) for stroke need to meet on a routine basis to discuss the provision of stroke care (monthly, quarterly, etc.) provided to patients at the health care organization LIPs include Medical Director, neurologists, ED MD, APNs, intensivists, PAs, etc Medical Directors should not be reviewing their own cases The process for resolving identified issues should be clear including the peer review process route and the areas identified for further review (process or practitioner issues) On-boarding of new MDs will be discussed

35 Credentialing and Privileges Discussion regarding how the facility verifies credentials for new practitioners Credentialing and Privileging documents for LIP files: MD, APN and PA Current DEA Appointment and re-appointment to the medical staff 4 hours of stroke education for all core stroke team members If a journal article, please include in APA format with journal, pages, title, hour verification, date, and any other identifying information. OPPE and FPPE Credentialing and Privileging documents for all LIPs All LIPs should be credentialed and privileged for all procedures they perform

36 HR and Competency Staff identified through tracers (open and closed records) All core stroke team members RN, technicians, case workers, social workers, pharmacists, OT, PT, speech, and others

37 HR and Competency Documents: License / certificate per job description Current job description Copies of all education records related to stroke per organization hour/course requirement The reviewer will review education on a rolling annual basis Copies of certificates (BLS, ACLS, PALS, etc.) and degrees per job description Orientation checklist Most recent performance evaluation Education for staff who work in specialty areas ED and ICU (as appropriate) should include documentation of education in NIHSS, dysphagia screening, IV thrombolytics administration per the HCO s requirements.

38 Closing Session The organization can select who they want to attend the closing conference You will be able to print the preliminary report once it is published The reviewer will discuss the results of the review The reviewer will share if they identified any best practices while at your organization and indicate how you can submit them to The Joint Commission s Leading Practice Library

39 Tips/Information The Joint Commission will provide a 30 day notice for initial review and a 7 day notice for recertification customers Assure your Certification Measure Information Process (CMIP) data is up to date Assure your CPG s are reviewed annually Assure your organization s website is up to date with staff and services for stroke patients Notify your staff in the areas where patients will be traced so they can prepare for their day Closed records should be ready for our review during the late morning (approximately 11:00 a.m., depending on the number of closed records that need to be reviewed)

40 Tips/Information The reviewer will need at least two computers on wheels In order to assure an efficient review process, we may ask two staff members to find different information on the same patient at the same time Assure that your team is ready to accompany the reviewer during tracers at the beginning of the day and after lunch Please consider limiting the number of staff who accompany the group Suggested staff you may want to consider to accompany the reviewer: Individual responsible for the program Stroke Medical Director or Stroke team member Scribe

41 DSC Standards and Elements of Performance Basic Review Program Management Delivering and Facilitating Care Clinical Information Management Supporting Self Management not applicable ASRH 14 standards 26 Elements of Performance

42 Approach to the Standards and Tips to Success

43 Program Management (DSPR) DSPR.1 The program defines its leadership roles EP1 -The program identifies members of its leadership team The organization appoints an ASRH medical director (Note: the director must have sufficient knowledge of cerebrovascular disease to provide administrative leadership, clinical guidance and input to the stroke program) What is sufficient knowledge? What (s)he doesn t need to be: Attendance at Regional/Ntl Stroke Mtg Classroom/Online programs Regional/State Affiliations Courtesy appointment in Neurology/Neurosurgery Board-certified in neurology or neurosurgery Board-certified in vascular neurology Published in Stroke Journals A member of the AHA/ASA

44 Program Management (DSPR) DSPR.1 The program defines the accountability of its leaders EP 2- Written documentation showing support of the ASRH program by the hospital or healthcare administration What this might look like: Letter of Support Part of the Program s charter Organizational chart (listing personnel) What would likely not be acceptable: Name mentioned in staff meeting minutes Newspaper article / staff bulletin

45 Program Management (DSPR) DSPR. 1 The program leaders identify the composition of the interdisciplinary team EP 4- The organization appoints an Acute Stroke Team ACUTE STROKE TEAM What this should include: PERSONNEL A physician, nurse or NP/PA TRAINING Continuing education Attendance at reg/ntl mtgs NICU experience INTERDISCIPLINARY TEAM What this should include: ED Manager PSC/CSC liaison Case manager Rehab Services Lab Palliative Care Radiology EMS liaison

46 Program Management (DSPR) DSPR.2 The program is collaboratively designed, implemented & evaluated EP1- The interdisciplinary team designs the program. The interdisciplinary team composition reflects the needs of the patient population. Transferred Patients Who should be included: Admitted Patients Who should be included: ED staff EMS liaison Stroke coordinator Case management Quality and Safety ED staff EMS liaison Stroke coordinator Case management Rehab team Palliative Care Discharge Planning Quality and Safety

47 Program Management (DSPR) DSPR.3 The program meets the needs of the target population EP 4- The services provided by the program are relevant to the target population The hospital collaborates with Emergency Medical Services (EMS) providers to ensure the following: EMS alerts hospital of suspected stroke patient The organization has access to EMS treatment protocols The organization and EMS use at least one field assessment tool There is a written transfers protocol The program has access to a PSC or CSC 24/7

48 Program Management (DSPR) DSPR.5 The program determines the care, treatment and services it provides EP1 - The program defines in writing the care, treatment and services it provides The organization s formulary or medication list must include an IV thrombolytic therapy medication approved by the USFDA for the treatment of ischemic stroke. Alteplase

49 Program Management (DSPR) DSPR.5 The program provides care, treatment and services in a planned and timely manner EP 3 24/7 on-call acute stroke team with one member responding the to the patient s bedside within 15 minutes of being called (there must be an NP, PA or MD on-site to supervise patient care, order medication and manage emergent issues 24/7 on-site laboratory testing (CBC, plts, coags, chem 7, troponin 24/7 on-site ability to perform a CT scan of the brain An MRI brain may be performed in lieu of the CT brain There must be a written process to notify the acute stroke team bedside consultation or telemedicine consult

50 Program Management (DSPR) DSPR.5: The program provides the number and types of practitioners needed to deliver or facilitate the delivery of care, treatment and services EP 7- Neurosurgical coverage is documented in a written plan and approved by neurosurgical services and the stroke team Neurosurgical services area available to patients within three hours of it being deemed necessary There is a written protocol for transfer that includes communication and feedback from the receiving facility

51 Delivering or Facilitating Clinical Care (DSDF) DSDF.1 Practitioners are qualified and competent EP 1- Practitioners have the education, experience, training and/or certification consistent with the program s scope of services, goals and objectives The organization s clinical staff have knowledge of the process used to notify designated practitioners of the need to respond to patients with an acute stroke ED practitioners demonstrate knowledge of IV thrombolysis therapy protocols for acute stroke including: Treatment during the first three hours after the patient was last known normal Indications / contraindications for thrombolytic therapy Patient/family education regarding the risks and benefits of thrombolytics Symptoms of clinical deterioration after thrombolytics

52 Delivering or Facilitating Clinical Care (DSDF) DSDF.1 Ongoing training and educational opportunities for staff EP 7- Practitioner competence / orientation / ongoing education EXAMPLES In-services Lunch and Learns Lectures Symposia On-line learning modules Huddles Conferences Walking Rounds Bedside demonstrations Simulation labs Shared lectures Gran rounds Newsletter Skills Fairs

53 Delivering or Facilitating Clinical Care (DSDF) DSDF.1 EP 7 Ongoing in-service and other training activities are relevant to the program s scope of services The medical director of the program receives at least 4 hours annually related to the care of patients with cerebrovascular disease. Members of the core stroke team, as identified by the organization, receive at least 4 hours annually of continuing education or other equivalent educational activity related to the care of patients with cerebrovascular disease. Emergency Department staff, defined by the organization, participates in educational activities related to stroke diagnosis and treatment a minimum of twice a year. The above requirements do NOT apply to the emergency physicians

54 DSDF.2 The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver of facilitate the delivery of clinical care. EP 2- Current literature approved by the stroke program leadership EP 3- ANNUAL REVIEW OR AS NECESSARY EP % of emergency department practitioners are educated on acute stroke protocols Written protocols for ischemic and hemorrhagic stroke Evidence-based dysphagia screening tool Time parameters outlined for the acute stroke work-up Use of IV thrombolytic therapy built into order-sets / pathways

55 DSDF.3 The program is implemented through the use of clinical practice guidelines selected to meet the patient s needs EP 2- Assessments and reassessments are completed according to the patient s needs and clinical practice guidelines An ED MD, NP (with prescriptive authority) or PA (with prescriptive authority) performs an assessment for a suspected stroke patient within 15 minutes of patient arrival to the ED Ongoing assessment are completed in accordance with the program s stroke protocol The NIHSS is used as an initial assessment (and performed by a qualified team member) of patients with acute stroke A blood glucose level is completed for any patient presenting with stroke symptoms

56 EP 2- Assessments and reassessments are completed according to the patient s needs and clinical practice guidelines The hospital has the ability to perform and read a non-contrast CT or MRI within 45 and 60 minutes respectively of being ordered Radiology reads may be done off-site but must be read by a boardcertified radiologist or physician with expertise in reading brain CT/MRIs Lab tests, ECG and Chest Xray are completed and resulted within 45 minutes of patient arrival if ordered by the practitioner Patients with stroke symptoms are screened for dysphagia prior to any oral intake

57 DSDF.2 EP 3- The program implements care, treatment, and services based on the patient s assessed needs (continued) Completion of lab tests, ECG and Chest Xray should NOT delay the administration of IV thromboytics Telemedicine / teleradiology equipment is on site for transmission of information Telemedicine link is initiated within 20 minutes of the ED MD or stroke team determining it is necessary

58 DSDF.5 The program coordinates care for patients with multiple needs and/or communicates the necessary information to manage these conditions to other practitioners EP 1- The program coordinates care for patients with multiple needs Protocols address policies for patient transfers Protocols geared to meeting patient and family needs i.e. hospice or palliative care Goal to transport patients to a higher level of care within two hours of arrival or when medically stable and track time parameters

59 Clinical Information Management (DSCT) DSCT.4 EP 2- The program shares information with relevant practitioners and or health organizations to facilitate continuation of care. CT/CTA/MRI/MRA/Labs (turn-around times) DSCT.5 EP 4- The medical record contains sufficient information to justify the care, treatment and services provided. Documentation indicates the reason eligible ischemic stroke patients did not receive IV thrombolytic therapy. DSCT.5 EP 5- The medical record contains sufficient information to document the course and results of care, treatment and services Practitioners document all assessments and interventions provided for stroke patients, including date and time, in accordance with program policies.

60 Performance Measurement (DSPM) DSPM.1 The program has an organized, comprehensive approach to performance improvement (a written performance improvement plan) EP1- The program leaders identify goals and set priorities: The program monitors its ability to administer IV thrombolytics within 60 minutes to eligible patients presenting for stroke care EP 2- Stroke performance measures are analyzed by the stroke team and the hospital s quality department: There is a specified committee that meets a minimum if twice a year to evaluate protocols and practice patterns

61 DSPM.3 The program collects measurement data to evaluate processes and outcomes: Data must be trended over time and may be compared to an external data source for comparative purposes. EP 2- The program collects data related to processes and outcome of care Stroke registry Stroke Code Activations Practitioner response times Diagnostic testing Acute treatments Patient diagnosis Door to IV tpa times Patient complications sich and serious life-threatening events Disposition Inter-rater reliability

62 The program evaluates patient satisfaction with and the perception of quality of care at the program level; patient satisfaction data are utilized for program-specific performance improvement activities

63 Questions? Thank you for you commitment to each other, communities, families and the patients you serve Without you, stroke would not have dropped to the 5 th leading cause of death in the United States

64 The Joint Commission Disclaimer These slides are current as of 4/27/2017. The Joint Commission reserves the right to change the content of the information, as appropriate. These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides. These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.

Element(s) of Performance for DSPR.1

Element(s) of Performance for DSPR.1 Prepublication Issued Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals

More information

PSC Certification: What really happens

PSC Certification: What really happens PSC Certification: What really happens Authors: Wendy J. Smith, BS, MA, RES, RCEP, RN, SCRN Christy Franklin, MS, RN, CNRN Julie Fussner, BSN, RN, CPHQ, SCRN Disclosures Wendy J. Smith- I have no actual

More information

Prepublication Requirements

Prepublication Requirements Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals

More information

Kenny Barajas DNP, RN, CEN

Kenny Barajas DNP, RN, CEN Advanced Disease-Specific Care Certification Requirements for Comprehensive Stroke Center Kenny Barajas DNP, RN, CEN Disease Specific Care Reviewer The Joint Commission Presenter Disclosure Statement ASRH,

More information

Update: Joint Commission Stroke Certification Standards and SAFER Scoring Matrix

Update: Joint Commission Stroke Certification Standards and SAFER Scoring Matrix Update: Joint Commission Stroke Certification Standards and SAFER Scoring Matrix David Eickemeyer, MBA Associate Director, Certification April 20, 2017 Today s Agenda Three Levels of Stroke Certification

More information

Proposed Requirements for Comprehensive Stroke Center

Proposed Requirements for Comprehensive Stroke Center Proposed Requirements for Comprehensive Stroke Center Please Note: The current requirements for Disease-Specific Care Advanced Certification Program for Primary Stroke are included in this document. Proposed

More information

HFAP Stroke Survey. Overview of the Survey Process 8/17/2011

HFAP Stroke Survey. Overview of the Survey Process 8/17/2011 HFAP Stroke Survey Surveyors Viewpoint Bernard C. McDonnell, D.O. Stroke Center Accreditation from the Surveyors Viewpoint 01.00.01 Primary stroke Center Facility Commitment. The leadership of the facility

More information

INCLUSION CRITERIA. REMINDER: Please ensure all stroke and TIA patients admitted to hospital are designated as "Stroke Service" in Cerner.

INCLUSION CRITERIA. REMINDER: Please ensure all stroke and TIA patients admitted to hospital are designated as Stroke Service in Cerner. ACUTE STROKE CLINICAL PATHWAY The clinical pathway is based on evidence informed practice and is designed to promote timely treatment, enhance quality of care, optimize patient outcomes and support effective

More information

DNV GL - Healthcare Advisory Notice Notice No:

DNV GL - Healthcare Advisory Notice Notice No: DNV GL - Healthcare Advisory Notice Notice No: 2015-06 DATE: September 3, 2015 SUBJECT: New Version Comprehensive Stroke Center Standards 2.0 DISTRIBUTION: All DNV GL - Healthcare Customers, Employees

More information

Stroke System-of- Care Plan. Mississippi State Department of Health

Stroke System-of- Care Plan. Mississippi State Department of Health Stroke System-of- Care Plan Mississippi State Department of Health Bureau of Acute Care Systems MSDH Board of Health Approved: October 14, 2015 Revised July 6, 2015 Stroke System-of-Care Plan Table of

More information

Stroke Coordinator Boot Camp

Stroke Coordinator Boot Camp Stroke Coordinator Boot Camp Gena Kreiner RN BSN FHS Stroke Coordinator Karen C. Kiesz MN RN CNRN SCRN MHS Stroke Program Manager Lisa Shumaker, BSN, RN, CMSRN (Moderator) PRMC- Everett Stroke Program

More information

Support (Level III) Stroke Facility Criteria Guidance

Support (Level III) Stroke Facility Criteria Guidance Support (Level III) Stroke Facilities ( SSFs ) - provides resuscitation, stabilization and assessment of the stroke victim and either provides the treatment or arranges for immediate transfer to a higher

More information

SARASOTA MEMORIAL HOSPITAL POLICY

SARASOTA MEMORIAL HOSPITAL POLICY smh0076850ps1070 SARASOTA MEMORIAL HOSPITAL POLICY TITLE EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: Job Title of Responsible Owner: Director, Patient Care 12/09/13 08/19/16 Clinical Non-Clinical

More information

2012 Medical Staff Update 2011 CHALLENGING STANDARDS/NPSGS

2012 Medical Staff Update 2011 CHALLENGING STANDARDS/NPSGS 2012 Medical Staff Update Laurel McCourt, M.D. TJC Surveyor: Hospital and Office-Based Surgery Programs, and Special Survey Unit 2011 CHALLENGING STANDARDS/NPSGS 2 Standard/NPSG 2010 Non Compliance 3 2011

More information

Disease Specific Care. Certification Review Process Guide

Disease Specific Care. Certification Review Process Guide Disease Specific Care Certification Review Process Guide 2018 Disease Specific Care Certification Review Process Guide 2018 Copyright: 2018 The Joint Commission Disease Specific Care Certification Review

More information

Congratulations! OMG! What have I gotten myself into? The Medical Staff Chapter and the Survey Process How to Prepare

Congratulations! OMG! What have I gotten myself into? The Medical Staff Chapter and the Survey Process How to Prepare The Medical Staff Chapter and the Survey Process How to Prepare Laurel McCourt, M.D. TJC Surveyor: Hospital and Office-Based Surgery Programs, and Special Survey Unit Congratulations! OMG! What have I

More information

Organization Review Process Guide Perinatal Care Certification

Organization Review Process Guide Perinatal Care Certification Organization Review Process Guide Perinatal Care Certification 2016 Perinatal Care Certification Review Process Guide for Health Care Organizations 2016 What s New? Review process and contents of this

More information

Getting Started: How to Operationalize Performance Measures for Your Acute Stroke Ready Hospital

Getting Started: How to Operationalize Performance Measures for Your Acute Stroke Ready Hospital Getting Started: How to Operationalize Performance Measures for Your Acute Stroke Ready Hospital January 17, 2018 11 AM to 1 PM CST Topics For Discussion State the five standardized performance measures

More information

Core Elements of Delivery of Stroke Prevention Services

Core Elements of Delivery of Stroke Prevention Services Core Elements of Delivery of A critical component of secondary stroke prevention is access to specialized stroke prevention services (SPS), ideally provided by dedicated stroke prevention clinics. Stroke

More information

Learning Experiences Descriptions

Learning Experiences Descriptions Anticoagulation Management Clinic Learning Experiences Descriptions The Anticoagulation Management rotation is an elective learning experience that focuses on the outpatient management of anticoagulation.

More information

Readiness Assessment Document for Acute Telestroke Collaboration (Sample. Checklist from OTN)

Readiness Assessment Document for Acute Telestroke Collaboration (Sample. Checklist from OTN) Readiness Assessment Document for Acute Telestroke Collaboration (Sample Checklist from OTN) Telestroke Referring Site Application This application should be completed in conjunction with your Regional/District

More information

Interpretation of The Joint Commission Standards Related to Pain Management. Agenda. The Joint Commission Mission 9/6/2012

Interpretation of The Joint Commission Standards Related to Pain Management. Agenda. The Joint Commission Mission 9/6/2012 Interpretation of The Joint Commission Standards Related to Pain Management ASPMN 22 nd National Conference Baltimore, MD September 13, 2012 Pat Adamski, RN, MS, MBA, FACHE Director, Standards Interpretation

More information

East Texas Gulf Coast Regional Trauma Advisory Council Regional Advisory Council - R (RAC-R)

East Texas Gulf Coast Regional Trauma Advisory Council Regional Advisory Council - R (RAC-R) East Texas Gulf Coast Regional Trauma Advisory Council Regional Advisory Council - R (RAC-R) RAC-R proudly supports and serves Jasper, Newton, Hardin, Orange, Liberty, Jefferson, Chambers, Galveston and

More information

1 st Annual Neurosciences Critical Care Symposium June 5, 2010 Karen Ellmers, RN, MS, CCNS

1 st Annual Neurosciences Critical Care Symposium June 5, 2010 Karen Ellmers, RN, MS, CCNS What does it mean to be a Primary Stroke Center? 1 st Annual Neurosciences Critical Care Symposium June 5, 2010 Karen Ellmers, RN, MS, CCNS ellmersk@ohsu.edu 1 What are the goals of a Primary Stroke Center?

More information

The Basics: Disease-Specific Care Certification Clinical Practice Guidelines and Performance Measures

The Basics: Disease-Specific Care Certification Clinical Practice Guidelines and Performance Measures The Basics: Disease-Specific Care Certification Clinical Practice Guidelines and Performance Measures June 21, 2017 Caroline Isbey, RN, MSN, CDE Associate Director, Certification David Eickemeyer, MBA

More information

Supplementary Online Content

Supplementary Online Content Supplementary Online Content Itrat A, Taqui A, Cerejo R, et al; Cleveland Pre-Hospital Acute Stroke Treatment (PHAST) Group. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke

More information

An Acute Care Nurse Practitioner Model of Care for Stroke Patients

An Acute Care Nurse Practitioner Model of Care for Stroke Patients An Acute Care Nurse Practitioner Model of Care for Stroke Patients Holly A. Schenzel, BSN, RN DNP Student, Creighton University, School of Nursing, Omaha, NE Email: hollyannmarie@hotmail.com Telephone:

More information

Module 1 Program Description

Module 1 Program Description Module 1 Program Description Palliative Care Program Description 1. What type(s) of communities does your palliative care program serve? Check all that apply. Urban Suburban Rural 2. Which counties does

More information

UNM SRMC NURSE PRACTITIONER (NP) & LICENSED INDEPENDENT PRACTITIONER (LIP) CLINICAL PRIVILEGES. Name: Effective Dates:

UNM SRMC NURSE PRACTITIONER (NP) & LICENSED INDEPENDENT PRACTITIONER (LIP) CLINICAL PRIVILEGES. Name: Effective Dates: o o o Initial privileges (initial appointment) Renewal of privileges (reappointment) Expansion of privileges (modification) INSTRUCTIONS All new applicants must meet the following requirements as approved

More information

Diagnostic Imaging: Surveyor Education, Survey Experience, and Trends

Diagnostic Imaging: Surveyor Education, Survey Experience, and Trends Compliance with the AAPM CT Clinical Practice and Joint Commission Guidelines Diagnostic Imaging: Surveyor Education, Survey Experience, and Trends On-Site Survey focused on patient care: Patient Tracer

More information

Trauma Service Area - B (BRAC) Regional Stroke Plan

Trauma Service Area - B (BRAC) Regional Stroke Plan Trauma Service Area - B (BRAC) Regional Stroke Plan Trauma Service Area- B (BRAC) P.O. Box 53597 Lubbock, TX 79453 806.791.2582 (office) BRAC serves the counties of Bailey, Borden, Castro, Cochran, Cottle,

More information

Stroke Distinction Report. Lakeridge Health Oshawa. Oshawa, ON. On-site Survey Dates: October 26, October 29, 2015

Stroke Distinction Report. Lakeridge Health Oshawa. Oshawa, ON. On-site Survey Dates: October 26, October 29, 2015 Stroke Distinction Report Lakeridge Health Oshawa Oshawa, ON On-site Survey Dates: October 26, 2015 - October 29, 2015 Report Issued: November 12, 2015 About the Distinction Report Lakeridge Health Oshawa

More information

Duke Life Flight. Systems of Care for Time Dependent Emergencies. Disclosures. Disclosures 9/19/2017

Duke Life Flight. Systems of Care for Time Dependent Emergencies. Disclosures. Disclosures 9/19/2017 Duke Life Flight Systems of Care for Time Dependent Emergencies Claire M Corbett, MMS, NRP Manager of Neurodiagnostics and Stroke Center New Hanover Regional Medical Center Wilmington, NC Disclosures Clinical

More information

Enhancing Your Skills in Stroke Quality Improvement & Data Analysis: Using Data to Drive Outcomes

Enhancing Your Skills in Stroke Quality Improvement & Data Analysis: Using Data to Drive Outcomes Enhancing Your Skills in Stroke Quality Improvement & Data Analysis: Using Data to Drive Outcomes Christy Franklin, BSN, MS, CNRN and Lynn Hundley, RN, MSN, APRN, CNRN, CCNS, ANVP Disclosures Christy Franklin

More information

Standardized Protocol for Assessment and Management of Acute and Chronic Patients: Anesthesia Pre-Op Clinic

Standardized Protocol for Assessment and Management of Acute and Chronic Patients: Anesthesia Pre-Op Clinic Standardized Protocol for Assessment and Management of Acute and Chronic Patients: Anesthesia Pre-Op Clinic Protocol for the Management of Acute and Chronic Illness and Injuries prior to the administration

More information

TRAUMA CENTER REQUIREMENTS

TRAUMA CENTER REQUIREMENTS California Trauma Center Level III Criteria California Code of Regulations,, Chapter 7 - Trauma Care System with American College of Surgeons (Green Book) references; includes FAQ clarifications TRAUMA

More information

1 Stand-Alone 2 Co-located (or embedded)

1 Stand-Alone 2 Co-located (or embedded) MODULE 1. Office/Clinic Program Description and Metrics Outpatient Clinic / Office-based Practice Description 1.A Data for [YEAR] reported for: 1.B Service Setting 1 Is this program serving an urban, suburban

More information

Abstraction Tricks and Tips for the Hospital Outpatient Quality Reporting (OQR) Program

Abstraction Tricks and Tips for the Hospital Outpatient Quality Reporting (OQR) Program Abstraction Tricks and Tips for the Hospital Outpatient Quality Reporting (OQR) Program Audio for this event is available via internet streaming. No telephone line is required. Computer speakers or headphones

More information

Bethesda Hospital PGY1 Residency Program Learning Experiences

Bethesda Hospital PGY1 Residency Program Learning Experiences Bethesda Hospital PGY1 Residency Program Learning Experiences Required rotations Orientation This rotation will orient the resident to hospital pharmacy and the responsibilities of a staff pharmacist.

More information

Abstraction Tricks and Tips for the Hospital Outpatient Quality Reporting (OQR) Program

Abstraction Tricks and Tips for the Hospital Outpatient Quality Reporting (OQR) Program Abstraction Tricks and Tips for the Hospital Outpatient Quality Reporting (OQR) Program Audio for this event is available via internet streaming. No telephone line is required. Computer speakers or headphones

More information

Overview of The Joint Commission s Primary Care Medical Home (PCMH) Certification

Overview of The Joint Commission s Primary Care Medical Home (PCMH) Certification Overview of The Joint Commission s Primary Care Medical Home (PCMH) Certification Joyce Webb, RN, MBA Project Director, Standards and Survey Methods Program Lead, The Joint Commission s PCMH Initiative

More information

Using Telemedicine to Enhance Meaningful Use Qualification

Using Telemedicine to Enhance Meaningful Use Qualification Beth DeStasio Director, Regulatory Affairs & Strategy, REACH Health September 2014 Copyright 2014 REACH Health, Inc. All rights Reserved Key Takeaways 1. As of September 4, 2014, the Center for Medicare

More information

SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE Subject: ADMISSION/TRANSFER OF STROKE PATIENTS Page 1 of 2 No: STK-1 Prepared by: Stroke Management Committee Original

More information

Evaluation of Telestroke Services

Evaluation of Telestroke Services Evaluation of Telestroke Services 2013 Telestroke Summit Heart and Stroke Foundation of New Brunswick and the Canadian Stroke Network Dr. Patrice Lindsay Director Best Practices and Performance, Stroke

More information

El Paso - Ambulatory Clinic Policy and Procedure

El Paso - Ambulatory Clinic Policy and Procedure Regulation Reference: El Paso - Ambulatory Clinic Policy and Procedure Title: ADMISSION & ESCORT OF PATIENTS TO UNIVERSITY MEDICAL CENTER- EL PASO AND/OR AREA HOSPITAL Policy Number: EP 3.6 Joint Commission

More information

SITE VISIT AGENDA Version

SITE VISIT AGENDA Version Pre Site Visit -- Chart Review Preparation: 1. Contact your assigned Site Surveyor to discuss paper or electronic chart preferences for the chart review. 2. In addition to the charts requested below, please

More information

Level 4 Trauma Hospital Criteria

Level 4 Trauma Hospital Criteria Level 4 Trauma Hospital Criteria Hospital Commitment The board of directors, administration, and medical, nursing and ancillary staff shall make a commitment to providing trauma care commensurate to the

More information

CAH PREPARATION ON-SITE VISIT

CAH PREPARATION ON-SITE VISIT CAH PREPARATION ON-SITE VISIT Illinois Department of Public Health, Center for Rural Health This day is yours and can be flexible to the timetable of hospital staff. An additional visit can also be arranged

More information

Nurse Practitioner - Outpatient Lung Transplant (1.0 FTE, Days)

Nurse Practitioner - Outpatient Lung Transplant (1.0 FTE, Days) Nurse Practitioner - Outpatient Lung Transplant (1.0 FTE, Days) Category: Nursing Advance Practice Job Type: Full-Time Shift: Days Location: Palo Alto, CA, United States Req: 5609 FTE: 1 Nursing Advance

More information

Information Technology Report to Medical Executive Committee

Information Technology Report to Medical Executive Committee March 10, 2015 z Information Technology Report to Medical Executive Committee Contents 1 Physician Training Opportunities for PowerChart Maternity and FetaLink Launch March 24 at Germantown Hospital 2

More information

Neurocritical Care Fellowship Program Requirements

Neurocritical Care Fellowship Program Requirements Neurocritical Care Fellowship Program Requirements I. Introduction A. Definition The medical subspecialty of Neurocritical Care is devoted to the comprehensive, multisystem care of the critically-ill neurological

More information

ELECTIVE COMPETENCY AREAS, GOALS, AND OBJECTIVES FOR POSTGRADUATE YEAR ONE (PGY1) PHARMACY RESIDENCIES

ELECTIVE COMPETENCY AREAS, GOALS, AND OBJECTIVES FOR POSTGRADUATE YEAR ONE (PGY1) PHARMACY RESIDENCIES ELECTIVE COMPETENCY AREAS, GOALS, AND OBJECTIVES FOR POSTGRADUATE YEAR ONE (PGY1) PHARMACY RESIDENCIES Introduction The competency areas, goals, and objectives are for use with the ASHP Accreditation Standard

More information

Select Medical TRANSITIONS OF CARE & CARE COORDINATION

Select Medical TRANSITIONS OF CARE & CARE COORDINATION Select Medical TRANSITIONS OF CARE & CARE COORDINATION Agenda Select Medical Overview Transitions of Care Right Patient, Right Level of Care,Right Time Chronic Critical Illness Syndrome Role of Long Term

More information

The following policy was adopted by the San Luis Obispo County EMS Agency and will become effective March 1, 2012 at 0800 hours.

The following policy was adopted by the San Luis Obispo County EMS Agency and will become effective March 1, 2012 at 0800 hours. SLO County Emergency Medical Services Agency Bulletin 2012-02 PLEASE POST New Trauma System Policies and Procedures February 9, 2012 To All SLO County EMS Providers and Training Institutions: The following

More information

The Joint Commission 2017 Medical Staff Standards Update

The Joint Commission 2017 Medical Staff Standards Update The Joint Commission 2017 Medical Staff Standards Update Session Code: TU07 Date: Tuesday, October 24 Time: 11:30 a.m. - 1:00 p.m. Total CE Credits: 1.5 Presenter(s): Louis Goolsby, MD The Joint Commission

More information

Nursing Care for Acute Ischemic Stroke Patients

Nursing Care for Acute Ischemic Stroke Patients Nursing Care for Acute Ischemic Stroke Patients Highlights of lessons learned 2016 Annie Sanford MSN, RN Stroke Program Manager Swedish Medical Center, Seattle, WA 1 Learning Objectives: By attending this

More information

Course: Acute Trauma Care Course Number SUR 1905 (1615)

Course: Acute Trauma Care Course Number SUR 1905 (1615) Course: Acute Trauma Care Course Number SUR 1905 (1615) Department: Faculty Coordinator: Surgery Dr. Joseph P. Minei Hospital: Periods Offered: Length: Parkland Health & Hospital System All year 4 weeks

More information

UW HEALTH JOB DESCRIPTION

UW HEALTH JOB DESCRIPTION NURSE CASE MANAGER - ED Job Code: 801009 FLSA Status: Mgt. Approval: B Liegel Date: 6-18 Department: Coordinated Care Department 93070 HR Approval: M Buenger Date: 6-18 JOB SUMMARY The Nurse Case Manager,

More information

2013 Stroke Symposium: UK Albert B. Chandler Hospital, Distinction Beyond. P avilion A Auditorium. Saturday, May 18. the Measures

2013 Stroke Symposium: UK Albert B. Chandler Hospital, Distinction Beyond. P avilion A Auditorium. Saturday, May 18. the Measures 2013 Stroke Symposium: Distinction Beyond the Measures Saturday, May 18 UK Albert B. Chandler Hospital, P avilion A Auditorium Overview This one day activity will give the learner a broad perspective of

More information

The Basics: Getting Started on Disease- Specific Care Certification

The Basics: Getting Started on Disease- Specific Care Certification The Basics: Getting Started on Disease- Specific Care Certification May 4, 2017 David Eickemeyer, MBA Associate Director, Certification Today s Objectives Define the main components of Disease- Specific

More information

Tele-urgent Services

Tele-urgent Services Ronald S. Weinstein, M.D. Director, Arizona Telemedicine Program Success factors Barriers Success factors Barriers to success 1 5. eicu (e Intensive Care Unit) 5. eicu (e Intensive Care Unit) 2 Teleradiology

More information

11/1/2016. Hospital Breakfast Briefing: Provision of Care, Treatment & Services. Publications and Record Restrictions.

11/1/2016. Hospital Breakfast Briefing: Provision of Care, Treatment & Services. Publications and Record Restrictions. Hospital Breakfast Briefing: Provision of Care, Treatment & Services November 3, 2016 Steve Chinn, DPM, MS, MBA Consultant Joint Commission Resources 1 Hospital Breakfast Briefings Part 10 Disclosure Statement

More information

Seven Day Services Clinical Standards September 2017

Seven Day Services Clinical Standards September 2017 Seven Day Services Clinical Standards September 2017 11 September 2017 Gateway reference: 06408 Patient Experience 1. Patients, and where appropriate families and carers, must be actively involved in shared

More information

MBQIP Measures Fact Sheets December 2017

MBQIP Measures Fact Sheets December 2017 December 2017 This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1RRH29052, Rural Quality

More information

Check all that apply [TEXT] if administered by a health system, select health system.

Check all that apply [TEXT] if administered by a health system, select health system. MODULE 1. Home Health Program Description and Metrics Home Health Program Description 1 Is this program serving an urban, suburban or rural 1 Urban community? 2 Suburban 3 Rural 2 Who administers your

More information

Proposed Standards Revisions Related to Pain Assessment and Management

Proposed Standards Revisions Related to Pain Assessment and Management Leadership (LD) Chapter LD.0001 Proposed Standards Revisions Related to Pain Assessment and Management 1 2 Leaders establish priorities for performance improvement. (Refer to the "Performance Improvement"

More information

Interprofessional Rounding Presentations

Interprofessional Rounding Presentations Interprofessional Rounding Presentations Sue Kelly & Diana Williamson, Grey Bruce Health Services Sandi Pincombe, St. Thomas Elgin General Hospital Sheila Hunt, London Health Sciences Centre INTER-PROFESSIONAL

More information

TITLE: Processing Provider Orders: Inpatient and Outpatient

TITLE: Processing Provider Orders: Inpatient and Outpatient POLICY and PROCEDURE TITLE: Processing Provider Orders: Inpatient and Outpatient Number: 13211 Version: 13211.10 Type: Patient Care Author: Carol Vanetti; Provider Order Policy Committee Effective Date:

More information

Neurocritical Care Rotation - EUH

Neurocritical Care Rotation - EUH Preceptor: Bill Asbury, B.S., Pharm.D. Office: EUH- EG35 Hours: ~ 8:00am-4:30pm Desk: 404-712-7491 Pager: 404-686-5500 pic 14028 ICU cell phone: 404-326-8256 PGY-2 Residency Training Program Neurocritical

More information

Title: Assessment and Management of Acute and Chronic Patients: Anesthesia Pre-Op Clinic

Title: Assessment and Management of Acute and Chronic Patients: Anesthesia Pre-Op Clinic Title: Assessment and Management of Acute and Chronic Patients: Anesthesia Pre-Op Clinic Protocol for the Management of Acute and Chronic Illness and Injuries prior to the administration of anesthesia

More information

Colorado Board of Pharmacy Rules pertaining to Collaborative Practice Agreements

Colorado Board of Pharmacy Rules pertaining to Collaborative Practice Agreements 6.00.00 PHARMACEUTICAL CARE, DRUG THERAPY MANAGEMENT AND PRACTICE BY PROTOCOL. 6.00.10 Definitions. a. "Pharmaceutical care" means the provision of drug therapy and other pharmaceutical patient care services

More information

Module 1 Program Description and Metrics

Module 1 Program Description and Metrics Module 1 Program Description and Metrics Outpatient Clinic / Office-based Program Description 1. Is this program serving an urban, suburban or rural community? Urban Suburban Rural 2. Who administers your

More information

The Joint Commission Standards and the Patients

The Joint Commission Standards and the Patients The Joint Commission Standards and the Patients 23 rd Annual National Forum on Quality Improvement in Health Care December 7, 2011 Orlando, Florida Pat Adamski, RN, MS, MBA Director, Standards Interpretation

More information

HIE Implications in Meaningful Use Stage 1 Requirements

HIE Implications in Meaningful Use Stage 1 Requirements s in Meaningful Use Stage 1 Requirements HIMSS Health Information Exchange Steering Committee March 2010 2010 Healthcare Information and Management Systems Society (HIMSS). 1 An HIE Overview Health Information

More information

UNIVERSITY OF WISCONSIN HOSPITAL AND CLINICS DEPARTMENT OF PHARMACY SCOPE OF PATIENT CARE SERVICES FY 2017 October 1 st, 2016

UNIVERSITY OF WISCONSIN HOSPITAL AND CLINICS DEPARTMENT OF PHARMACY SCOPE OF PATIENT CARE SERVICES FY 2017 October 1 st, 2016 UNIVERSITY OF WISCONSIN HOSPITAL AND CLINICS DEPARTMENT OF PHARMACY SCOPE OF PATIENT CARE SERVICES FY 2017 October 1 st, 2016 Department Name: Department of Pharmacy Department Director: Steve Rough, MS,

More information

Trauma Center Pre-Review Questionnaire Notes Title 22

Trauma Center Pre-Review Questionnaire Notes Title 22 This Pre-Review Questionnaire is designed to accompany the spread sheet appropriate for the Trauma Center being reviewed For use with review of Level III Trauma Center with American College of Surgeons'

More information

Partnering with the Care Management Department. Medical Staff and Allied Health Practitioner Orientation

Partnering with the Care Management Department. Medical Staff and Allied Health Practitioner Orientation Partnering with the Care Management Department Medical Staff and Allied Health Practitioner Orientation 10/2015 Department of Care Management Medical Directors of Care Coordination Inpatient Case Managers

More information

Innovation. Successful Outpatient Management of Kidney Stone Disease. Provider HealthEast Care System

Innovation. Successful Outpatient Management of Kidney Stone Disease. Provider HealthEast Care System Successful Outpatient Management of Kidney Stone Disease HealthEast Care System Many patients with kidney stones return to the ED multiple times due to recurrent symptoms. Patients then tend to receive

More information

EP15: Describe and demonstrate interdisciplinary collaboration using continuous quality and process improvement.

EP15: Describe and demonstrate interdisciplinary collaboration using continuous quality and process improvement. 1 EP15: Describe and demonstrate interdisciplinary collaboration using continuous quality and process improvement. Interdisciplinary collaboration is an essential component of Riverside Medical Center

More information

STATEMENT OF PURPOSE: Emergency Department staff care for observation patients in two main settings: the ED observation unit (EDOU) and ED tower obser

STATEMENT OF PURPOSE: Emergency Department staff care for observation patients in two main settings: the ED observation unit (EDOU) and ED tower obser DEPARTMENT OF EMERGENCY MEDICINE POLICY AND PROCEDURE MANUAL EMERGENCY DEPARTMENT OBSERVATION UNITS BRIGHAM AND WOMEN S HOSPITAL 75 FRANCIS STREET BOSTON, MA 02115 Reviewed and Revised: 04/2014 Copyright

More information

Human Resources & Nursing

Human Resources & Nursing 2017 Hospital Breakfast Briefings Web-conference Series Human Resources & Nursing November 2, 2017 Faculty: Kathy Eichner, RN, MSN, CJCP Principal Consultant, Joint Commission Resources 1 Disclosure Statement

More information

Hospital Outpatient Quality Measures. Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: January, 2018

Hospital Outpatient Quality Measures. Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: January, 2018 Hospital Outpatient Quality Measures Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: January, 2018 Background Hospitals have separate quality measures for the outpatient population. These measures

More information

Psychological Specialist

Psychological Specialist Job Code: 067 Psychological Specialist Overtime Pay: Ineligible This is work performing psychological assessments or counseling students. Administers intelligence and personality tests. Provides consultation

More information

INPATIENT PROGRAM ENVIRONMENT Brain Injury Specialty Program

INPATIENT PROGRAM ENVIRONMENT Brain Injury Specialty Program INPATIENT PROGRAM ENVIRONMENT Brain Injury Specialty Program INPATIENT PROGRAM ENVIRONMENT Upon admission, patients and families are oriented to the Rehabilitation Program, and are involved in an evaluation

More information

Proposal for Stroke Program: The purpose of this proposal is to identify the need to increase resources allocated to the JCMC Primary Stroke Center.

Proposal for Stroke Program: The purpose of this proposal is to identify the need to increase resources allocated to the JCMC Primary Stroke Center. Proposal for Stroke Program: The purpose of this proposal is to identify the need to increase resources allocated to the JCMC Primary Stroke Center. Background: JCMC was established as a Primary Stroke

More information

Outpatient Quality Reporting Program

Outpatient Quality Reporting Program The Question and Answer Show Moderator: Karen VanBourgondien, BSN, RN Speaker(s): Pam Harris, BSN, RN June 21, 2017 10:00 am Isn't Q2 submission due August 1, 2017? August 1, 2017 deadline is for Quarter

More information

Family Practice Clinic

Family Practice Clinic Family Practice Clinic FNP Job Description (Hospital Privileges) General: The Family Nurse Practitioner (FNP) assesses, plans and provides comprehensive patient care independently or in autonomous collaboration

More information

VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides

VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE Training Slides 061015 Why Take Action to Prevent Readmissions? Better patient care and patient experience Home

More information

Creating the New Care Design L2. George Kerwin, CEO Patient of Bellin Health Bellin Health Team. Objectives

Creating the New Care Design L2. George Kerwin, CEO Patient of Bellin Health Bellin Health Team. Objectives Creating the New Care Design L2 George Kerwin, CEO Patient of Bellin Health Bellin Health Team Objectives Identify the five views of the Production System necessary to Create a Connected Personal Experience

More information

Aneurin Bevan University Health Board Stroke Services Redesign Programme

Aneurin Bevan University Health Board Stroke Services Redesign Programme Aneurin Bevan University Health Board Services Redesign Programme 1 Introduction This report aims to update the Health Board on progress with the Services Redesign Programme of work which commenced in

More information

UNDERSTANDING THE CONTENT OUTLINE/CLASSIFICATION SYSTEM

UNDERSTANDING THE CONTENT OUTLINE/CLASSIFICATION SYSTEM BOARD OF PHARMACY SPECIALTIES CRITICAL CARE PHARMACY SPECIALIST CERTIFICATION CONTENT OUTLINE/CLASSIFICATION SYSTEM FINALIZED SEPTEMBER 2017/FOR USE ON FALL 2018 EXAMINATION AND FORWARD UNDERSTANDING THE

More information

PARTICULARS, SCHEDULE 2 THE SERVICES, A Service Specification. 12 months

PARTICULARS, SCHEDULE 2 THE SERVICES, A Service Specification. 12 months E09/S(HSS)/b 2013/14 NHS STANDARD CONTRACT FOR VEIN OF GALEN MALFORMATION SERVICE (ALL AGES) PARTICULARS, SCHEDULE 2 THE SERVICES, A Service Specification Service Specification No. Service Commissioner

More information

Valorie Sweigart, DNP g, Samuel Shartar, RN, CEN Emory Healthcare

Valorie Sweigart, DNP g, Samuel Shartar, RN, CEN Emory Healthcare Valorie Sweigart, DNP g, Samuel Shartar, RN, CEN Emory Healthcare Why build Principles of observational medicine ROI ED Hospital Clinical implications Define intended d use Open, closed or mixed use Impact

More information

HOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS

HOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS HOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS The following checklist can be used to verify that the regulatory requirements are addressed in hospice contracts

More information

2016 Medical Staff Standards Update Panel Featuring TJC, NCQA, URAC, DNV, and HFAP (Part 1) THE JOINT COMMISSION. Objectives

2016 Medical Staff Standards Update Panel Featuring TJC, NCQA, URAC, DNV, and HFAP (Part 1) THE JOINT COMMISSION. Objectives 2016 Medical Staff Standards Update Panel Featuring TJC, NCQA, URAC, DNV, and HFAP (Part 1) Paul Ziaya, MD, Veronica C. Locke, MHSA, Donna Merrick, BNS, MEd, Patrick Horine, MHA, and Karen Beem, MS, RN

More information

Trauma Verification Q&A Web Conference

Trauma Verification Q&A Web Conference Trauma Verification Q&A Web Conference August 23, 2016 COTVRC@facs.org Your Trauma Quality Programs Staff Tammy Morgan Manager Trauma Center Programs Molly Lozada Verification Manager Trauma Verification

More information

Colorado Association Medical Staff Services

Colorado Association Medical Staff Services Colorado Association Medical Staff Services AHP Conundrum: To Privilege or Not to Privilege? June 17-18, 2011 Presented by Todd Sagin, MD, JD HG Healthcare Consultants, LLC (215) 402-9176 toddsagin@comcast.net

More information

Clinical Applications

Clinical Applications Clinical Applications Ronald S. Weinstein, M.D. Director, Arizona Telemedicine Program Success factors Barriers Success factors Barriers to success 1 Tele-urgent Services 1. Teleradiology 2. Telecardiology

More information

Molina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)

Molina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800) Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience

More information

Sentinel Stroke National Audit Programme (SSNAP)

Sentinel Stroke National Audit Programme (SSNAP) Sentinel Stroke National Audit Programme (SSNAP) Acute organisational audit proforma 2016 Clinical Standards, Royal College of Physicians, London. On behalf of the Intercollegiate Stroke Working Party.

More information