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, PSC and CSC Reviewer for The Joint Commission No Financial Disclosure
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.
Objectives Inspire your journey for ongoing development of your Comprehensive Stroke Program Provide you with strategies on how to prepare for your next onsite review Identify challenging standards and leading practices to ensure delivery of high quality care
Disease-Specific Care Certification The Joint Commission s Disease-Specific Care (DSC) Certification Program provides an evaluation of a clinical program that delivers care to a defined patient population. Certification is designed to evaluate clinical care in disease management programs provided in all types of settings, including hospitals, ambulatory care, homecare, free standing emergency centers, and nursing care centers, as well as physician offices.
Disease-Specific Care Certification Certification is not connected to an organization s accreditation status, although the organization, if eligible for accreditation, must achieve accreditation by The Joint Commission to be eligible for DSC certification.
Disease Specific Advanced Certifications Acute stroke ready hospital(asrh) Chronic kidney disease(ckd) Chronic obstructive pulmonary disease(copd) Comprehensive stroke center(csc) Heart failure(achf) Inpatient diabetes care(idc) Lung volume reduction surgery(lvrs) Primary stroke center(psc) Total hip and total knee replacement(thkr) Ventricular assist device destination therapy(vad) Palliative Care
Tools for Success https://www.jointcommission.org/assets/1/18/2017_dsc_organization_rpg.pdf
Other Resources
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:
Clinical Practice Guidelines
The Joint Commission Resources Access your Joint Commission Connect extranet site at https://customer.jointcommission.org Obtain a site license for the E-dition Call Customer Service at 630-792-5291 (between 8:00 A.M. and 5:00 P.M. central time, Monday through Friday Programs not yet certified can contact Business Development at 630-792-5291 or email certification@jointcommission.org The Standards Interpretation Group (SIG) provides answers to frequently asked questions online at https://www.jointcommission.org/standards_information.jcfaq.a spx. The Joint Commission s Performance Measurement page at https://www.jointcommission.org/performance_measurement.a spx
Facts Acute Stroke Ready- 26 Primary Stroke Centers 1107 Comprehensive Stroke Centers 123
Requirements Assessed at Application 1. Volume of cases 2. Advanced imaging capabilities 3. Post-hospital care coordination for patients 4. Dedicated neuro-intensive care unit (ICU) beds for complex stroke patients 5. Peer review process 6. Participation in stroke research
CSC Volume of Cases/Requirements Demonstrates that care is provided to 40 or more patients in a two year period with a diagnosis of subarachnoid hemorrhage caused by an aneurysm. Demonstrates that it is capable of treating aneurysms by performing 30 or more endovascular coiling or microsurgical clipping procedures in a two year period. Demonstrates that intravenous (IV) tissue plasminogen activator(tpa, Alteplase) is administered 25 or more times per year for eligible patients. Note 1: Providing IV tpa to a total of 50 eligible patients over a two-year period is acceptable. Note 2: IV tpa administered in the following situations can be counted in the requirement of 25 administrations per year. IV tpa ordered and monitored by the CSC via telemedicine with administration occurring at another hospital IV tpa administered by another hospital, which then transferred the patient within 24 hours to the CSC.
CSC Volume of Cases/Requirements Advanced imaging capabilities: The CSC will be able to provide advanced imaging with multimodal imaging capabilities 24 hours a day, 7 days a week for the following: Catheter angiography Computed tomography angiography (CTA) Magnetic resonance angiography (MRA) Magnetic resonance imaging(mri), including diffusion-weighted MRI
CSC Volume of Cases/Requirements The CSC performs advanced imaging with multimodal imaging capabilities for the following when indicated by patient need: Carotid duplex ultrasound Extracranial ultrasonography Transcranial Doppler Transesophageal echocardiography (TEE) Transthoracic echocardiography (TTE)
CSC Volume of Cases/Requirements Dedicated neuro-intensive care unit (ICU) beds for complex stroke patients The hospital will have dedicated neuro-intensive care unit (ICU) beds for complex stroke patients, including licensed independent practitioners and staff with the expertise and experience to provide on-site, neuro-critical care 24 hours a day, 7 days a week.
CSC Volume of Cases/Requirements The CSC has an interdisciplinary program-level review, including a peer review process that is as follows: Part of the CSC s quality improvement process A performance improvement plan when needed Note: An interdisciplinary program-level review is defined as a review at the program level to assess causes of patient adverse outcomes with the aim of decreasing the incidence of such outcomes.
Peer Review Criteria for selection of complex stroke patients reviewed at meeting Both ischemic and hemorrhagic strokes Method for referring case for review Multi-level process Protected peer review Monitoring and comparing complication rates Process improvement Highlight successes for team to learn from
Peer Review Membership Inter-specialty Emergency Medicine Neurology Neurosurgery Interventional Provider Radiologist Intensivist Hospitalists Vascular Surgery Cardiology Inter-disciplinary Physicians Nurse Practitioner Physician Assistants Nurses Quality Technologists Administration
CSC Volume of Cases/Requirements Participation in stroke research: The comprehensive stroke center currently participates in patient-centered stroke research that is approved by the Institutional Review Board.
Core Standards versus Advanced Standards Organizations must meet all Core Standards for Disease Specific Certification IN ADDITION to advanced standards for the program
Core Standards Certification Participation Requirements (CPR) Program Management (DSPR) Delivering or Facilitating Clinical Care (DSDF) Supporting Self-Management (DSSE) Clinical Information Management (DSCT) Performance Measurement (DSPM)
Endovascular Care Staffing model for 24/7 Roles and Responsibilities Staffing model for more than one case Who calls you in? Time frame for response if on-call Inclusion/exclusion criteria When does consenting occur? By whom? Anesthesia involved in care? How are they notified? Moderate sedation? Who monitors? Competency in place? Who documents? Where?
Endovascular Care Orientation and competency Educational requirements in care of cerebrovascular patients Do you give Alteplase? Do you mix? Do you have competency? Do you recover patients there? Remove sheaths? Who performs neurological assessments during time in department? What does hand-off look like between departments? Standardized orders for assessments and monitoring Process improvement activities
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
CSC Review Schedule 2 Reviewers Day 1 Day 2 0800-0930 Opening session 0930-1000 Planning session 1000-1030 Emergency Department 1030-1230 Tracers 1230-1300 Lunch 1300-1530 Tracers 1530-1630 Issue Resolution/Closing 0800-0830 Daily briefing 0830-1030 Tracers 1030-1230 System tracer/data session/pi 1230-1300 Lunch 1300-1500 HR/Education/Credentialing 1500-1530 Prepare report 1530-1600 Issue resolution report to admin 1600-1630 Closing conference
Opening Session Your program s time to shine! Engage team members across continuum 90 minutes If a provider has a restricted schedule, please share with reviewer so schedule can be accommodated to speak with them
Opening Session Highlights Program mission, goals, and objectives Program structure, Program leadership and management Program design, Stroke team composition: including core members, and extended members Developing, implementing, and evaluating the program Target population for the program: Complex stroke patients who have the need for emergent care, advanced imaging, and a surgical intervention such as clipping for aneurysm, coiling for aneurysms, and stenting of the extracranial carotid. The target population also includes complex stroke patients who received IV tpa or IA tpa.
Opening Session Highlights Identified needs of the program population The selection, implementation, and evaluation of clinical practice guidelines Model of neuro-icu care Evaluation of clinical practice guidelines use and appropriateness to the target population Performance improvement process, including evaluation of the disease management program s efficacy Community relationships, Use of telemedicine
Opening Session Highlights What does stroke team look like? Time frame for initiating stroke alert processes Is there a stroke system designation at state level for EMS? Transfer center? Transfer agreements? Formal or informal processes Telemedicine acute care or follow-up process Management of two or more stroke alerts at one time and/or shared responsibility for telestroke Your community/patient population
Opening Session Highlights Location and number of interventional suites (Radiology, Cath Lab, Surgery) Neuro Critical Care Unit/beds location, numbers Stroke Unit or designated unit Key transitional care processes: EMS to ED, ED to Stroke Unit, Stroke Unit to home, rehabilitation, skilled facility Research - types of opportunities for patients to participate. Who coordinates, when is this offered?
Opening Session Highlights Medical staff model Primary care Hospitalists Intensivists Neurologists Neurosurgeons Admitting/attending physician? Consultation?
Planning Session
Schedules and call-schedules for specialties covering 24/7 Neurologist Interventionalist Intensivist Neurosurgeon IR Suite staff Residents APN s or PA s Anesthesia
Planning Session Protocols to understand process flows ED Imaging In-house stroke alerts Order sets Dated documents: Last reviewed or revised Roles and responsibilities defined Anything we could find on paper provide reviewer up front Schedules and callschedules for specialties covering 24/7 Neurologist Interventionalist Intensivist Neurosurgeon IR Suite staff Residents APN s or PA s Anesthesia
Planning Session Preparation of documents: List of last 4/12 months What reviewers like to have available for open medical records Stroke Log Date of admission Age Provider and/or specialty Type of stroke Any stroke intervention procedure completed: IV Alteplase Thrombectomy Coiling, Clipping, CAS, CEA (All services) Ventriculostomy Decompression (evacuation/craniectomy)
Planning Session Preparation of documents: What reviewers like to have available for closed medical records Date of admission Length of stay Age Disposition Provider and/or specialty Electronic Health Record navigator
Emergency Department Session Describe unit-beds, staffing, resources Stroke protocols-ems arrival, walk-in, 2 or more stroke alerts Tools used by staff to identify stroke patients Stroke response activation, team activities (CT, lab, RX, RAD, Neuro) Who initiates orders, Who admits or consults Off hour process EMS protocols-state legislation for transport of stroke patients How many systems feed into your ED Education: ED staff, EMS (feedback) Bypass or diversion 20-30 minutes
Tracer Locations Locations touching complex stroke patients Emergency Department Radiology Lab POCT Pharmacy Interventional Radiology / Cath Lab Operating Room Post-Anesthesia Recovery Room
System Tracer/Data Session/PI Data-how abstracted, validated, analyzed, used for process improvement Performance improvement plan Meeting minutes How data is reported up and down the organization PSC and CSC measures Stroke alert data Patients perception of care Complication rates, peer review process Patient call back process including Modified Rankin scoring Public reporting of interventions 120 minutes
Credentialing and Competencies Allied Health Onboarding-Human resources Orientation-Organization and unit specific Performance evaluation Initial/Ongoing competencies Continuing education Medical Staff Med staff appointment Provider privileges CME FPPE OPPE 120 minutes
Issue Resolution Resolve issues identified during review Submit last minute IOU s *The goal of The Joint Commission is to be transparent throughout the review process and nothing should be a surprise 30 minutes
Closing Session Core group session Organization session *Report is preliminary: Summary of findings
Standards and Pitfalls Certification Participation Requirements (CPR) Program Management (DSPR) Delivering or Facilitating Clinical Care (DSDF) Supporting Self-Management (DSSE) Clinical Information Management (DSCT) Performance Measurement (DSPM)
The Joint Commission s Survey Analysis for Evaluating Risk (SAFER) Matrix Immediate Threat to Life (a threat that represents immediate risk or may potentially have serious adverse effects on the health of the patient, resident, or individual served) Likelihood to Harm a Patient/Staff/Visitor HIGH MODERATE LOW LIMITED PATTERN WIDESPREAD Scope
Why are findings Scored in Different Standards? Dysphagia Screen Do you have an evidenced based tool? Did you perform the task prior to PO meds? Order Sets Do you have a current CPG derived order set? Did your provider use the correct order set? Did your provider use an order set? Consents Did the patient receive the information needed for informed consent? Was the consent dated and signed? Did you follow your incapacity/emergency consent procedures?
Certification Participation Requirements (CPRs) Address specific requirements for participation in the certification program and for maintaining a certification award Do you meet the requirements?
Program Management (DSPR) Designing and implementing the program Evaluating the program Offering a relevant program for patients Providing safe and adequate access to care Conducting the program in an ethical manner Supplying reference resources to practitioners Offering the program in safe and accessible facilities
Program Management (DSPR) DSPR.1-The program defines its leadership roles EP 4-The CSC documents the roles and responsibilities for member of the core stroke team EP 6-Providers use order sets: derived from CPG s EP 6-Variation in practice between specialist for same procedure EP 7-Providers practice within scope of practice (licensure, certification, training and competency) DSPR.2 The program is collaboratively designed, implemented, and evaluated DSPR.3 The program meets the needs of the target population EP 3-Identify target population EP 4-EMS: Partnership/Guidelines
Program Management (DSPR) DSPR.5 The program determines the care, treatment, and services it provides EP 1-Participates in patient-centered research approved by IRB EP 4-Informed consent: procedures, date, time and signatures. DSSE.1 EP 1 Lack of risks, benefits and alternatives EP 6-Detailed plan to meet the needs of two complex patients at the same time: Bedside or telemedicine EP 7-Neurosurgeon cannot be on call at any other hospital: Documents back up if covering two services Fellows: neurocritical care & cerebrovascular experience Residents: neurocritical care & cerebrovascular experience: training in residency program NP/PA: Documented neurocritical care & cerebrovascular experience/competency (ENLS etc.) DSPR.6 The program has current reference and resource materials EP 1-Practitioners have access to reference materials (CPG s): Acute assessment of IS and hemorrhagic stroke
Delivering or Facilitating Clinical Care (DSDF) Using qualified, competent practitioners Delivering or facilitating the delivery of care using evidence-based clinical practice guidelines Individualizing care to meet patients needs Managing comorbidities and concurrently occurring conditions Initiating discharge planning and facilitating subsequent care, treatment, and services
Delivering or Facilitating Clinical Care (DSDF) DSDF.1 Practitioners are qualified and competent (document competency) DSDF.2 The program develops a standard process originating in CPG s or evidenced based practice to deliver or facilitate the delivery of clinical care DSDF.3 The program is implemented through the use of clinical practice guidelines selected to meet the patient s needs. EP 2-The assessment(s) and reassessments(s) are completed according to the patient s needs and clinical practice guidelines EP 2-Documentation tools/abbreviated assessment tools do not allow for ongoing assessment of patient specific deficits EP 2-Vital signs, distal pulse checks, groin checks, neuro checks, wounds/incision, dressing etc.
Delivering or Facilitating Clinical Care (DSDF) DSDF.3 The program is implemented through the use of clinical practice guidelines selected to meet the patient s needs. EP 3-Laboratory results should not delay stroke intervention Physical, Occupational, Speech therapy or social work/case management needs are assessed in a timely manner according to the organizations/programs requirement Timely management of blood pressure in ICH Timely management of hyperglycemia
Delivering or Facilitating Clinical Care (DSDF) DSDF.4 The plan of care is developed using an interdisciplinary approach and patient participation. EP 2-Assessed for cognitive decline, depression and other social issues Depression screening consistency of when and who performs it Illicit drug or alcohol abuse appropriate referral process in place EP 3-Individualized plan of care is based on patient s goals and the time frames to meet those goals Engagement of patient and family in goal setting
Delivering or Facilitating Clinical Care (DSDF) DSDF.5 The program manages co-morbidities and concurrently occurring conditions and/or communicates the necessary information to manage these conditions to other practitioners. EP 1-Process to receive transfers including time frames EP 3-Depression screening positive no protocol to address positive screen DSDF.6 The program initiates discharge planning and facilitate arrangements for subsequent care, treatment, and services to achieve mutually agreed upon patient goals. EP 1-SNF, rehab, outpatient services, home care, palliative care
Supporting Self-Management (DSSE) Assessing patients self-management capabilities Providing support for patients in self-management activities Involving patients in developing the plan of care Educating patients in the theory and skills necessary to manage their disease(s) Recognizing and supporting self-management effort
Supporting Self-Management (DSSE) DSSE.1 The program involves patients in making decisions about their care, treatment, and services EP 1- Informed consent Potential benefits, risks, side effects of patient's proposed stroke interventions and care Likelihood of the patient achieving his or her goals Any potential problems that might occur as a result of the intervention Reasonable alternatives
Supporting Self-Management (DSSE) DSSE.1 The program involves patients in making decisions about managing their disease or condition EP 2-The program assesses the patient s readiness, willingness, and ability to engage in self-management activities EP 3-The program assesses the family and/or caregiver s readiness, willingness, and ability to provide or support selfmanagement activities when needed EP 5-Patients and practitioners mutually agree upon goals Templated documents, used to document
Supporting Self-Management (DSSE) DSSE.2 The program addresses the patient s self-management plan EP 1 The program promotes lifestyle changes that support selfmanagement activities EP 2 The program evaluates barriers to lifestyle changes EP 4 The program assesses and documents the patient s response to recommended lifestyle changes EP 5 The program addresses the education needs of the patient regarding disease progression and health promotion
Supporting Self-Management (DSSE) DSSE.3 The program addresses the patient s educational needs EP 1-The program s education material comply with recommended elements of care, treatment, and services EP 3-The program presents content in an understandable manner according to the patient s level of literacy EP 5-The program addresses the education needs of the patient regarding his or her disease or condition and care, treatment, and services
Clinical Information Management (DSCT) Proactively gathering and sharing information across the continuum to coordinate care across settings and overtime Providing easy access to patient-related information Preserving confidentiality of patient information Maintaining data quality and integrity Integrating and interpreting data from various sources Using aggregate data to support the program s information needs and direction setting
Clinical Information Management (DSCT) DSCT.4 The program shares information with relevant practitioners and/or healthcare organizations about the patient s disease or condition across the continuum. EP 2-The program shares information with relevant practitioners and/or healthcare organizations to facilitate continuation of patient care Summary of events at transferring facility in medical record Orders and treatment reflected in medical record Nurse Case Management document in the same electronic health record
Clinical Information Management (DSCT) DSCT.5 The program initiates, maintains, and makes accessible a medical record for every patient. EP 4-The medical record contains sufficient information to justify the care, treatment, and services provided. Does it tell the story EP 4-Documentation indicates the reason eligible ischemic stroke patients did not receive IV thrombolytic therapy EP 5-The medical record contains sufficient information to document the course and results of care, treatment, and services *Documentation of care during transport, procedures (MRI) or transfers
Performance Measurement (DSPM) Having an organized, comprehensive approach to performance improvement Developing a performance improvement plan Trending and comparing data to evaluate processes and outcomes Using information garnered from measurement data to improve or validate clinical practice Using participant-specific, care-related data Evaluating the participants perception of the quality of care Maintaining data quality and integrity
Performance Measurement (DSPM) DSPM.1 The program has an organized, comprehensive approach to performance improvement EP 1-Identify goals and set priorities for improvements in a performance improvement plan EP 2-Peer review process EP 6-Monitoring complications and identify area of opportunity DSPM.2 The program maintains data quality and integrity EP 2-The program monitors data reliability and validity
Performance Measurement (DSPM) DSPM.3 The program collects measurement data to evaluate processes and outcomes EP 3-The program collects patient satisfaction data relevant to its target population EP 4-Phone call within 7 days from member the stroke team EP 6-Public reporting of interventional outcomes (CEA and CAS on website) DSPM.4 The program collects and analyzes data to determine variance from the clinical practice guidelines EP 1-The program tracks data variances at the patient level
Follow-up Phone Call Define intent of phone call Make it meaningful to patient and program Readmission prevention (appointment, transportation, medication, equipment) Satisfaction of comprehensive stroke care Reinforce education Successful in reaching? Get alternate phone numbers Share with patient/family that you will be calling and for what reason Have them call you back
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
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