Comprehensive Stroke Center Certification: The … vs. CSC Primary Stroke Center (>1000) – Stabilize and provide emergency care for patients with acute stroke – Either admit or

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Comprehensive Stroke Center Certification: The Joint

Commission Perspective

Daniel Castillo, MD, MBA Medical Director Healthcare Quality Evaluation

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Effectiveness of Medical Care

“Until the second quarter of this century, therapy had very little effect on morbidity and mortality. One should, therefore, 40 years later, be delightfully surprised when any treatment at all is effective, and always assume that a treatment is ineffective unless there is evidence to the contrary.” Archie Cochrane (1972)

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Knowledge Translation

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

From Clinical Research Into Practice

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

A Brief (and Selective) History of Health Care Quality 1970s: Quality “assurance” begins 1980s: Data begin to show that evidence from

RCTs is not guiding practice 1990s: The era of “guidelines”

– 1992: 48% of AMI pts get β blockers – 1998: Median state = 72% β blockers (AMI) – 1998: Median state = 55% warfarin (afib) – 1996-00: RAND: 47-55% get effective Rx

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

The Joint Commission Certification - Goals Improve quality of patient care by

reducing unwanted variation in clinical processes

Provide framework for program structure and management

Provide an objective assessment of clinical excellence

Improve knowledge translation and access to excellent care

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

TJC Stroke Centers

Not TJC PSC

Joint Commission PSCs continue to improve the

rate of t-PA administration

Stroke 2012;43:A192

Date of PSC Certification

MEDPAR Data FY 2001- 2010 n=3275 hospitals

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

PSC vs. CSC Primary Stroke Center (>1000)

– Stabilize and provide emergency care for patients with acute stroke

– Either admit or transfer to a CSC

Comprehensive Stroke Center (>70) – Provide all needed levels of care to

patients with strokes, including –Special interventions –Highly technical procedures

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Models of Stroke Care

Primary Stroke Center

1000 – 1200

Acute Stroke Ready Hospitals

1200 - 1800

CSC 75 – 200

Academic medical center, tertiary care facility

Wide range of hospitals; standard stroke care; stroke unit; uses tPA

Rural hospitals; basic care; drip and ship; use tele-technologies

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

CSC Certification Program Development & Continuous Improvement

Requirements substantially derived from the Brain

Attack Coalition (Alberts et al, Stroke, 2005; and Leifer et al, 2011); and the American Heart Association (Miller et al, Stroke, 2011)

A 21-member Technical Advisory Panel including representatives nominated by AHA, AACCN, ACEP, SSCM, ENA, CMS, SVIN, AAN, SVS, AANS/CNS, ASN participated in development

Field reviews were conducted for broad national feedback

First reviews September, 2012

Presenter

Presentation Notes

This slide – and the next one – outline the process that we used to develop CSC certification - literature review - a panel for stroke experts - collected online feedback on the proposed standard - did some pilot tests - and conducted the first review in Sept. 2012.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Criteria for Standards Development

Focus on standards that research & leading practice guidelines have shown to be effective in improving quality and safety

In the eyes of the customer:

ConsumedResourcesSafety&QualityinΔValue =

Evidence Based

Value

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Stanford Hospitals and Clinics: A CSC Success Story

Presenter

Presentation Notes

Stanford certainly received a lot of press about their achievement. But to hear them tell the story, they had been working towards this for 20 years. That’s when three physicians (neurology, neuro surgery, and an interventionalist) decided that they would put aside their personal preferences to treat pts and work together to determine the best path for each and every patient, without regard to turf or pride. These three physicians are still there and their approach has infected the staff. Dr. Steinberg says “What keeps us here is our shared enthusiasm for innovation and our shared passion for discovery — and our shared passion for helping patients." CEO Rubin added that the center's founders "knew from the very start that the most effective way to battle complex stroke cases was to create a truly coordinated, multidisciplinary team that united experts from every related field — not just those dedicated to neurology, neurosurgery and interventional neuroradiology, but also experts in nursing, rehabilitation, emergency medicine and pharmacy, amongst others. This approach has improved patient outcomes and pioneered significant advances in stroke diagnosis and treatment."

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Program Components

Quality & Safety of Care

Structure JC DSC Standards + BAC CSC Recommendations

Outcome Standardized

Performance Measures

Process Clinical Practice Guidelines

Presenter

Presentation Notes

Many of you are already familiar with TJC’s certification model which considers structure, process and outcome through the implementation of standards, guidelines and measures. The bulk of what I’’ll be speaking about today is these requirements…what you need to do to become certified as a CSC by TJC.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Structure: Disease-Specific Care Standards Program Management

– 10 Standards Delivering or Facilitating Clinical Care

– 4 Standards Supporting Self-Management

– 3 Standards Clinical Information Management

– 5 Standards Performance Measurement and

Improvement – 6 Standards

Presenter

Presentation Notes

The 28 DSC standards address the structure of a disease mgmt program and are required for all types of certification, including CSC. These standards include everything from the design, implementation and evaluation of the program to individualizing care based on a patients needs to sharing info to caregivers across the continuum. They are high-level requirements about the structure of a program.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Structure: BAC Recommendations

Personnel and Clinical Expertise including Interventional Neurology

Diagnostic Imaging: Techniques and Personnel

Neurosurgery and Vascular Surgery Infrastructure American Heart Association, Inc. “Recommendations for Comprehensive Stroke

Centers: A Consensus Statement from the Brain Attack Coalition.” Stroke: Journal of the American Heart Association, July 2005.

Presenter

Presentation Notes

The BAC, in its 2005 article about CSCs, outlined 4 areas that differentiate a CSC. What TJC has done is to consider all of the details in each of these areas and link them to our existing DSC standards. This allows us to evaluate the CSC requirements in a larger context, and it also gives us the opportunity to score noncompliance with the BAC recommendations.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Process: Clinical Practice Guidelines Current evidence-based guidelines are

embedded in the CSC standing orders. Evaluated with patient tracer activity Most frequently-cited requirement for

improvement: 21% of reviews in 2012 cited for not delivering care according to CPGs

Presenter

Presentation Notes

So, moving on to the next component of certification: Clinical Practice Guidelines. What TJC is interested in here is that the care you are providing is grounded in evidence-based guidelines. These need to be fully embedded in your standing orders and implemented in care delivery. During an onsite visit, we will evaluate this thru patient tracers. This is a technique where our reviewers evaluate standards compliance and hospital systems of care by following the course of individual patient flow and treatment. This area, implementing CPGs, is the most frequently cited area of non-compliance during certification visits. In fact, it has been identified as a RFI in 21% of the visits we have conducted so far in 2012. As you are preparing for certification, I would recommend that you pay careful attention to this because it is something we will definitely be looking at.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Outcome: Performance Measurement CSCs are currently required to collect

and report data on the PSC Measure Set

Effective January 1, 2015, CSCs will begin data collection on 8 new CSC performance measures

Include management of both ischemic and hemorrhagic stroke patients

Presenter

Presentation Notes

The third and final component of certification is Outcomes, as demonstrated by Performance Measures. Today, certified CSCs are required to collect and report data to us on the PSC measure set. We have drafted CSC measures and they are currently being pilot tested in 65 hospitals. The pilot test will continue thru June. Once we are sure they are reliable, valid, and indeed GOOD measures, we will make the details behind them public. Right now, our goal is to have the measures implemented on 1/1/2014. We also anticipate that the PSC measures will continue to be required for CSCs even after the new CSC measures are rolled out. Again, I want to repeat that as of right now, and thru 2013, the measures used for CSC are the PSC measures.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Comprehensive Stroke Center Certification Goal is to improve stroke care and

recognize elite group of centers treating complex stroke patients

Exclusive benefits from both AHA and TJC: – National agenda thru CSC quarterly networking events – Special recognition at International Stroke Conference – Standardized performance measures (1/2014) – National advertising – Ability to promote CSC with exclusive AHA/TJC Service

Marks

Presenter

Presentation Notes

CSC certification was never designed as something that every single hospital would be capable of doing. We are seeking the most elite providers, providing the most sophisticated treatments to the sickest patients, and recognizing them in the hope that the science will continue to develop and improve. So in addition to the benefits of certification I mentioned on the previous slide, there are a few other things that the AHA and TJC are doing to meet this goal: - the AHA is hosting quarterly networking groups to develop a national agenda for CSCs. The first meeting is coming up this week, so we’ll see what this “national agenda” will include, but we are thinking things like political advocacy, sharing best practices and advancing science thru research - Developing performance measures specific to CSC. The costs for developing a measure set total 400-600K. So this is no meager undertaking - National advertising - I have a sample of that on the next slide - Special recognition event at the ISC - Use of the AHA / TJC service marks to promote your achievement.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

For Standards/NPSG question: – 630-792-5900, Option 6 or – http://www.jointcommission.org/Standards/

OnlineQuestionForm/

Daniel Castillo – 630-792-5937 – [email protected]

http://www.jointcommission.org/Standards/OnlineQuestionForm/

http://www.jointcommission.org/Standards/OnlineQuestionForm/

mailto:[email protected]

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

The Joint Commission Disclaimer Statement

These slides are current as of November 6, 2014. 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.

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Thanks!

Documents

Comprehensive Stroke Center Certification: The … vs. CSC Primary Stroke Center (>1000) – Stabilize and provide emergency care for patients with acute stroke – Either admit or