Hospitals in the Piedmont Healthcare system in Georgia have made great strides in safety and quality by improving their care for stroke patients. Consolidating some accreditation survey activities was part of the successful strategy.

The initiative led to six of the system’s hospitals receiving certification in stroke care from DNV GL Healthcare, in Milford, OH, which offers hospital accreditation integrating ISO 9001 with the Medicare Conditions of Participation. Piedmont Healthcare uses DNV GL Healthcare for accreditation throughout its system.

Debbie Camp, RN, MHA, CCM, SCRN, stroke program manager at Piedmont Newnan Hospital in Georgia, was hired to help that hospital achieve designation as a certified stroke center. She worked with other hospitals in the system to standardize processes so they all could make improvements to their stroke programs at the same time. They also worked with the accreditor to streamline the survey process.

“We set up our annual stroke surveys so that they would all coincide ... which meant we had two weeks of surveys with DNV. The stroke managers from four hospitals would all do the surveys together. We learned a lot from doing that,” Camp reports. “We recognized that we had an opportunity to do what they call a system or consolidated survey. The surveyors would come, and we had to do our presentations. Because we had standardized everything, the surveyors were hearing the same thing each time.”

Previously, each hospital survey started with a half day of presentations and then a full day of assessments. With the consolidated process, the stroke managers at the hospitals can spend a day going over their programs together. Then, when the surveyor visits each hospital, managers can review the tracer that DNV uses to track a patient’s experience through the hospital, beginning at the moment he or she enters the facility.

“The surveyor is able to spend a lot more time on the floor with the bedside nurses, rehab services, radiology. They’re able to go to all these departments and make sure the staff really knows what is going on,” Camp says. “If the surveyor is there when we have a code stroke come in, they actually go down to the ED [emergency department] and see the code stroke in action.”

Strong Collaboration Necessary

The tracer looks at each step of the care process, involving many different elements of the hospital. Camp says it helps the stroke program optimize its multidisciplinary approach.

“The stroke program cannot be successful unless you have really strong collaboration among radiology, lab, rehab, transportation — all these services, in addition to the unit where the patient actually lands, like the ICU [intensive care unit] or stroke unit,” Camp says. “You have to have support from case management, dietary, [and] chaplain service. There’s nothing we do that is not impacted by each division of the hospital.”

Piedmont Healthcare also consolidated how its stroke programs addressed any deficiencies found in the accreditation survey. In previous years, it was common for one hospital to be dinged on a certain element of stroke care and respond with the appropriate improvement, only to have another Piedmont stroke center cited for the same deficiency the next year.

To change that pattern, the hospitals began considering any survey deficiency (NC1 or NC2) and opportunities for improvement (OFIs) at any hospital to be a systemwide problem.

“If one hospital is having trouble with it, then that is something for the entire system to pay attention to. We all look at our processes to see what is going on,” Camp says. “We are able, as a system, to request changes in our electronic medical record to improve processes. Everyone [has] input before we do it, but everyone benefit[s] from the changes immediately. It has really improved our quality program and outcomes for our patients.”

A primary focus in the improvement effort was making sure stroke patients received the clot-busting drug alteplase quickly, and then were admitted to receive intensive care. One of the Piedmont Healthcare hospitals, Piedmont Henry Hospital in Stockbridge, GA, had problematic “door out” times of more than eight hours in early 2017. Within months, the system’s stroke improvement efforts had reduced that time to less than three hours by the summer of 2017.

The stroke programs also sought to decrease the number of stroke patients arriving at Piedmont Henry by private vehicle, a factor that is known to delay the introduction of alteplase. The percentage of patients arriving by private vehicle was cut by more than half (from 56% in 2012 to 25% in 2017). The use of ambulances rose from 41% to 73%, the result of community education about the need for emergency transport for anyone suspected of experiencing a stroke.

Include Frontline Workers

Camp and colleagues worked closely with frontline clinicians to improve the documentation process, acknowledging that in many cases of apparently insufficient care, the proper care was provided but not documented correctly.

“People make mistakes. Most of the time, it’s just that the care was not documented. If it’s not documented, it officially didn’t happen,” Camp notes. “As a system, we tried to provide our clinicians with ways to improve documentation, like changes to the EMR [electronic medical record]. We shared everything we did with the other hospitals rather than operating only within our own silos.”

Camp credits input from frontline clinicians with much of the improvement that led to four Piedmont Healthcare hospitals achieving stroke certification. Seemingly small changes to a process can produce important results, she says. The clinicians at the bedside often can tell leaders why a big idea is misguided.

“You need to standardize and bring the people at the bedside into the discussion to figure out how to do things better,” Camp explains. “One of the worst things we do sometimes is to have people come in and dictate how things should be done. They have the best intentions and think they really do have a better way. Sometimes, we have to say no, that’s not how it’s done at the bedside.”

Transparency also is important, Camp says. Not only do Piedmont Healthcare hospitals collaborate and share data, but Camp and colleagues regularly share their experiences and best practices with other hospitals in the region.

That cooperation is facilitated by the Georgia Coverdell Acute Stroke Registry (GCASR) program, named in honor of the late U.S. Sen. Paul Coverdell, R-GA, who died of a massive stroke in 2000. Funded by the Centers for Disease Control and Prevention, the GCASR recognizes states in the southeastern United States have the highest incidence and mortality of stroke, and encourages an active exchange of data and ideas.

“A lesson I’ve learned is that if you have a program within your program, whatever it may be, don’t just sit at your desk and try to fix it. Call up your counterparts at other hospitals and health systems, and see what they’re doing,” Camp offers. “Sometimes, I know how Piedmont does it, but I want to know how Emory does it, how WellStar does it, so we can look for common problems and how somebody else has successfully addressed it. We share a lot in Georgia, and it benefits patients in a big way.”


  • Debbie Camp, RN, Stroke Program Manager, Piedmont Newnan Hospital, Georgia. Phone: (770) 400-1000.