Raise the bar for stroke care certification program

Growing number certified by JCAHO program

How would you like to be able to tell patients, their families and friends, payers, and news reporters that you are among a select few organizations certified by the Joint Commission on Accreditation of Healthcare Organization’s Primary Stroke Center Certification program?

The program, which was launched in November 2003, recognizes hospital stroke care programs that meet national quality standards, raising the level of care provided to stroke patients.

Surveyors come on-site to assess compliance with national standards, performance measurement and improvement activities, qualifications and competencies of practitioners, and processes encouraging patient self-management.

Currently, 16 organizations are certified as primary stroke centers, and approximately 30 additional programs have applied.

The stroke program at Sacred Heart Medical Center in Spokane, WA, has been in existence since 1997. "We submitted our application for Primary Stroke Center certification in mid-October 2003 and were surveyed in December 2003. We were among the first in the nation to be surveyed and certified," reports Sena Blickenstaff, director of neuroscience services, which includes quality and operational oversight for the organization’s stroke program.

"In preparation for the survey, we reviewed our systems, processes, and documentation demonstrating outcomes and compliance with evidence-based best practices. We also spent a day conducting mock surveys just to get people ready, but we really relied on the strength of our program that had been in place for years," she explains.

The surveyors randomly audited 10% of charts, looked at patient outcomes data, and evaluated staff education specifically related to stroke, including certifications to administer the National Institutes of Health (NIH) stroke scale.

"As it turned out, we had two stroke patients come in back to back during the survey. The surveyors dropped everything and observed our stroke team in action, which included timing our responsiveness throughout the stroke program continuum of care," Blickenstaff says.

The survey team talked to all the departments involved in a stroke patient’s care, including ancillary departments and patient transporters, asking staff, "What is your role? What do you do for this patient?"

"It was actually fun to show off our program and to have people so excited about what we are doing," Blickenstaff adds.

Surveyors also talked to the emergency medical services (EMS) personnel who had brought the patient in, asking questions about their training and their role in the stroke program.

"They were able to talk about the extensive outreach training we have done with them and say, Here is a sheet of questions we ask, including the question, When was the patient last seen normal?’" Blickenstaff points out.

Throughout a one-day survey at Good Samari-tan Hospital in San Jose, CA, various aspects of practice were reviewed by the surveyors.

"Heavy detail was focused on issues such as processes, availability of services 24 hours a day, seven days a week, and our overall conceptual care according to evidence-based medicine," says Steven A. Matarelli, PhD, RN, vice president of clinical practice administration, adding that the survey results were released 45 days later.

A straightforward process

The certification process is very straightforward and follows the Joint Commission’s disease-specific certification guidelines, according to Blickenstaff.

"They brought the certification guidelines and walked through them. It is a pass-or-fail survey. You either have it or you don’t," she says. "We didn’t feel like we were under the microscope. The surveyors treated it more like they were consultants coming in to help us. When we finished, they told us our stroke program had set the bar very high for everyone."

Here are several tips from recently certified organizations:

Begin with the Brain Attack Coalition Guidelines, evidence-based literature, and Joint Commission disease-specific certification guidelines.

"Those items were our road map when we decided to pursue certification," Blickenstaff adds. "The guidelines gave us a better picture of where our next steps needed to be."

For example, the national goal is for acute stroke patients to be evaluated by a physician in under 10 minutes, door-to-CT scan in 25 minutes, and door to drug in 60 minutes.

"Early on, we were not meeting those benchmarks. So we had to look at our internal systems and processes, and by applying performance improvement methodology, we have a clear understanding of what we need to do to improve our systems and processes and ultimately achieve those benchmarks," Blickenstaff explains.

Good Samaritan has had an organized stroke program for more than seven years that follows the Brain Attack Coalition Guidelines as well as other evidence-based practices found in stroke literature, Matarelli reports.

"At the time of the certification process, we had treated approximately 2,000 stroke patients and administered over 80 t-Pa infusions for the treatment of ischemic stroke in those patients who qualified for t-Pa," he says.

Address the entire continuum of care.

To improve stroke care, you need to consider how patients are moved throughout the organization, Blickenstaff says. "It isn’t just one department. These patients touch several different departments within a medical center," she explains.

The patient typically presents to the emergency department (ED) where he or she is quickly triaged and evaluated. The patient then moves to the radiology department for timely diagnostic evaluation.

Depending on those findings, the patient may return to the ED, be transferred to the neuro-interventional suite or radiology department to perform further diagnostic work-up, or be sent to the OR.

"So looking at throughput and what systems you need in place to ensure that the patient is getting from Point A to B and C in a timely matter is very critical," Blickenstaff continues.

Once the initial, emergent treatment has been provided, you have to make sure that other services and ancillary departments are on the same page as well. Therapies such as physical therapy, outpatient therapy, speech, food and nutrition, and case management all must work closely together to provide a collaborated, coordinated program of care.

"It all has to work in tandem for the patient to have good outcomes," Blickenstaff notes.

Perform effective data analysis.

At Sacred Heart Medical Center, data are discussed at monthly stroke operations committee meetings, which include representatives from all involved departments.

A data set collection of around 50 different elements gauges quality, including customer satisfaction, timeliness indicators for both intravenous and intra-arterial t-PA, secondary prevention, and demographic information.

"The goal is to get a picture of how our program is working from a quality and customer service standpoint," Blickenstaff says.

Some data analysis is done electronically by using the electronic medical record and medication bar code scanning.

"Data collection analysts, who are all nurses, also review the charts to get down to the microscopic level," she says.

If an area needs improvement, the next step is to determine whether it is a systems problem or a learning opportunity for a specific individual, Blickenstaff says.

Give real-time feedback to staff.

Stroke coordinators and case management give real-time feedback to staff at Sacred Heart. For example, the time frame to get patients from the ED to CT scan was not meeting national standards.

"We knew that if we improved the activation and transport process and had patient transport standing by to assist the ED nurse in getting the patient to and from CT, that would ultimately facilitate the appropriate treatment and/or intervention being implemented in a timely manner," she says.

This process change was implemented but not always followed consistently, Blickenstaff points out.

"There may be a lag in getting information disseminated so that everybody is up to speed on whatever new systems and processes are implemented. The coordinator is an integral component of the stroke program and can provide that critical real-time feedback," she explains. "They are an extra level of support."

The stroke coordinators also ensure the NIH stroke scale is administered in a timely manner and done consistently, Blickenstaff adds.

Have the team meet for real-time care conferences.

If a patient is not progressing as anticipated for whatever reason, the organization’s stroke coordinator sets up a "stroke round," getting all the key players to convene for a care conference. "If you waited for all the data to come in for these patients, it’s too late," she adds. "This gives us an opportunity to provide that patient with the right treatment at the right time. If a particular therapy or treatment is not working, we can regroup and say, Now what do we need to do?’"

For example, there could be a nutrition issue if a stroke patient hasn’t had a dysphagia screening and is unable to swallow. "Issues such as this are something our stroke coordinator and stroke rounds care conferences can look at in a real-time manner," Blickenstaff notes.

Quality managers play a key role.

Quality is an important aspect of stroke care monitoring, Matarelli says.

"Staff from the quality department are vital members of the team and aid in data capture, submission to our database, and analysis and process improvements using either the failure mode effect analysis process or a more traditional approach using FOCUS-PDCA," he adds. (FOCUS-PDCA is a performance improvement methodology in which FOCUS is an acronym for: F: find a process to improve, O: organize an effort to work on improvement, C: clarify current knowledge of the process, U: understand process variation and capability, S: select and test changes aimed at improvement. PDCA stands for plan, do, check, act.)

Selecting outcomes data

Quality and stroke teams have collaborated in improving medication administration safety and streamlining processes for lab and diagnostic study computer ordering, explains Matarelli, who serves as both the organization’s patient safety officer and the director of the stroke program.

"Stroke is an authorized outcomes team’ within the hospital quality team, and its data are reported to that team, the medical staff executive council, and the board of trustees," he adds.

The goal is to ensure all stroke team processes and changes in process conform with the National Patient Safety Goals as well as other housewide safety initiatives.

"We do not have a stroke unit in our hospital, but rather use the process for stroke care throughout the organization," Matarelli notes.

Select outcomes data to collect and analyze.

Both Sacred Heart Medical Center and Good Samaritan have selected four outcomes measurements for the initial data collection and reporting period, which will be submitted to the Joint Commission’s Disease Certificate Program in accordance with the program rules.

Good Samaritan’s data collection tool and integrated data management source is "Get With The Guidelines" for Stroke, a product of Cambridge, MA-based Outcome Sciences, Matarelli says.

The four outcomes measurements are door-to-CT time; door-to-needle time for the administration of t-Pa for qualified ischemic stroke patients; compliance with discharge medication, treatment, and diet program; and measuring the NIH stroke scale on those patients who qualify for t-Pa prior to administration and patients with an NIH stroke scale score on the day of discharge lower than their initial score, indicating improvement.

"These four outcomes measurements are based on our previous data collection sets," Matarelli explains.

Implement a process for in-house strokes.

An in-house code stroke program is used at Sacred Heart Medical Center for patients who have strokes while in the hospital.

"We do a lot of open-heart surgery and transplants, and those patients are at very high risk for stroke because of the procedures," explains Blickenstaff. "If a patient already under our roof has a stroke, an internal system mobilizes the stroke team, as a separate process from patients coming through the ED. The surveyors were very impressed with that," she says.

[For more information on the Joint Commission’s Primary Stroke Center Certification program, contact:

Sena Blickenstaff, Director, NeuroScience Services, Sacred Heart Medical Center, Providence Neuro- science Center, 105 W. 8th Ave., Suite 1000. Spokane, WA 99204. Phone: (509) 474-3739. E-mail: BlickeS@ SHMC.org.

Steven A. Matarelli, PhD, RN, Vice President, Clinical Practice Administration, Good Samaritan Hospital, 2425 Samaritan Drive, San Jose, CA 95121. Phone: (408) 559-2348. E-mail: steven. matarelli@hcahealthcare.com.]