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Tuesday 10:50 CST, September 30, 2014

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Comprehensive Stroke Center Certification

June 6, 2012
Stroke ranks as the number four cause of death in the United States, following diseases of the heart, cancer, and chronic lung-related diseases.  Each year, ≈ 795,000 people experience a new or recurrent stroke. Approximately 610,000 of these are first attacks, and 185,000 are recurrent strokes. These numbers equate to one stroke victim every 40 seconds on average.  Stroke is also a leading cause of long-term disability with a mean lifetime cost estimated at $140,048 per stroke survivor (Roger VL, et al., 2012).
Building on its Disease-Specific Care Primary Stroke Center Certification model, The Joint Commission has developed a new certification program for comprehensive stroke centers in collaboration with the American Heart Association and American Stroke Association.  The Technical Advisory Panel (TAP) for this project met in June 2011 to identify and discuss the potential feasibility and utility of proposed draft performance measures for comprehensive stroke care; provide input and guidance about the scope of individual measure application, including patient population, care settings, and appropriate measure inclusions and exclusions; and, prioritize a subset of draft measures.  The TAP identified eight draft measures which were posted for public comment. Following analysis of comments received during a 60-day period, the draft measures were refined and measure specifications developed for a total of ten draft measures.  

Pilot Testing

The Joint Commission is seeking volunteer hospitals to pilot test draft comprehensive stroke (CSTK) performance measures.  Registration to volunteer as a pilot test site will remain open through July 31, 2012.  Data collection will occur for patients discharged October 1, 2012 through March 31, 2013. The measure set includes patients with an ICD-9-CM Principal Diagnosis Code for ischemic stroke, subarachnoid hemorrhage, and intracerebral/ intraventricular hemorrhage in the initial patient population, and also patients who undergo advanced neurointerventional procedures (i.e., aneurysm clipping and coiling, intravenous (IV) and intra-arterial (IA) thrombolytic (t-PA) therapy, mechanical endovascular reperfusion procedures).  Pilot sites must provide care for these patient groups and be capable of collecting data for all ten draft measures in the set.  
The essential objectives for pilot testing include 1) obtaining information about how the measures and specifications can be enhanced to provide more meaningful and reliable data and 2) assessing the reliability of the measures and associated data elements to ensure that measure results can be compared across multiple organizations.  To meet these objectives, participating hospitals will be asked to implement data collection and reporting of all measures and provide feedback regarding the data collection effort, the usefulness of the measures, and their understanding of the measure specifications.
A small subset of participating hospitals will be randomly selected and asked to host an on-site visit by Joint Commission staff to assess measure data reliability.  During this visit, Joint Commission staff will re-abstract data previously abstracted and transmitted by the hospital and also will conduct group interviews with hospital staff involved with data collection.  These one day on-site visits will most likely occur in January and February, 2013.  
Participation in this pilot test will provide participating organizations with a unique opportunity to influence the approach that may ultimately be crafted to ensure the quality of care provided by Joint Commission designated Comprehensive Stroke Certification programs.  It is important to note that the purpose of the pilot test phase is to assess the measures and their specifications.  The pilot test will not assess the performance of individual organizations.  Project personnel are in no way associated with The Joint Commission’s accreditation and certification process.  Participation in, and findings from, the pilot test will have no impact on any organization’s accreditation or certification status.  All testing information will be confidentially maintained with The Joint Commission’s Division of Healthcare Quality Evaluation and no organization-specific information will be known to anyone other than project personnel.  Any reports produced and distributed as a result of this pilot test will contain only aggregate data, without hospital identifiers.  

Responsibilities of a Pilot Test Site

  • Access training materials, measures, algorithms, data dictionary, and data collection forms online at a web address to be supplied later.
  • Attend an online training session, reviewing measures, algorithms and data collection forms.
  • Collect data for eligible patients discharged during a 6 month period; data collection will begin for patients discharged October 1, 2012.  The data submission schedule is as follows:
Data Collection for Patients Discharged: Data Submission Deadline
October 1 through October 31, 2012 November 15, 2012
November 1 through November 30, 2012 December 15, 2012
December 1 through December 31, 2012 January 15, 2013
January 1 through January 31, 2013 February 15, 2013
February 1 through February 28, 2013 March 15, 2013
March 1 through March 31, 2013 April 15, 2013
  • Submit data online monthly, as described above.
  • Attend monthly conference calls to review any data collection/submission issues that arise.
  • Provide feedback to The Joint Commission as requested.
  • If selected for a site visit by The Joint Commission, provide previously-abstracted patient records and access methods for Joint Commission staff, who will re-abstract selected records. 

Responsibilities of The Joint Commission

  • Prepare and distribute training materials, measures, algorithms, data dictionary, and data collection forms online.
  • Conduct online training session(s), reviewing measures, algorithms, and data collection forms.
  • Conduct monthly conference calls.
  • Receive and analyze submitted data, selecting a subset of hospitals for an on-site visit for re-abstraction purposes.
  • Conduct reliability site visits, as described, recording and analyzing re-abstracted data in comparison to the original data submitted by the hospital.

What Happens During and After the Pilot Test?

Original data and re-abstracted data will be compared for convergence, and reasons for mismatches will be determined.  Pilot test findings, including findings from reliability visits, will be presented to the Technical Advisory Panel, with recommendations for measure enhancement.  Data collection for all finalized measures will be required by programs currently certified or seeking Comprehensive Stroke Certification.  

How to Register for Consideration as a Pilot Site

Please complete this brief questionnaire to register for consideration as a Pilot Site.  All questionnaires will be reviewed and you will be notified by August 31, 2012 via e-mail whether your organization has or has not been selected as a pilot site.
For further information or questions, please contact Karen Kolbusz, Associate Project Director.

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