Facts about Primary Stroke Center Certification | Joint Commission
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Facts about Primary Stroke Center Certification

January 6, 2015

The Joint Commission's Primary Stroke Center Certification Program, launched in December 2003, was developed in collaboration with the American Heart Association/American Stroke Association (AHA/ASA). Currently, there are more than 1,000 certified primary stroke centers in 49 states plus Puerto Rico. Certification is available only to programs in Joint Commission-accredited acute care hospitals.

The Certificate of Distinction for Primary Stroke Centers recognizes centers that follow the best practices for stroke care. Applicants for advanced certification must meet the requirements for Disease-Specific Care Certification plus additional, clinically specific requirements and expectations. Certified primary stroke centers:

  • Use a standardized method of delivering care

  • Support patient self-management activities

  • Tailor treatment and intervention to individual needs

  • Promote the flow of patient information across settings and providers, while protecting patient rights, security and privacy

  • Analyze and use standardized performance measure data to continually improve treatment plans

  • Demonstrate their application of and compliance with clinical practice guidelines published by the AHA/ASA or equivalent evidence-based guidelines

Certification process

On-site certification reviews are conducted by reviewers with expertise in stroke care. The certification decision is based on the evaluation of standards, implementation of clinical practice guidelines and performance measurement activities. Primary Stroke Centers that successfully demonstrate compliance in all three areas are awarded certification for a two-year period. At the end of the first year, the organization is required to participate in a conference call to attest to its continued compliance with the standards and to review performance improvement activities.

Standards

The standards are published in the Comprehensive Certification Manual for Disease-Specific Care. They incorporate the “Recommendations for the Establishment of Primary Stroke Centers” developed by the Brain Attack Coalition. The chapters address:

  • Program management

  • Delivering or facilitating clinical care

  • Supporting self-management

  • Clinical information management

  • Performance improvement and measurement

Performance measurement

Certified primary stroke centers must collect and report on eight stroke core measures. Data can be self-submitted quarterly to The Joint Commission through a secure extranet site, or data can be submitted through a vendor. The eight stroke core measures (also approved as a core measure set for The Joint Commission’s ORYX program) are: 

  • Venous thromboembolism (VTE) prophylaxis*

  • Discharged on antithrombotic therapy

  • Anticoagulation therapy for atrial fibrillation/flutter

  • Thrombolytic therapy*

  • Antithrombotic therapy by end of hospital day two

  • Discharged on statin medication*

  • Stroke education*

  • Assessed for rehabilitation

Certified programs must use the current version of the Specifications Manual for National Hospital Inpatient Quality Measures manual. Future versions are posted six months prior to the effective date, and “Release Notes” show all the changes made to a particular version.  Questions about core measure specifications can be submitted to the Performance Measurement Q&A Forum.

*Data collection for four measures – VTE prophylaxis, thrombolytic therapy, discharged on statin medication, and stroke education – continues to be a requirement of the Centers for Medicare & Medicaid Services (CMS) Hospital Inpatient Reporting Program (HIRP). 
 
Government recognition

Currently, 19 states require or recognize The Joint Commission’s Primary Stroke Center or Comprehensive Stroke Center Certifications for designation as a primary stroke center. These include Delaware, Florida, Georgia, Illinois, Maryland, Missouri, New Mexico, North Dakota, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, Virginia and Washington. For more information about government recognition, contact Jen Hoppe, associate director, State Relations, 630-792-5261.

Information available to the public

Quality Reports for Joint Commission certified Primary Stroke Centers are available on the Quality Check™ website. 

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Primary Stroke Center Certifcation

 

 
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