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HFAP Stroke Certification19th Annual Stroke Belt Consortium February 201419 Annual Stroke Belt Consortium February, 2014

Therese (Tess) Poland

Terms

• Terms

C tifi ti• Certification

• Benefits of Certification

• HFAP Stroke Certification

• What’s Around the Turnpike

P li I li i• Policy Implications

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Terms

• Designation is operational & political

Att t ti i th i f t• Attestation is the issuance of a report on subject matter that is the responsibility of another party (with & without validation)

• Certification involves an onsite audit by an external organization, of the hospitals e e a o ga a o , o e osp a sperformance against established criteria

CSC PSC

CSC

PSC 4- Levels

VA

KY

IN

MO?

4- Levels

Stroke Center

CSC

CSC PSCSRC

Free standing children's

CSC PSCCSC

PSC4

Levels

CSC PSCSRC

CSCPSCSRC

4Levels

AL

TN

GA

LA

AR

MS

SC

NC

TX

FL

?

OK

PSC

CSC PSC

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ST Level EMS By-Pass

Desig Attest & Application

Data Task Force Provider Leg

AL C P & R Yes Voluntary Yes Yes PHDSPTF TJC ? HJR 32

AR YesData ListRegister

Register/GWTG

AASCTF TJC Ref Bill 326

GA P & R Yes YesSRC ‘/wSurvey

PCRAHA Task

ForceTJC Open SB59

IN C & P NoList

?DesPCR SPTF

TJCHFAP

IC 25-22.5?Des HFAP

KY P No GWTG KHDSP+Q TJC RefEnactedPolicy

LA 4 LevelsStandards

No Yes SRC

No SurveyGWTGLERN

LERN+Q TJC Only Supported

MS C P & R . Voluntary NA GWTG TFHDSP TJC OnlyHB 759 SB

2314

NC P & R Yes List PCR JWHDSP+Q All Bill 456

SC 4 Levels Yes GWTG SSCAC+Q TJC/EquivA62, R81,

SC 4 Levels Yes GWTG SSCAC+Q TJC/EquivS588

TN C & P No GWTG TSSCTF+Q TJC Only Bill 4011

VA 4 Levels Yes Des & List CHQI VSSTF+Q TJC DNV Enacted

FL C & PStandards

Yes Des & List Attest ‘/w Certification

GWTG HDSPState/

TJC/EquivEnacted

TX C P & RStandards

No 2yrsLoA

?SurveyYes

RACRegional Advisory

CouncilsTJC/Apply

HB2344SB1687

Attestation

• Challenges for self attestation / internal audit:– Stroke Coordinator is most likely to complete theStroke Coordinator is most likely to complete the

attestation documents because they are the holder of information. Familiarity enables cultural bias and reduces objectivity

– Responses are limited by the respondents knowledge / interpretation of the question / standard

Specialty program requires specialty knowledge if– Specialty program requires specialty knowledge, if attestation is completed by someone other than the stroke coordinator, information may be limited by the respondents ‘scope’

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Certification Provides

• Objective assessment• Promotes understanding of expectations to g p

customer• Builds confidence in hospital regarding

compliance with requirements• Deficiencies may be deemed critical which

may revoke certification• Provides accountability• Provides accountability

– Compliance monitoring– Corrective action follow-up– Sub-audits at various stages in cycle

Benefits of Certification

• Organize hospital delivery structures towards advanced levels of treatmenttowards advanced levels of treatment

• Improves patient outcomes & LOS

• Improves coordination of care

• Reduces the burden of long-term costs associated with poor outcomesassociated with poor outcomes

• Potential to improve reimbursement rates

• Boosts staff morale and reduce turn-over

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Certification Incentives

• US Center for Medicare and Medicaid Services: implementation of strokeServices: implementation of stroke measures

Pay for Participation Pay for Performance

• Organized stroke care reduces risk:14% Death– 14% Death

– 18% Death or institutionalized care– 18% Death or dependency

Gorelick, P.B. (2012). Primary and Comprehensive Stroke Centers History, Value and Certification Criteria, Journal of Stroke. 15 (2) 78-89.

HFAP Stroke Certification

• Comprehensive Stroke Centers

• Primary Stroke Centers

• Stroke Ready Centers

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What sets HFAP Apart?

• HFAP clinicians provide bi-weekly teleconferencing with clinical staff to assist withteleconferencing with clinical staff to assist with implementation and standards interpretation

• The organization receives a copy of the complete standards manual, which includes scoring procedure used by surveyors

• Three-year certification with an• Three-year certification with an mid-cycle review

• One price inclusive of all costs over the three year period

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Customers Perspective

• “Surveyor was attentive to every detail. Excellent insight into our challenges. Very positive.”insight into our challenges. Very positive.

• “It was clear HFAP surveyors wanted our Stroke Program to "shine" and offered helpful suggestions to reach our goals. The surveyors' approach was nonthreatening and collegial, staff who were interviewed felt at ease, it was a great , glearning experience!”

• “Respectful of staff, courteous, friendly. Listen well. Provides helpful suggestions and applauds our hard work and efforts.”

Customers Perspective

• “As my new role as Stroke Coordinator this was a wonderful experience working with the surveyors.wonderful experience working with the surveyors. They were very knowledgeable about the stroke process and offered improvements as needed to the stroke program.”

• “I do believe that HFAP does force us to continually re-examine our programming and y p g gdoes improve the quality of stroke care in our facilities/communities.”

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What's Happening Around The Turnpike?

• Legislative change and impact on hospitalsEMS bypass– EMS bypass

– State attestation

– State Agency Handoff• Accreditation

• Certification

Policy Implications

• Designation through self evaluation / attestation without an on site validationattestation without an on-site validation

• Sustainability of funding for state attestation

• Value-Based Purchasing impact on CAHs and small rural hospitalsa d s a u a osp a s

• Potential financial penalties associated with inadequate measure performance

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Questions

Therese Poland (RN, BSN, MSN)Quality and Certification

Healthcare Facilities Accreditation Programe: tpoland@hfap.org p: 312-202-8076

www.hfap.org Healthcare Facilities Accreditation Program @HFAPquality

References• Higashida, R., Alberts, M.J., Alexander, D.A., Crocco, T.J., Demaerschalk, B.M.,

Derdeyn, C.P., Goldstein, L.B., Jauch, E.C., Mayer, S.A., Meltzer, N.M., Peterson, E.D., Rosenwasser, R.H., Saver, J.L., Schwamm, L., Summers, D., Wechsler, L. and Wood, .P. (2013). Interactions Within Stroke Systems of Care: A Policy , ( ) y yStatement From the American Heart Association/American Stroke Association. Stroke, 44:00-00.

• Simons, R. & Kilpatrick, A. (2002). Assuring Optimal Trauma Care: The Role of the Trauma Center Accreditation, Trauma and Critical Care. 45 (4) 288-295.

• Gorelick, P.B. (2012). Primary and Comprehensive Stroke Centers History, Value and Certification Criteria, Journal of Stroke. 15 (2) 78-89.

• Castka, P. (2013). Audit and Certification: What Do Users Expect? Study conducted by the Q21 Research Group University of Canterbury and Jointconducted by the Q21 Research Group, University of Canterbury and Joint Accreditation Systems Australia and New Zealand (JAS-ANZ).

• Hunter, R.M., Davie, C., Rudd, K., Thompson, A., Walker, H., Thomson, N., Mountford, J., Schwamm, L., Deanfield, J. Thompson, K., Dewan, B., Mistry, M., Quoraishi, S. & Morris, S. (2013). Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model. PLOS ONE, 8 (8) e70420, 1-9.