The Joint Commission reports high interest in new certification program for Comprehensive Stroke Centers
New certification program offers potential for improved recognition, reimbursement
More than 900 hospitals have been certified as Primary Stroke Centers since The Joint Commission (TJC) and the American Heart Association (AHA)/American Stroke Association (ASA) introduced the Primary Stroke Center certification program back in 2003. But now both TJC and the AHA/ASA believe the time is right to enable hospitals capable of treating the most complex types of stroke to seek designation as Comprehensive Stroke Centers, a higher level of certification that recognizes institutions with the advanced resources, technology, and personnel to care for patients with the most severe and challenging types of stroke.
The accrediting agency says the new program, which was launched September 1, has already attracted considerable attention and interest from hospital administrators who believe their centers could benefit from the higher level of certification. At press time, dozens of hospitals were in the process of seeking certification as Comprehensive Stroke Centers, explains Jean Range, MS, RN, CPHQ, the executive director of Disease-Specific Care Certification at TJC.
"We believe that this is really the next step in providing a mechanism to support organizations that are looking to provide state-of-the-art care for patients with stroke," says Range. "This [type of designation] is also being added to some state-based and county-based legislation as well, so it makes a lot of sense to move to comprehensive stroke certification at this time."
Expert panel calls for higher-level program
As with the move to establish a certification program for Primary Stroke Centers, the new higher-level certification program is in response to recommendations by the Brain Attack Coalition, a multidisciplinary panel that includes representatives from professional groups such as the American College of Emergency Physicians, the National Institutes of Health (NIH), the Congress of Neurologic Surgeons, the American Academy of Neurology, the Centers for Disease Control, the AHA/ASA, and other groups that are responsible for stroke care in the United States.
"We all convened over the course of several years under the auspices of the NIH, and we developed these criteria. We researched them, we vetted them, and got them published," explains Mark Alberts, MD, FAHA, a professor of neurology and chief of the Division of Stroke and Cerebrovascular Disease at Northwestern University in Evanston, IL, and a spokesperson for the AHA/ASA.1
Alberts explains that Primary Stroke Centers were designed and conceptualized to deal with the large number of stroke patients who have "relatively uncomplicated strokes." These are typically ischemic stroke patients who don't require a lot of emergency interventions, endovascular therapy, or surgery, he says.
"The elements, the processes, the personnel, and the infrastructure of a Primary Stroke Center would be perfectly capable of taking care of a run-of-the-mill, uncomplicated stroke patient," notes Alberts. "However, when you start talking about patients with large strokes, complicated strokes, hemorrhagic strokes, or strokes in the setting of multi-system disease or failure, then you really need the resources, personnel, and the infrastructure of a Comprehensive Stroke Center."
Which hospitals should consider becoming certified as Comprehensive Stroke Centers? Alberts says that many of the large academic medical centers that are referred have very sick, very complex patients who require advanced diagnostic and treatment approaches that fit the definition of a Comprehensive Stroke Center. However, he adds that some large community hospitals may have the resources and specialists to fit the definition as well.
"Getting certified might be advantageous in terms of increasing their recognition, increasing their profile, and, maybe even down the road, with government agencies and insurance carriers, perhaps supplementing their reimbursement because the elements of a Comprehensive Stroke Center should translate into better outcomes," observes Alberts.
Program builds toward a stroke system of care
However, Range emphasizes that it is clear that not all Primary Stroke Centers should even consider this advanced level of certification. "Our objective and our mission is to improve the quality of care for patients and safety, and so clearly we would like to see organizations that are appropriate for the designation of Comprehensive Stroke Center step up, and we would like to see organizations that are candidates for seeking certification as a Primary Stroke Center continue to come forward as well, and they are doing so," notes Range. "Ultimately what we would like to see is Primary Stroke Centers working collaboratively together with regional Comprehensive Stroke Centers in almost a system process."
Alberts agrees, explaining that an underlying concept behind the different levels of certification is to have a well-defined stroke system of care that has some similarities to the network of trauma centers in which there are different levels. With respect to stroke care, Alberts sees four different tiers of hospitals.
"At the very bottom would be hospitals that don't do stroke; they have no interest or expertise. A tier up from that would be hospitals that are acute stroke-ready hospitals that would be able to receive acute stroke patients, diagnose, and then stabilize them, and then very rapidly transport them to either a Primary Stroke Center or a Comprehensive Stroke Center," he explains. "These acute stroke-ready hospitals would typically be very small hospitals in small cities or rural locations, and they would network with a Primary Stroke Center if they had a patient with an uncomplicated, straightforward stroke, or a Comprehensive Stroke Center if it looked like the patient had a large stroke, a bleeding stroke, or something that was going to be very complex to diagnose and treat."
The Primary Stroke Centers are the foundation of the system, says Range, describing them as hubs with many spokes. While there are nearly 1,000 of these centers across the 50 states and Puerto Rico, most experts anticipate that there will ultimately be about 200 Comprehensive Stroke Centers. "This fits with the description that these will be referral centers that provide a different level of services," she says.
Certification includes two-day, on-site evaluation
The Comprehensive Stroke Center certification process includes a two-day, on-site evaluation by two evaluators from TJC, explains Range. "However, depending on the outcome of this evaluation, there may be corrective action plans that need to be developed," she says. "Certification is not awarded until those corrective action plans have been accepted, and any requirements for improvement have been cleared."
Since the time it takes to become certified can vary, it was not yet clear when the first Comprehensive Stroke Centers will become certified. However, there is high interest in the new program, according to M.J. Hampel, MPH, MBA, the senior associate director of Disease-Specific Certification at TJC. "I am not quite as busy as I was back in 2003 when we launched Primary Stroke Center certification, but the questions we have been getting are very detailed around the requirements," she says.
For example, Hampel explains that many hospital administrators want to know what the case volume requirements are for institutions that are interested in becoming certified as Comprehensive Stroke Centers. She notes that the requirements state that hospitals must:
- receive a minimum of 20 subarachnoid hemorrhage patients per year;
- perform a minimum of 15 endovascular coiling or surgical clipping procedures for aneurysm per year;
- administer IV tPA to an average of at least 25 eligible patients per year.
Ultimate goal: Improved outcomes
In the next few months, Alberts anticipates that dozens of hospitals will become certified as Comprehensive Stroke Centers, and he believes that patients will ultimately benefit from a strengthened network of stroke care. "The bottom line for me has always been improving patient outcomes," he says. "At a Comprehensive Stroke Center, we are dealing with the sickest stroke patients, the most complex patients, the patients that require the most intensive care, and, in some cases, require surgery or other interventions. For those patients to have a better outcome in terms of reduced death or disability is a very good outcome for patients and it is a good outcome for the health care system in terms of using our limited resources in an efficient manner."
Reference
- Alberts M, Latchaw R, Selman W, et al. Recommendations for Comprehensive Stroke Centers: A consensus statement from the Brain Attack Coalition. Stroke 2005;36:1597-1616.
Sources
- Mark Alberts, MD, FAHA, Professor of Neurology, Chief, Division of Stroke and Cerebrovascular Disease, Northwestern University, Evanston, IL. E-mail: [email protected].
- M.J. Hampel, MPH, MBA, Senior Associate Director, Disease-Specific Certification, The Joint Commission, Oakbrook Terrace, IL. E-mail: [email protected].
- Jean Range, MS, RN, CPHQ, Executive Director, Disease-Specific Care Certification, The Joint Commission, Oakbrook Terrace, IL. E-mail: [email protected].
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