At last count, 12 hospitals have received the coveted designation as "Comprehensive Stroke Centers," a new level of certification for advanced stroke care by the Joint Commission.
The Joint Commission examination process isn't exactly easy, neither on the heart, nor the brain of the physicians and other healthcare leaders being evaluated.
In formal announcements of their accomplishment, nearly all hospitals describe the Joint Commission review using one word: "rigorous."
"They were tough on us," neurologist Bob Carter, MD, PhD, chief of neurosurgery at the UC San Diego Medical Center in California told me in a recent interview, sharing some behind-the-scenes insights about the Joint Commission's in-depth analysis.
"They asked us a lot of hard questions, and pored over records in detail. It was probably the most rigorous [review] I had in 35 years as a neurosurgeon. This was one of the toughest exams we had."
UC San Diego Medical Center is among the most recent recipients of the Comprehensive Stroke Center designation established by the Joint Commission and the American Heart Association/American Stroke Association.
The designation recognizes significant effort in everything from training to infrastructure to providing state-of-the-art complex stroke care. As HealthLeaders Media reported in November, the comprehensive review process is much more extensive and lengthy than what is required for lesser designations, such as that of a Primary Stroke Center.
Gregory Albers, MD, director of the Stanford Stroke Center at Stanford Hospital and Clinics in Palo, Alto, CA, calls it a tough process. The stroke team leader recalled that the Joint Commission asked how long it took for neurosurgeons to get to the operating room. Albers told them. Then they asked to see the data that proved it.
As Carter told me, the Joint Commission not only evaluates records and outcomes, but also the necessity for "team-based" approaches, as well as proof of the roles that practitioners and nurses play in providing care. In addition, the commission focused on patient safety and patients' understanding of procedures following discharge, Carter says.
What's more, some of the Joint Commission's insightful questions prompted the UC San Diego Medical Center to re-examine their procedures in stroke care, Carter said. In fact, that response reflects how they made their journey toward the Comprehensive Stroke Center designation in the first place.
Several years ago, as they examined their primary stroke care program, officials of the UC San Diego Medical Center found there were gaps in stroke care for the city's aging population.
While primary stroke centers can handle many patients, certain other patients with severe conditions required a higher level of care, which the hospital believed it wasn't providing.
San Diego then took steps to target patients who too often fall through the cracks in stroke care, according to Thomas Hemmen, MD, PhD, director of the stroke program at UC San Diego Medical Center.
"There's a significant proportion of stroke patients who have a really large blood clot in the brain, or they have a brain bleed or a stroke that is so severe that it either [triggers] a coma or seizure," Hemmen explains.
"They need to come to a place where, at the door, all options are on the table. If you need to go to a surgery right away; if you need to go to the cath lab to remove the large blood clot right away or you go to the intensive care unit where a specialized physician who is trained in the neurology of intensive care looks after your brain function."
The UC San Diego Medical Center team's multidisciplinary programs often target the elderly. Four in 10 of its stroke patients are over the age of 80, Hemmen says. An estimated 7 million Americans have had some form of stroke, the fourth-leading cause of death in the U.S.
Treating patients is one thing. Awaiting the Joint Commission's decision on certification is something else. And, Carter admits, that's a little scary. When his organization went through the process, he wondered if it would work out. "They put us through the wringer and made me respect the process more. I think we were confident, but yeah, we were a little nervous."
The Joint Commission, for instance, examined each record of patients with a hemorrhagic stroke. Carter says. "They pored through the charts very carefully and made sure our reports matched up with what their reviews had," Carter says. "That's a level of rigor and detail that you typically would not necessarily get. I thought it was pretty impressive."
The Joint Commission didn't stop strictly at the end result of clinical aspects of care, but it delved into how they got to those outcomes—through the "emphases on team work and process," he adds. The commission made it clear that, for comprehensive care, a successful hospitalization is not the only endgame, Carter says.
"They very much wanted to understand that we educated the patient for discharge, and made sure that patients understood the implications of their strokes and the implication of downstream medical care and the monitoring they would need. They were rigorous and made us prove what we said we were going to do."
There is much talk about alignment in healthcare, not only with physicians, but with nurse practitioners in coordinating care. That was evident in the Joint Commission's review, Carter says. "It wasn't good enough to say, ‘We have a nurse educator.' We had to show what the practitioner did, and they made us prove we did what we said we were doing."
The Joint Commission review also showed that despite the hospital's progress, there were still lessons to be learned, with specific details of stroke care that will continue to be reviewed and evaluated. "They made us look at every process," Carter says. "Is this a necessary process? Or, is this just a historical process that we've done?"
As a result of the Joint Commission's detailed review, the San Diego hospital, for instance, evaluated its use of CAT scans. "We found small things contributing to delays (in care), such as the way the CAT scans were ordered," he says. Eventually, the hospital adjusted its electronic medical record [system] to improve "time and efficiency" in using CAT scans as well as other procedures, Carter adds.
While there are now 12 comprehensive stroke centers, Carter anticipates that there may eventually be dozens more, as well as more than 1,000 primary care stroke centers "when this all shakes out with the Joint Commission."
Unfortunately, not all stroke centers, despite their designation, work together as a team to provide stroke care. That should change, Carter says. All stroke centers need to better coordinate care for stroke patients, especially under emergency conditions. Carter equates such an effort as similar to trauma centers.
"When there's an auto accident, it's immediately known where to send the patient," Carter says, noting that EMS crews immediately decide what's necessary for an injured motorist, and what hospital is equipped to provide best treatment. That's been successful," Carter says. "The same should be done for a stroke patient."
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
