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ENCSN Quality Improvement Workgroup

Workgroup Goal: "The QI workgroup will help make stroke care monitoring and quality improvement tools such as the American Heart Association's 'GetWithTheGuidelines'-Stroke(GWTG) and the North Carolina Stroke Care Collaborative (NCSCC) available to Eastern North Carolina hospitals in order to improve a hospital's level and quality of care for stroke patients."

Workgroup chairs: Cris Small, csmall@pcmh.com (252) 847-2494, and Ron Cromartie, Ron.cromartie@heart.org, 919) 463-8332





Next Meeting
February 16, 2010 (2:30-3:30)
Conference Call line 218-486-1616, passcode *950659*

  • Quality Improvement Workgroup Meeting Minutes, 1/13/10
  • Quality Improvement Workgroup Meeting Minutes, 11/19/09
  • Quality Improvement Workgroup Meeting Minutes, 10/14/09
  • Quality Improvement Workgroup Meeting Minutes, 9/24/09
  • Quality Improvement Workgroup Meeting Minutes, 7/9/09
  • Quality Improvement Workgroup Meeting 4/8/09 (no meeting minutes)
  • Quality Improvement Workgroup Meeting Minutes, 3/24/09
  • Quality Improvement Workgroup Meeting Minutes, 2/23/09
  • Quality Improvement Workgroup Meeting Minutes, 1/15/09

    • Quality Improvement Resources

    The Joint Commission Disease-Specific Care Update

    World Stroke Organization Clinical Practice Guidelines

    Development Handbook for Stroke Care

    The clinical practice guideline development handbook for stroke care has been developed by the WSO Stroke Guideline Sub-Committee from January to June 2009.

    This handbook has been developed to provide a basic guide for healthcare professionals who wish to develop or adapt clinical guidelines for stroke care across any point in the continuum of care.

    This handbook is particularly intended for healthcare professionals who manage stroke patients in developing countries or where healthcare resources are scarce. It aims to promote the use of evidence-informed care through locally developed or adapted guidelines without compromising the quality of the resource.



    QI Tools: Dysphagia Screening

    See below for a document on implementing a dysphagia screening program from the Canadian Stroke Registry.

    American College of Emergency Physicians Article on tPA Litigation



    CMS to focus on stroke care in U. S. hospitals.

    A new rule from the U.S. Centers for Medicare and Medicaid Services unveiled an upcoming addition to the structural measures for payment determination: participation in a database registry for stroke care, such as Get With The Guidelines®-Stroke from the American Heart and American Stroke Association.

    Beginning in 2010, hospitals must note whether they participate in such a registry when submitting Medicare claims for stroke. The rule also identifies stroke care quality measures hospitals may be required to report for reimbursement beginning in 2012. All of the measures listed in the rule have been included in Get With The Guideline-Stroke since 2001.

    For the thousand-plus acute care hospitals already participating in Get With The Guidelines-Stroke, the rule indicates that their stroke quality improvement efforts are being recognized and rewarded at the highest levels.

    For hospitals that do not currently participate in Get With The Guidelines-Stroke, it means the new CMS requirement can be met by implementing an award-winning program demonstrated to improve patient outcomes. This presents an ideal opportunity for hospitals not currently participating in Get With The Guidelines-Stroke to join. Those hospitals that begin participating in the initiative by January 1, 2010, will be able to report to CMS that they are participating in a qualifying registry for stroke care.

    More information on Get With The Guidelines-Stroke can be found at www.americanheart.org/getwiththeguidelines.


    Press Release


    August 2009 TJC update (Joint Commission)

    Performance measurement: Stroke Panel advises no change to t-PA measure

    At this time, no change is being made to the t-PA administration measure for stroke (STK-4: Thrombolytic Therapy), based on the advice of The Joint Commission’s Disease-Specific Care Stroke Performance Measure Advisory Panel, which convened August 12. The panel discussed possible changes to the stroke measure due to a May 28, 2009 science advisory issued by the American Heart Association (AHA)/American Stroke Association (ASA) which expanded the timeframe for t-PA administration from three to four-and-one-half hours. The panel recommended that no changes be made to the measure at this time because the Food and Drug Administration has not approved the expanded timeframe. In the meantime, the American Stroke Association’s Get With The GuidelinesSM-Stroke (GWTG) program will collect data on several different timeframes. The advisory panel will reconvene in early 2010 to review the GWTG data and to see if the FDA has approved any changes to the prescribing guidelines for t-PA. Note to certified primary stroke centers: Currently, there is no penalty (i.e., standards non-compliance) for cases in which t-PA is administered beyond the three-hour timeframe, nor will there be in the future. (Contact: Karen Kolbusz, kkolbusz@jointcommission.org)

    UPDATE: National Reporting of Stroke Measures

    (provided by NCSCC Staff, June 2009)

    Purpose
    The purpose of this update is to inform NC Stroke Care Collaborative (NCSCC) hospitals’ stroke staff [and ENCSN QI workgroup members] of the current issues around national reporting of stroke measures. NC Department of Public Health (DPH) is not the authority on these issues. Our goal is to notify you of the developments of which we are aware. We encourage you to discuss these topics with your Quality Improvement/Performance Improvement Departments. The information below summarizes recent actions by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) related to stroke performance measures.

    Background
  • In 2008, the National Quality Forum (NQF) endorsed 8 of the 10 stroke consensus measures listed below. The dysphagia screening and smoking cessation measures were not endorsed.

    Measure ID # Measure Short Name
    STK-1 Venous Thromboembolism (VTE) Prophylaxis
    STK-2 Discharged on Antithrombotic Therapy
    STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter
    STK-4 Thrombolytic Therapy
    STK-5 Antithrombotic Therapy By End of Hospital Day 2
    STK-6 Discharged on Statin Medication
    STK-8 Stroke Education
    STK-10 Assessed for Rehabilitation

    TJC
    Effective Oct. 1, 2009, TJC will include the 8 NQF-endorsed stroke measures as a new measure set for core measure reporting for accredited hospitals. For more information about issues related to TJC, go to these sites:

    TJC Performance Measurement
    http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/

    Specifications Manual, starting October 1, 2009
    http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Future+NHQM+Manuals.htm

    TJC Stroke Core Measures
    http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/STK+Core+Measures.htm

  • Outcome Science is developing the capability for stroke measure submission directly to TJC from the Patient Management Tool for an annual fee of $2,887. Joint Commission PSC hospitals will not be charged the fee. All GWTG-Stroke hospitals were contacted via email. For details, contact Outcome at (888) 526-6700.
  • We encourage you to discuss this with your Quality Improvement/Performance Improvement departments or those responsible for TJC core measures at your institution.

    CMS
  • CMS publishes the Inpatient Prospective Payment System (IPPS) annually which outlines the reportable performance measures that impact hospital reimbursement rates for Medicare patients under the National Hospital Inpatient Quality Measures.
  • On April 30, 2009, the FY2010 IPPS proposed rule was published. The document is available online at:
    http://www.regulations.gov/fdmspublic/component/main?main=DocumentDetail&o=09000064809ac032
  • The IPPS includes a “structural measure” proposing to require hospitals to report whether or not they are participating in a stroke registry, and if so, the name of the registry. This would go into effect October 2009.
  • The IPPS rule proposed that the 8 NQF-endorsed stroke measures NOT be collected until October 2010.
  • CMS is considering submission of the data via existing registries (e.g.: the NCSCC or GWTG-Stroke) as well as submission via electronic medical records.

    Action Requested
    We are in the middle of a 60-day comment period for the proposed rule. Comments are due June 30, 2009. Hospital staff is encouraged to offer comments.

    Comments can be submitted electronically to the CMS website:
    http://www.regulations.gov/fdmspublic/component/main?main=DocumentDetail&o=0900006480971cd2
    Click on the comment icon for Document ID CMS-2009-0034-0003

    Suggested Talking Points*
    These are suggested talking points. We encourage you to use these as a guide but to comment using your own language.
  • 1. Indicate support of the inclusion of the 8 NQF-endorsed stroke quality indicators in the FY2010 RHQDAPU initiative.
  • 2. Explain your participation in the NCSCC and your support for data collection to be done via existing registries to reduce the burden for hospitals.
  • 3. Indicate your support for the dysphagia and smoking cessation measures to be included in the stroke set.
  • 4. Explain how focusing on stroke measures has improved the quality of care provided at your institution.

    *These talking points are only the opinions of the state program managers for the Centers for Disease Control and Prevention (CDC) Paul Coverdell National Acute Stroke Registry and do NOT reflect any official position of the CDC, the American Heart Association, or the NC DPH.

    For more information, please contact the Quality Improvement/Performance Improvement Department at your institution.

    The Joint Commission 10 Harmonized Stroke Measures



    8 NQS/CMS Measures


    Stroke Quality Improvement Endorsed by the NC Stroke Advisory Council

    Justus-Warren Heart Disease and Stroke Prevention Legislative Task Force

      RECOMMENDATION #3
      The Council recommends expanded use of recognized stroke registries to monitor and improve the quality of acute stroke care in NC. Performance improvement stroke tools must be designed to:

      • Improve the quality of stroke care
      • Facilitate secondary prevention
      • Enhance communication between emergency responders, hospitals, providers and other key stroke stakeholders
        (11;"Prelimary Findings and Recommendations of a NC System of Stroke Care," 2007)
        NOTE: This recommendation was used to successfully request NC legislative funding in 2007.

      Download full 2007 Stroke Advisory Report, "Preliminary Findings and Recommendations for a NC System of Stroke Care."



    Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition

      Alberts MJ et. al. Recommendations for Comprehensive Stroke Centers: A Consensus Statement From the Brain Attack Coalition. Stroke 2005;36;1597-1616. Download article.



    NC Map of Stroke QI Programs


    CDC Division of Heart Disease and Stroke Prevention (DHDSP) Data Products/Documents

    Below is a downloadable word document with hypertext links to many CDC Division of Heart Disease & Stroke Prevention online guides, documents, and websites that could be useful to those needing national or statewide data on stroke and heart disease.

    NC Stroke Care Collaborative/NC Stroke Registry (NCSCC)


    Contact: Carol Murphy
    cmurphy@unc.edu
    (919) 843-2396
  • Download NCSCC brochure here
  • Download NCSCC January 2010 Quarterly Newsletter here
  • Download NCSCC February 2009 Newsletter here

      (Map Accurate as of December 2009)

      Paul Coverdell National Acute Stroke Registry For Quality Improvement. The goals of the North Carolina Stroke Care Collaborative are to: Evaluate the current state of stroke care in North Carolina; Facilitate quality of stroke care improvements in NC hospitals; Build a foundation for a state-wide stroke registry.

      More Information about NCSCC



    Get with the Guidelines-Stroke (GWTG-Stroke)

    Contact: Ron Cromartie, FAHA Senior Consultant, Quality Improvement
    American Heart Association
    Mid-Atlantic Affiliate
    Quality Improvement Initiatives
    Get With The Guidelines
    3131 RDU Center Drive, Suite 100
    Morrisville, NC 27560
    (919) 463-8332 (direct)
    (919) 463-8292 (fax)
    (919) 491-6595 (mobile)
    Ron.cromartie@heart.org

  • Download GWTG brochure here
  • GWTG Stroke Fact Sheet
      Get With The Guidelines-Stroke (GWTG-Stroke) helps ensure continuous quality improvement of acute stroke treatment and ischemic stroke prevention. It focuses on care team protocols to ensure that patients are treated and discharged appropriately. The program is available for implementation at acute care hospitals nationwide.


    Presentations from the GWTG-Stroke Meeting
    5/13/09 in Durham, NC

    Get With The Guidelines Publications and Program Results
    Links to articles relevant to Stroke QI:
    • Schwamm L., Fonarow G., Reeves M., Pan W., Frankel M., Smith E., Ellrodt G., Cannon C., Liang L., Peterson E., LaBresh K. Get With The Guidelines-Stroke is Associated with Sustained Improvement in Care for Patients Hospitalized with Acute Stroke or TIA. Circulation (December 2008) News Release

    • Reeves M., Fonarow G., Zhao X., Smith E., Schwamm L. Quality of Care in Women With Ischemic Stroke in the GWTG Program. Stroke (February 2009)

    • LaBresh K.A., Reeves M.J., Frankel M.R., Albright D., Schwamm L.H. Hospital Treatment of Patients with Ischemic Stroke or Transient Ischemic Attack with Get With The Guidelines. Arch Intern Med (2008;168(4):411-417) Read article (February 2008)

    • Reeves M., Smith E., Yu Y., Schwamm L. Off-Hour Admission and In-hospital Stroke Case Fatality in the Get With The Guidelines-Stroke Program. Stroke. DOI: 10.1161/STROKEAHA.108.519355. Read article (November 2008)