Application / Reapplication For

Application / Reapplication for

Comprehensive Stroke Center

Certification

Eligibility

To be eligible to apply for Comprehensive Stroke Center Certification, healthcare facilities must be currently accredited.

Eligibility is assessed pre-survey by the submission of required documents and the provision of information within this application.

All applications must be accompanied by the appropriate fees. Contact the HFAP office for specifics regarding your facility.

For questions regarding this process, please contact our offices at or 312-202-8258.

A Program of the American Osteopathic Association

142 East Ontario Street Chicago, IL 60611-2864

Required Documents

Comprehensive Stroke Certification

142 East Ontario Street, Chicago, Illinois 60611-2864 • 800-621-1773 x 8258 • 312-202-8258

To initiate the HFAP Comprehensive Stroke Center certification process, submit the following documents along with the biennial registration fee. These materials will be reviewed by the surveyor team in advance of the onsite survey to determine eligibility.

Administration

1. Application Form, completed

2. Application for Certification Survey Agreement, signed (last page)

3. Business Associate Agreement, signed

4. Organizational Chart, depicting the Comprehensive Stroke Center

5. Copy of the current state hospital license

Written Protocols

Protected stroke beds in the ICU02.00.01
Stroke Unit 02.00.02
Selection criteria, management, and monitoring of patients receiving tissue Plasminogen Activator (tPA) Therapy and anticoagulant reversal drugs02.00.05
Use of intravenous vasopressor, antihypertensive, and positive inotropic agents02.00.05
Process once the operating room order is activated to ensure and OR is staffed and ready to operate within 2 hours of order02.00.07
Admission inclusion and exclusion policy 02.00.01; 02.00.02; 02.02.01
Stroke assessment protocol with time parameter interventions relating to triage, stabilization, stroke workup, diagnostic tests and use of medications02.02.02
Process for endovascular recanalization02.00.07; 02.02.01
Process for the rapid assessment of patients with TIA02.02.01; 02.02.02
Use of therapeutic hypothermia protocols02.02.01
Nursing management and monitoring Hemorrhagic stroke (intracerebral hemorrhage and subarachnoid hemorrhage)02.02.01
Nursing management and monitoring malignant ischemic stroke with craniectomy02.02.01
Nursing management and monitoring increased intracranial pressure02.02.01
Nursing management and monitoring atrial fibrillation02.02.01
Nursing management and monitoring respiratory management for invasive and non-invasive ventilation02.02.01
Nursing management and monitoring nursing care of patients receiving thrombolytic and/or intra-arterial rescue therapy02.00.05; 02.02.01
Rehabilitation02.02.04
Discharge planning02.03.05
Post-Hospital care coordination and follow-up02.03.05

Required Documents

Comprehensive Stroke Certification

142 East Ontario Street, Chicago, Illinois 60611-2864 • 800-621-1773 x 8258 • 312-202-8258

Documents

The neurological evaluation tool utilized throughout facility02.02.02
The Acute Stroke Team Response Log (recent sample page)02.04.03
Research plan01.03.01

Quality Data

Submit all items above and the following QAPI monthly outcome data(SM1-21):

1. SM-1 Stroke team arrival

2. SM-2 Laboratory policies/data that reflect turnaround time

3. SM-3 Neuroimaging studies that reflect timeline for completion and interpretation of CT/MRI brain scans

4. SM-4 Neurosurgical services are available within timeframe if need, if applicable

5. SM-5 Patients eligible for tPA received tPA within three (3) hours of symptom onset and if not, documentation to reflect reason and plan of correction

6.SM-6 Number of patients received 1st dose antithrombotic therapy by end of hospital day 2

7.SM-7 Number of patients given prescription for antithrombotic at time of discharge

8.SM-8 Anticoagulation Therapy for Atrial Fibrillation/Flutter

9.SM-9 Venous Thromboembolism (VTE) Prophylaxis

10.SM-10 Discharged on Statin Medication

11. SM-11 Stroke education prior to discharge

12. SM-12 Dysphagia screen prior to receiving anything by mouth

13. SM-13 Assessed for physical rehabilitation

14. SM-14 Door-to-Needle time

15. SM-15National Institutes of Health Stroke Scale Score on Arrival -1

16. SM-16Severity Measurement on Arrival

17. SM-17Clipping / Coiling within 48 hours

18. SM-18Nimodipine Treatment within 24 hours to <21 days

19. SM-19INR Reversal

20. SM-20Diagnostic Neuroangiography within 24 hours

21. SM-21Physical rehab referral prior to discharge

Section A: Organization Information

Hospital Name (as it should appear on the Comprehensive Stroke Center Certificate):

Street Address

City/State/Zip

Main Facility Telephone NumberWeb Site Address

Does your hospital have Wi-Fi capabilities in all areas of the building? No Yes
Medicare Provider Number:Medicaid Provider Number:
Is this hospital part of, owned, operated, managed by, or affiliated with another organization such as a corporate health system or a multi-hospital group? No Yes If yes, provide information:
Corporate Name

Corporate Street Address

City/State/Zip

Corporate CEO NameEmail

PhoneCorporate Web Site Address

Section B: Quality / Statistical Information

HFAP requires that all data / statistics reported are for the most recent twelve (12) month reporting period (three (3) months for initial Stroke Certification Application and six months available at time of survey), unless otherwise stated.

A. Total Number of patients treated (according to the Acute Stroke Protocol):

Indicate the number of Acute Stroke Response Team members for each category.

Role / Total / Role / Total
Neurologists / Nurse Practitioner
Physicians with cerebrovascular experience / APNs (neuroscience)
Other: / Registered Nurses
Other: / Other:

SECTION C: Existing Accreditation / Certification

Indicate below, any addition certification(s) the Primary Stroke Center currently holds.

Check all that apply:

 / Organization / Enter accreditation / certification organization name and date of expiration.
Accreditation / From: / Expiration date:
Laboratory / From: / Expiration date:
Radiology / From: / Expiration date:
Other: / From: / Expiration date:
Other: / From: / Expiration date:
Other: / From: / Expiration date:
Other: / From: / Expiration date:
Other: / From: / Expiration date:

SECTION D:

Service Provision / Compliant
Neurosurgical coverage is available by phone within 20 minutes and onsite within 45 minutes of request / No Yes
Credentialed Medical Director/designee available 24hours, 365days / No Yes
Credentialed Neurointerventionalist available 24hours, 365days / No Yes
Credentialed Physician with imaging experience in head CT and brain MRI available 24hours, 365days / No Yes
Credentialed Diagnostic radiologist (includes telemedicine) available 24hours, 365days / No Yes
Credentialed Critical Care Physician available 24hours, 365days / No Yes
Credentialed Physician with cerebrovascular experience available 24hours, 365days / No Yes
Credentialed Neurosurgeon with expertise in cerebrovascular surgery available 24hours, 365days / No Yes
Credentialed Surgeon with expertise in carotid endartectomy available 24hours, 365days / No Yes
Credentialed emergency department physicians experience in diagnosis and treatment of patients with ischemic stroke, ICH & ACH and the use of IV thrombolytic therapy available 24hours 365days / No Yes
There is a peer review process for review and management of acute stroke patients / No Yes
Stroke Center participates in human research and has a current research activity plan / No Yes
ICU has designated beds with designated nursing team and medical team who have training and expertise in neurocritical care in the diseases that the patients have / No Yes
Stroke Unit is established to provide continuity of care following the immediate, hyperacute phase of an acute stroke / No Yes
X-Ray and ECG services are available to be performed and read within 45 minutes of request, 24 hours a day - every day of the year / No Yes
Lab testing is performed within 45 minutes is available 24hours, 365days / No Yes
Neuro-imaging services are available to be performed and read) within 45 minutes, 24hours, 365days and include:
MR angiography- MRA (head and neck)
MRA (head and neck) available within 2 hours of being ordered
MRI (head and neck), including diffusion weighted MRI
CT (head & neck) angiography
Catheter angiography performed within 60 minutes of being ordered
Extracranial ultrasonography
Additional Services available as per physician order:
Carotid duplex ultrasound
Transthoracic Echocardiography
Transesophageal Echocardiography
Transcranial Doppler / No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
Neurosurgical evaluation is conducted within 45 minutes and an operating room is staffed and ready to operate within two (2) hours of order 24hours, 365days / No Yes
CSC cares for 20 (or more) subarachnoid hemorrhage patients per years / No Yes
CSC performs 25 clippings and or; endovascular coiling’s surgeries (acute or elective) for aneurysms per year / No Yes
CSC performs 25 carotid stents and or endarterectomy’s per year / No Yes
CSC submits all applicable performance measures to a recognized database (and HFAP) / No Yes

SECTION E: Contact Information

Chief Executive Officer:

____

NamePreferred Title

____

TelephoneFax

Medical Director – StrokeCenter:

____

NamePreferred Title

____

TelephoneFax

Medical Director – Emergency Department:

____

NamePreferred Title

____

TelephoneFax

Director / Manager of Stroke Unit (if applicable):

____

NamePreferred Title

____

TelephoneFax

Accreditation Coordinator / Contact Person:

____

NamePreferred Title

____

TelephoneFax

Application for Certification Survey Agreement

The undersigned makes application to the Healthcare Facilities Accreditation Program (HFAP) for a Comprehensive Stroke Center certification survey of this facility. As the administrative representative of this facility, I certify that the facility meets all eligibility requirements for Comprehensive Stroke Center certification by the Healthcare Facilities Accreditation Program (HFAP) and grant permission to the state licensing agency or any other licensing/accreditation group to release facility records to HFAP for any review deemed necessary as part of the accreditation process.

The Healthcare Facilities Accreditation Program (HFAP) will ensure that all information received in the course of facility application, survey, and accreditation review will be maintained confidential and used for the sole purpose of reaching a certification decision except as otherwise required by law.

I certify that the information contained in this application for Comprehensive Stroke Center certification is accurate and true. I understand that providing falsified documents of information may be grounds for denial or revocation of facility certification.

By signing this application for HFAP Comprehensive Stroke Center certification, I understand that the facility is responsible for timely payment of all applicable certification fees including those costs associated with the biennial survey, any directed or mid-cycle surveys, and intra-cycle data processing fees. Non-payment is grounds for denial or revocation of certification.

In the event that this facility has any disagreement with HFAP regarding any aspect of the certification procedures or decisions, I understand that the facility has the right to appeal such decision in accordance with the HFAP appeal procedures in place at the time of appeal. Final decision rests with the Board of Trustees of the American Osteopathic Association (AOA). The facility shall not be entitled to compensatory damages of any type from HFAP or any of its representatives resulting from any controversy related to certification. HFAP’s aggregate liability shall not exceed the sum of (a) the fees paid to HFAP pursuant to this Agreement.