Abstract TP354: Comprehensive Stroke Center Recertification Visit Preparation

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Abstract

Background and Issues: The Comprehensive Stroke Center (CSC) Program Coordinator (PC) started her role at the same time as the CSC recertification application was due. The required documentation and components of a program that need to be presented to reflect compliance with standards is extensive. By having less than 6 months to become familiar with the program, address gaps, educate staff, and partner with providers and other disciplines, and assure optimal patient care is provided; a team approach using a multitude of preparation/communication methods was needed.

Purpose: The purpose of this program effort was to identify and implement strategies that prepare the organization for a successful CSC Recertification.

Methods: Many approaches were used in the preparation process which included: Observe and shadow in key areas (ED, IP, NICU, IR, IP Rehab, Clinic, Neurocritical Care, Neuro IP Team and other areas); Review evidence to assure most current guidelines provide basis for program; Consolidate Primary and Comprehensive Stroke Center standards; Complete gap analysis; Engage Interprofessional team; Identify our documents which reflect standards compliance; Identify educational needs/provide education; Develop online resources and tools for constant accessibility; Collaborate on presentation materials; Communicate, communicate, communicate; Practice presentation and interaction; Complete a team walking tour of survey; Engage staff in a mock survey; Keep everyone updated via newsletters and staff meeting updates.

Results and Conclusions: Team members and staff verbalized a high degree of readiness for the survey with the preparation methods utilized. Lessons learned include: Prioritize actions based on our patient-centered mission/vision/values; Realize that everything may not be in its final state before the survey but have a plan to ensure completion; Engaging the full team in the preparation process helps identify potential issues and solutions that may not have otherwise been known; Utilize technology to expedite communication and education; have a physical presence throughout the care process areas.

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