TJC Updates
As many of you have probably heard, the Stroke Program recently received notification from TJC of a scheduled recertification. Due to the availability of several essential team members during the chosen dates, our program elected to defer to a later date.
What happened?
In a typical site-visit year, a stroke program is provided with a 3-month 'open window'. During this window of time, a program provides TJC with 5 pre-selected avoid dates and is prepared to be available for the remainder of their scheduled window.
Alternatively, the ongoing pandemic and associated travel restrictions have led to an extensive delay in TJC's ability to complete these site visits. Due to this delay, our program has remained in our open window since July of last year. This extended window has increased the likelihood that key team members will be unavailable during proposed site visit dates.
What does this mean for the team?
Due to the recent deferral, our program will continue in the current open window until TJC is available to set up another visit. By continuing to provide the best care possible for our patients, we feel that we will be ready whenever TJC schedules our survey.
The Joint Commission (TJC) offers Comprehensive Stroke Center (CSC) Certification in collaboration with the American Heart Association/American Stroke Association. This designation signifies that a hospital is dedicated to the highest standard of stroke care at every touch point in the stroke care continuum. This patient-centric approach is better for our patients and their families. CSC is the highest level of certification for hospitals with specific abilities to receive and treat the most complex stroke cases.
20 SAH by aneurysm per year
15 endovascular coiling and surgical clippings per year for aneurysm
25 tPA eligible patients per year (50 over 2 years)
IV tPA ordered & monitored via telemedicine at another hospital is acceptable
IV tPA administered at outside hospital and transferred to CSC site is acceptable
Carotid duplex ultrasound
Catheter angiography on site 24/7
CT angiography on site 24/7
Extracranial ultrasonography
MR angiography (MRA) on-site 24/7
MRI with diffusion on-site 24/7
Transcranial Doppler
TEE and TTE available
Follow up phone calls (home/transfers)
Involvement of case managers/social workers
Physical Therapy involvement
Occupational Therapy involvement
Speech Therapy involvement
Review of all information gathered from phone calls/ transfers must be utilized to drive a dynamic change in the program. Prepare to speak to this process.
Multi-disciplinary teams should be able to discuss intervention and involvement of the teams into the patient’s plan of care, teaching, goal setting with the patient/family, assuring the goals are individualized to meet the needs of the patient.
Discussion of risk factors and strategies for modifications.
Discussion of the patient’s willingness and ability to learn.
Discussion of support services: dietary, activity, medications, follow up appointments and other self-support requirements.
Dedicated Neuro-intensive care beds
24/7 on-site LIP’s with neurovascular training (APN, PA, N-Intensivists, Fellows, Residents)
Neuro surgery must be able to demonstrate the ability to care for two complex stroke patients at one time with appropriate providers
Be prepared to discuss and document your neurosurgical coverage including on call and back up on call MDs and staff for 24/7 coverage.
IR must be able to demonstrate the ability to care for two complex stroke patients at one time with appropriate providers.
Be prepared to discuss and document your IR coverage including on call and back up on call MD’s and staff for 24/7 coverage.
Active IRB’s
Currently enrolling patients
The on-site review process identifies areas of strength and areas for improvement in program quality. During this process, two reviewers from TJC come to the hospital for two days in order to conduct a full review of our program.
In between the years when TUKHS has the in-person TJC site visits, the stroke program team meets with a representative of TJC on a group phone call to review progress made and verify that the program is continuing to meet all certification requirements.