Achieving Certification

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Primary stroke center certification by the Joint Commission is based broadly on three components: standards, guidelines, and performance measures. Under the umbrella of components are 11 criteria that must be met for certification, according to M.J. Hampel, MPH, MBA, senior associate director of the Joint Commission’s Disease-Specific Care Certification Program.

To become a certified by the Joint Commission as a primary stroke center, hospitals must:
• have a designated medical director;
• provide proof that the stroke program is supported by the organization’s administration;
• collaborate with providers of emergency medical services;
• have a neurosurgeon available on-site or maintain a transfer agreement with a hospital that has an on-site neurosurgeon;
• be able to perform a cranial CT scan or brain MRI scan on acute stroke patients within 25 minutes of an order written by the emergency-department physician, read the scan within 20 minutes of its completion, and be capable of performing such scans at all times;
• have all laboratory work completed and reported within 45 minutes of the order;
• be prepared to offer therapy using recombinant tissue plasminogen activator (tPA) if the patient is a candidate for it;
• ensure that the emergency-department staff has 24-hour access to consultation regarding the administration of tPA;
• conduct initial and ongoing education for the staff;
• perform at least one public-education activity per year; and
• keep a stroke log that tracks the team’s response times and monitors service trends.
—E. Burke