1. Accredited by Agréé par The Accreditation Canada Stroke Distinction Program: A Quality Improvement Strategy Wendy Nicklin, President and CEO April 9, 2014 Wendy Nicklin, President and CEO April 9, 2014

2. © Accreditation Canada/Agrément Canada Disclosure Statement I have no conflict of interest or any financial gain associated with any material I am presenting today. - Wendy Nicklin 2

3. © Accreditation Canada/Agrément Canada 3 Outline  Stroke Statistics in Canada  Accreditation Canada and the Stroke Distinction Program National and International  Program components and enhancements  Impact of participating in the Stroke Distinction Program through identified performance measures

4. © Accreditation Canada/Agrément Canada Accreditation Canada  Major national accreditation body for organizations across all health sectors in Canada, incorporated in 1958  An independent, non-governmental, non-profit organization funded by its members  Over 1200 client organizations (6,000 sites)  International presence, including in Bermuda, Brazil, Italy, Saudi Arabia, Kuwait, and Ecuador  Accredited by ISQua 2014 4

5. © Accreditation Canada/Agrément Canada 5

6. Stroke Statistics in Canada  Third leading cause of death 6% of all deaths are due to stroke (Statistics Canada, 2012)  Every year, patients spend more than 639,000 days in acute care hospitals and 4.5 million days in residential care facilities (Canadian Stroke Network, 2011)  23% of patients are treated on a stroke unit In hospitals with a stroke unit, 47% are not treated within the unit (Canadian Stroke Network, 2011) 6

7. © Accreditation Canada/Agrément Canada Stroke Statistics in Canada  Mortality rate is 43 per 100,000 people Lower than most OECD members Lowest among comparable countries  In-hospital mortality rate is 9.7 per 100 patients Higher than the OECD average: 8.5 per 100 patients 7

8. © Accreditation Canada/Agrément Canada Rationale for the Stroke Distinction Program  More accountability is being placed on stroke care services  Stroke care services are high cost and high impact  Statistics Canada reports that stroke is one of the leading causes of death and adult disability  The Public Health Agency of Canada notes that stroke is one of the most impactful chronic diseases in Canada  Improving care and outcomes will result in efficiencies  Developed to recognize excellence in stroke care 8

9. © Accreditation Canada/Agrément Canada 9 Stroke Distinction Program  Accreditation Canada developed the program in collaboration with the Canadian Stroke Network  Focuses on Canadian Best Practice Recommendations for Stroke Care  Recognizes clinical excellence, leadership, quality, safety, & innovation  On-site survey every 2 years  Stroke distinction is an optional program http://www.strokebestpractices.ca

10. © Accreditation Canada/Agrément Canada 10 Distinction Cycle

11. © Accreditation Canada/Agrément Canada Stroke Distinction Across Canada  12 organizations currently participating in the Stroke Distinction program 9 have achieved stroke distinction  7 Canadian  2 International 3 have begun the process

12. © Accreditation Canada/Agrément Canada International Stroke Distinction™ Introduced in Spring 2012 Implemented in Latin America (Brazil) and Europe (Italy) Highly recommended for organizations focused on innovation and research in stroke care 12

13. © Accreditation Canada/Agrément Canada Components of Stroke Distinction 13 The standards:  Acute Care  Rehabilitation  Integrated Systems Other program components:  Performance indicators  Protocols  Innovation  Client Education

14. © Accreditation Canada/Agrément Canada Performance Indicators  Data is submitted regularly every 6 months between on-site visits  Organizations are required to: Collect and submit data on all core indicators; Collect and submit data on at least 2/11 optional indicators Achieve the minimum data thresholds for:  Meet thresholds for 7/9 core acute indicators  Meet thresholds for 3/4 core rehabilitation indicators  Provide an action plan for unmet core thresholds 14

15. © Accreditation Canada/Agrément Canada Core Performance Indicators IndicatorAcuteRehabIntegrated Stroke / TIA mortality rates Proportion of ischemic stroke clients who receive acute thrombolytic therapy (tPA) Median time to administration of acute thrombolytic agent Proportion of clients treated on stroke unit Proportion of clients treated on a unit where stroke clients are clustered and meet all other stroke unit criteria Length of stay in an acute care hospital setting for clients admitted following an acute stroke event Length of stay in an inpatient rehabilitation setting for clients admitted following an acute stroke event Readmission to acute care for stroke related causes Proportion of acute stroke clients discharged to inpatient rehabilitation Proportion of clients prescribed antithrombotic therapy Proportion of clients with initial dysphagia screening at admission 15

16. © Accreditation Canada/Agrément Canada Protocols Acute  Emergency Medical Services (EMS) stroke screening  EMS bypass / direct transport to stroke centres (including air ambulance)  EMS pre-notification of stroke  Emergency Department notification of hospital-based stroke team  Neurovascular imaging for potential stroke patients (rapid access to CT)  tPA eligibility screening (based on current Canadian Stroke Strategy Canadian Best Practice Recommendations for Stroke Care criteria)  tPA administration  Administering acute ASA therapy  NEW FOR 2015 SURVEYS: Formal criteria for identifying appropriate clients for referral to inpatient rehabilitation 16

17. © Accreditation Canada/Agrément Canada Protocols Rehab  NEW FOR 2015 SURVEYS: Formal intake criteria for triaging client referrals and accepting clients for inpatient rehabilitation Acute & Rehabilitation  Swallowing ability assessment  Initial assessment of rehabilitation needs  Assessing and managing diabetes mellitus  NEW FOR 2015 SURVEYS: Pressure ulcer prevention  NEW FOR 2015 SURVEYS: Falls prevention 17 Requirements: Adopt and Implement At least 6/11 acute care protocols At least 2/3 rehabilitation protocols

18. © Accreditation Canada/Agrément Canada Innovation and Excellence Organizations must have at least one Q.I. project that meets all of the following criteria:  Is evidence based, e.g. aligned with accreditation standards and current Canadian Best Practice Recommendations for Stroke  Adds to the overall quality of stroke services within the facility or the region  Includes a completed evaluation, and measures sustainability of the project or initiative  Communicates findings within the organization and externally  Is notable for what it could contribute to the delivery of stroke services 18

19. © Accreditation Canada/Agrément Canada Patient and Family Education  Information provided at each phase of acute care, rehabilitation, community reintegration and long-term recovery should be relevant to the patient’s and the family’s changing needs  Organizations’ patient and family education must meet requirements set by Accreditation Canada  Availability of education material on the unit  Record of patient education 19

20. © Accreditation Canada/Agrément Canada Impact of participating in the Stroke Distinction Program through identified performance measures 20

21. © Accreditation Canada/Agrément Canada 21 Results from Hospital A, Canada Stroke Distinction Scorecard Core Indicators:Apr – Sept 2012 Oct 2012 – Mar 2013 Stroke / TIA mortality rates2.1%2.1% 3.0%3.0% Proportion of ischemic stroke patients who receive acute thrombolytic therapy (tPA) 16.2%19.2% Median time to administration of acute thrombolytic agent 6060Avg. 58.5 Media n 55 Proportion of clients treated on a stroke unit (acute stroke services)75%74.9% Length of stay in an acute care hospital setting for patients admitted following an acute stroke event Avg= 10.65; Media n= 7.2; 25th%tile= 4.4 ; 50th%tile= 7.2; 75th%tile= 13; 90th%tile= 20.6 Avg= 9.15; Media n= 7.0; 25th%tile= 4.0 ; 50th%tile= 7.0; 75th%tile= 11; 90th%tile= 18.0 Readmission to acute care within 90 days for stroke related causes 1.6%1.6%1.2% Proportion of acute stroke clients discharged to inpatient rehabilitation 14.1%21.3% Proportion of clients prescribed antithrombotic therapy (acute stroke services) 94.1%95.6% Proportion of clients with initial dysphagia screening at admission (acute stroke services) 26.9%26.7% Optional Indicators: Optional: Proportion of stroke / TIA patients who receive brain CT / MRI within 24 hours 94.9%96.4% Optional: Number of days from stroke onset to admission to inpatient rehabilitation Avg: 13.3 75th%tile= 15 Avg: 11.9 75th%tile= 13

22. © Accreditation Canada/Agrément Canada 22 Results from Hospital B, Canada 2010-2012 - Focused Process Improvements Led to: 20% Stroke Unit Utilization 5% In-hospital Mortality Rate 6.7% 90-day Readmission Rate 15% Dysphagia Screening Focused Review of Complication Rates: Quality Improvement Planning

23. © Accreditation Canada/Agrément Canada Performance Outcomes: Stroke Distinction and provincial average * Source: Institute for Clinical Evaluative Sciences, Ontario Stroke Evaluation Report 2012 23 IndicatorStroke Distinction Clients from Ontario (Source: Accreditation Canada Distinction Program) Provincial Average * (Source: Registry of the Canadian Stroke Network, Ontario Stroke Audit) Rate of tPA administration 17%10% Door-to-needle time of less then 60 minutes 78%54%

24. © Accreditation Canada/Agrément Canada International Stroke Distinction™ High satisfaction from the client organizations that have implemented the program with particular focus on improvement in integration of care and transparency in treatment process 24

25. © Accreditation Canada/Agrément Canada Results from Hospital C, Brazil  Patient and family education strengthened due to stroke program  Documentation including checklists developed for each member of multidisciplinary team  Organization developing telemedicine-based stroke protocol for application at other sites within its network 25

26. © Accreditation Canada/Agrément Canada Why organizations choose Stroke Distinction? To build and accelerate excellence and innovation throughout the program and across programs Improved awareness of best practices To support the development and sustainability of a culture of improvement To promote interest in and drives the use of performance data on an ongoing basis 26

27. © Accreditation Canada/Agrément Canada Why organizations choose Stroke Distinction? To demonstrate ongoing commitment to excellence: Supports improvement of patient outcomes Confirms best practice care for patients and families Strengthens team performance: recruitment and retention of staff; supports interprofessional teamwork; improves communication and morale Promotes research funding 27

28. © Accreditation Canada/Agrément Canada Ongoing updates: 2014 Revision of standards Coordinated administration of tPA to ensure it is initiated within one hour of hospital arrival and monitor their administration times Providing clients with written discharge information including action plans, follow- up care, appointments, and recovery goals Screening and follow up of clients with changes in cognition Screening and follow up of clients with depression Determining smoking status and provide information on smoking cessation Self-assessment Other Distinction products Trauma Distinction coming in Fall 2014 28

29. © Accreditation Canada/Agrément Canada Thank you for your interest! 29 Questions and Discussion

30. © Accreditation Canada/Agrément Canada Wendy Nicklin President and Chief Executive Officer 613-738-3800 / 800-814-7769 ext. 268 Wendy.Nicklin@accreditation.ca Wendy.Nicklin@accreditation.ca www.accreditation.ca www.accreditation.ca ACCREDITATION CANADA: Driving Quality Health Services 30

31. © Accreditation Canada/Agrément Canada 31 Proud to be a Top 25 employer for five consecutive years Fier de faire partie des 25 meilleurs employeurs depuis 5 années consécutives