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Stroke Program Receives Joint Commission Advanced Certification as a Comprehensive Stroke Center

In 2013, The Joint Commission (TJC) and the American Heart Association/American Stroke Association awarded Mischer Neuroscience Institute (MNI) at Memorial Hermann-Texas Medical Center the highly coveted Comprehensive Stroke Center (CSC) certification. MNI is the first and only stroke program in Texas to meet TJC’s rigorous standards, solidifying its position among an elite group of providers focused on complex stroke care.

Comprehensive Stroke Center certification recognizes hospitals with the infrastructure, staff and training to receive and treat patients with highly complex strokes. Between September 2012, when TJC released its new qualifications for CSC certification, and MNI’s rigorous onsite review in March 2013, the stroke team geared up to meet the new standards.

Comprehensive Stroke Center

“We had a great program as a Joint Commission-certified Primary Stroke Center, but we had some work to do to build a Comprehensive Stroke Center, which is many steps higher,” says Nicole Harrison, RN, administrative director of neuroscience at MNI. “Close collaboration among neurologists and neurosurgeons was critical to achieving the advanced certification, which goes beyond the Primary Stroke Center focus on ischemic stroke to encompass the surgical treatment of hemorrhagic stroke. We had great roads in place, and during our six-month preparation for the review we built the overpasses.”

A stroke leadership committee comprised of physicians and other caregivers from key departments at Memorial Hermann-Texas Medical Center was formed to guide the processes necessary to achieve the certification. The group held weekly meetings for six months to ensure that all standards of practice and protocols were integrated across every discipline.

“Collecting the data we needed for CSC certification allowed us to see evidence-based opportunities to make our stroke care even better,” Harrison says. “We made significant improvements in the peer-review process, and we also implemented a cognitive screening and depression screening process for every patient prior to discharge and post discharge.”

To ensure that the Stroke Program had the necessary support to achieve Comprehensive Stroke Center certification, new team members were added, including additional stroke coordinators, data extractors and advanced nurse practitioners. Harrison credits Memorial Hermann-TMC administration and Sean I. Savitz, M.D., medical director of the Comprehensive Stroke Center, with ensuring MNI’s success throughout the certification process.

“Our administrative leadership team was crucial in securing the resources we needed to make this certification happen,” she says. “Without that support, MNI couldn’t have achieved this milestone.”

“It is a difficult certification to achieve, and the accomplishment is truly a multidisciplinary effort,” says James Grotta, M.D., co-director of MNI and professor and chair of the department of Neurology at UTHealth Medical School. “Only 59 centers across the country have achieved this goal, and no others in Texas. We met very particular and exacting requirements and in the process created new pathways to work as a team in providing care for all of our patients, including those admitted to other service lines. It speaks to the excellence of our stroke team and the outstanding treatment we provide.”

Harrison cites education as an integral piece of the certification. “We’re already seeing benefits for patients,” she says. “We have the infrastructure in place to sustain the two-year certification into the future and to continue to improve.”