Comprehensive Stroke Center
The Department of Radiology is part of the Comprehensive Stroke Center. Interventional Neuroradiology Division Chief Ajit Puri, MD was involved with this site visit. Read the update below about the preliminary results.
FROM: Michael Gustafson MD, MBA, President, UMass Memorial Medical Center, Brian Silver MD, Interim Chair Dept. of Neurology, Director Stroke Center, Barbara Fisher, MBA, Senior Vice President, Clinical Services
DATE: Wednesday, January 30, 2019
SUBJECT: Comprehensive Stroke Center preliminary certification report
Many of you are aware that the Medical Center had its first Joint Commission disease specific certification site visit over the last 2 days to achieve accreditation as a Comprehensive Stroke Center. Two surveyors were on site visiting all areas throughout the Medical Center that touch our stroke patients over the course of their diagnosis, treatment and recovery. Overall, the preliminary report strongly validates that we provide a comprehensive multi-disciplinary stroke program that fully meets the Joint Commission standards.
“This is a fabulous report,” said one of the Joint Commission surveyors during the exit conference highlighting the survey findings. “Organizations across the country would be thrilled to have these results. You should feel really proud of the work that you’re doing for both your patients and your community.”
The surveyors highlighted the collaboration between multi-disciplinary teams to create a comprehensive continuum of care, as well as our highly-educated and passionate staff.
“Your greatest strength is your people,” one of the Commission commented. “Everyone that was with us was able to demonstrate their knowledge and speak to their clinical practice. You have some excellent leaders and teams committed to the stroke program and knowledge just exudes from them.”
They also highlighted several best practices at the Medical Center, including:
- Streamlined and fast-track processes, such as the EMS to CT pathway and CT to intervention, resulting in “door to needle” times approaching just 30 minutes
- Staff education throughout the departments supported by managers of our units
- Exceptional staff and community outreach to raise the awareness of stroke warning signs
The surveyors noted that most organizations applying for their initial Comprehensive Stroke Center certification receive between 8-15 recommendations for improvement, while our organization received only seven ‒ and several of the areas already have improvement plans in place. Opportunities for improvement include more consistent use of order sets, clinical practice guidelines and patient education materials. We will be preparing our corrective action plan in response to the report and once that is submitted and approved, we will receive our formal certification.
The multiple conditions associated with stroke require care provided in many departments and areas of the Medical Center ‒ physicians, paramedics, nurses, radiology techs, therapists, care coordinators and so many others work together to care for patients with this highly complex disease. We want to express our gratitude to all those involved in the care of our stroke patients. We wouldn’t be successful in providing the coordinated, high-level of care to our patients without the combined participation of all.
We as caregivers should be proud of the level of care that we provide to our patients, and we’re looking forward to becoming the first Comprehensive Stroke Center in Central Massachusetts.