SOW for Stroke Center Accreditation Services_PM_KI.docx

Statement of Work for the Michael E. DeBakey VAMC Stroke Center Accreditation

1. General Information:

1.1 Purpose: The Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) requires services for Stroke Center Accreditation, through a management system certification/accreditation agreement. The requested Management System will provide certification/accreditation for the Stroke Center at MEDVAMC.

1.2 Background: The Neurology Department at the Michael E. DeBakey VA Medical Center (MEDVAMC) is requesting the purchase and contract agreement to gain certification/accreditation for the MEDVAMC Stroke Center to function at the level of a Comprehensive Stroke Center.

Minimum Requirements:

The Prime Certifying Body shall have certified at least 150 Comprehensive Stroke Centers within the United States.

The two surveyors need to be licensed as an RN, MD, DO, or PA required. Each one of the surveyors need at least 3 years' experience in the healthcare industry required. They should have served at least 1 year as a CSC Stroke Coordinator required. They should have an ability to walk and stand for up to 4 hours at a time and maneuver throughout all areas of a hospital from floor to floor, either by stairs or elevator. The surveyors should be able to lift and carry up to 10 pounds in addition to transporting one’s own luggage for multiple-day travel and push, pull reach, bend, twist, stoop and kneel with that which is lifted, carried, or transported.

1.3 Objective:

The prime contractor should have Certification at the level of the Comprehensive Stroke Certified Center (CSC) ought to cover the following aspects :

CSCs are designed to be a part of a larger stroke system of care which will include all levels of stroke care. The CSC certification will mean that a hospital is equipped to evaluate, stabilize and to provide emergency care to all patients with acute stroke symptoms and admit the patient to a dedicated stroke unit or designated stroke beds. The intent of the CSC is to be fully capable to provide initial and complex diagnostic services, stabilization, emergent care and interventional therapies to patients with an acute stroke.

The certifying organization should ensure that the CSC has the personnel, infrastructure, and expertise to diagnose, treat and support stroke patients who require highly intensive medical and surgical care, specialized tests, or interventional therapies. The types of patients who might use and benefit from a CSC include, but are not limited to, patients with ischemic strokes, large vessel occlusions, hemorrhagic strokes, or strokes from unusual etiologies that may require specialized testing or interventional therapies such as but not limited to clipping, coiling, thrombectomies, as well as other endovascular, and/or surgical procedures.

In addition, CSCs function as a resource center for other Veterans Health Administration facilities in their region and the nation, such as Primary Stroke Centers (PSC), Primary Plus Centers (PSC + thrombectomy capable centers) and Acute Stroke Ready Hospitals (ASRs). This might include providing expertise about managing cases, offering guidance for triage of patients in collaboration with emergency medical service providers, making diagnostic tests or treatments available to patients treated initially at an ASR, PSC or PSC+ and being an educational resource for other hospitals and health care professionals.

Overview of the survey process and components This outside evaluation by the certifying body is designed as an annual review of the stroke components within an organization and to work with the leaders and front-line staff to have a constant review of the program and how they are performing against recognized standards and the organizations own policies and procedures.

Experienced, qualified surveyors, who were once nurse stroke coordinators themselves, will review organizations and assess stroke systems from pre- notification from field EMTs to onsite assessments including diagnostic tests, administration of thrombolytic therapies, interventional and/or endovascular procedures and post procedure care.

Stroke patients benefit from provision of high-quality basic medical care as well as some high impact specific treatments, such as thrombolysis and thrombectomies or other invasive procedures that are often time dependent.

A standard patient protocol/pathway should include assessment of neurological impairment, vascular risk factors, swallowing, fluid balance and nutrition, cognitive function, communication, mood disorders, continence, activities of daily living and rehabilitation goals.

Good communication and shared decision making with patients and their families are key to high-quality stroke care. Patients with mild or moderate disability, who are medically stable, can continue rehabilitation at home with early supported discharge teams rather than needing a prolonged stay in hospital. Veterans Health Administration directives, National clinical guidelines and prospective audits are integral to monitoring and developing effective stroke services. Surveyors discuss best practices and changes in requirements, highlighting both the organizations successes and any non-conformances in their practice.

During a certification survey Once on site, surveyors assess compliance with the certification requirements for services and in locations in which the stroke program operates for patient care services for stroke. The objective of assessment activities is to determine compliance with the requirements through observations, interviews and document review.

The surveyors will focus attention on:

· actual and potential patient outcomes

· required processes

· the care and services provided, including the appropriateness of the care and services within the context of the certification requirements and identified best practices

· leadership involvement, commitment and oversight of the stroke program

· data collection, analysis and reporting The surveyors will visit:

· the emergency department

· imaging locations

· interventional/surgical suites (if applicable)

· ICU/ designated inpatient units

· rehabilitation areas (if applicable) and

· other patient care settings, as appropriate to the level of services provided

The surveyors will review:

· stroke program policies

· stroke program protocols

· stroke management order sets

· stroke committee meeting minutes

· transfer agreements

· telemedicine process and documentation

· on call schedules

· clinical records

· personnel files, competency, and required stroke education records

· provider credentialing files and required stroke education records

· other documentation necessary to validate information gained from observations and interviews

Acute Stroke Team The identified Stroke Team is responsible for initiating treatment of a patient who is exhibiting signs and symptoms of stroke in an effort to improve outcomes. The Stroke Team is comprised of members who have been assigned by the Stroke Committee to initially assess and care for those patients who exhibit signs and symptoms of stroke. Identified members of the Stroke Team will receive eight hours of education related to care of the stroke patient as recommended by the Stroke Committee. Use of evidence-based practice, monitoring of key quality outcomes, efficient utilization of resources, education and collaboration with community partners are essential key elements to providing excellence care for the stoke patient.

EMS (Emergency Medical Services) Relationship The certifying organization recognizes the essential role EMS plays in the care of the stroke patient. EMS representatives are members of the Stroke Committee in most organizations. EMS pre-hospital assessment and treatment protocols including dispatch and drive by protocols are valuable components to a community wide effort to improve care of the stroke patient. Case review of the pre-hospital management is included in the required stroke performance improvement plan.

The stroke center is required to partner with EMS to educate EMS, hospital staff and the communities served through drills, classes and teaching materials. The stroke program recognizes EMS as an essential partner in this process and their commitment to this shared goal is evident through their participation in process development, staff and community education, process and flowchart development and sharing of performance data. believes certification as a Stroke Center is essential to reaching and maintaining this goal and has included certification as a Stroke Center as part of the organization’s strategic plan and financial budget. The organizations’ Performance Improvement Plan, Staff and Community Education Plans include prevention and care of the stroke patient and are developed in conjunction with EMS.

Assessment of Patients with Symptoms of Stroke, Timely Diagnosis and Treatment The stroke center is evaluated on its utilization of practice protocols and processes to ensure early recognition, diagnosis and treatment of all stroke patients regardless of their presentation to or location within the facility. The patient has been assessed and treatment decisions have been made within 45 minutes of the arrival to the emergency department. Performance of all assessments are timed and recorded in the medical record per individual stroke center policy.

Quality Management All aspects of the care of the stroke patient including quality monitoring and evaluation of processes are included and incorporated in the stroke programs Improvement Plan and evaluated by the certifying organization. Opportunities for improvement are identified based upon metric results and or patient outcomes. As appropriate process improvement projects are initiated, corrective action taken, and effectiveness of actions are assessed. This information is presented to the Stoke Committee and then to the Quality Improvement Committee, Medical Executive Committee (MEC) and the Director of the VA Medical Center. 100% of all Stroke Alert patients’ charts are reviewed by the stroke committee identified data abstractors. While opportunities for improvement exist at each step in the process, the following indicators and goals have been identified as the initial focus. The outcomes of these measures will be reported to the Stroke Committee and areas of improvement will be identified with corrective action plans for improvement developed:

· tPA considered/thrombolytic therapy administered.

· Screening of patients for dysphasia

· Deep Vein thrombosis prophylaxis

· Lipid profile during hospitalization (discharged on cholesterol reducing medication if needed)

· Offering of Patient Education about stroke

· Smoking cessation/advice/counseling

· Plan/assessed for rehabilitation considered

· Antithrombotic medications started within 48 hours

· Antithrombotic medications prescribed at discharge

· Anticoagulants prescribed for patients with atrial fibrillation

· CT exams for patients who are candidates for thrombolytic therapy within 45 minutes of arrival

The Stroke Center also monitors those indicators which may have impact on the overall outcome of care from a global perspective. The following performance indicators will be monitored and reported to the Stroke Committee on a quarterly basis as they relate to care of the stroke patient and the outcome of those patients. Areas for improvements will be identified with corrective action plans for improvement developed:

· Threats to patient safety

· Medication therapy/medication use

· Effectiveness of pain management system

· Infection control system, including nosocomial infections

· Utilization Management System

· Customer Satisfaction

· Unanticipated deaths

In addition to the above performance indicators the Comprehensive Stroke Center will evaluate all organized services and processes, both direct and supportive, including services provided by any contracted service. The monitoring shall include the use of internal reviews (audits) and data related processes of the Comprehensive Stroke Center at scheduled intervals, not to exceed one year.

Education The Stroke Center recognizes education of EMS providers at all levels/certifications, hospital staff, all medical staff, their office staff and the community is essential to reducing morbidity and mortality and providing excellent care to the stroke patient. Education provided in a collaborative effort with EMS ranges from early recognition of stroke signs and symptoms, prevention, activation of EMS through 911, current treatment options, and evidence-based protocols. Education will be provided through both formal and informal means based on the subject matter and the intended audience.

Community Education The stroke center realizes the importance of educating the community regarding the causes, signs and symptoms of stroke as well as emerging stroke prevention strategies. In an effort to meet the needs of the community the stroke program is required to provide the education as it relates to causes of stroke, signs and symptoms of stroke as well as stroke prevention.

An education plan will be developed annually and submitted to the Stroke Team Committee for approval.

Evaluations will be done at the end of each educational session in an effort to assess the individual’s knowledge of material presented.

The certifying body believes that through this commitment, including collaboration with EMS, the use of evidenced–based assessment/treatment protocols, education to care providers and the community and an on-going outcomes evaluation and improvement process our goals will be realized.

Multidisciplinary Stroke Committee The Stroke Committee is a multi-disciplinary multi-skilled committee with representation from EMS, patient care staff and leadership from ED, Nursing, Quality, Administration, Ancillary Support Services, Education and Medical staff. The Stroke Committee exists to facilitate a system focus on prevention and care of the stroke patients across the continuum, to strengthen the relationship between local EMS and improve the care of the stroke patient in the communities we serve. The Stroke Committee meets at least quarterly and reports to the host hospital, Quality Improvement Committee, the MEC and Board members.

The stroke medical director in conjunction with the Stroke Coordinator usually chairs the committee. The committee is responsible for overseeing the following:

· Establishment of processes and protocols in the management of stroke patients including those presenting to the ED, in -house or outpatient.

· Education and Competency Assessment of staff involved in the care of these patients.

· Education of the community including all hospital staff on signs and symptoms of stroke, measures to take, and prevention.

· Review of cases for continuous ongoing improvement

· Review, analysis of performance data

The surveyors will interview the multidisciplinary stroke team which consists of the medical director, Midlevel stroke coordinators, nurses, pharmacists, occupational and physical therapists, speech and language therapists, dieticians and case managers/social workers. Input may also be provided by pharmacists and other departments as needed. The stroke team is expected to have close links with radiology, neurosurgery, vascular surgery, neurology, geriatric medicine and cardiology.

It is expected that the stroke team works together to facilitate the adherence to stroke program policies, procedures, protocols and access to care for patients. The stroke team shall develop stroke protocols (pathways), based on current evidence-based practice for the treatment of emergent and ongoing care for acute stroke patients. These should be shared with emergency department practitioners, EMS providers, and ICU and/or Stroke Unit for the care of acute stroke patients.

Medical Care and Documentation The multidisciplinary stroke unit team aims to provide individualized holistic care and meets regularly to share updates and plan care. They may communicate to the team usually by having a weekly multidisciplinary team meeting, but many stroke units also have a short ‘board round’ at least once per day. Patients and their families are actively involved in their care and receive consistent information and support. Stroke unit teams have protocols for common problems and provide a training program for all team members. They work closely with other components of the stroke service, early supported discharge teams and community services to plan for transfer of care.

The surveyors will review individual patients’ medical records to determine compliance with the protocols which are fundamental to improving outcome following acute stroke and the importance of providing high-quality basic medical care. Patients should be monitored for early and late clinical deterioration. Prompt action to determine a neurological or non-neurological cause and early treatment is essential. Close monitoring according to evidence-based protocols, in vital signs, neurological assessment, blood pressure management, lower than normal oxygen levels and newly developed bleeds can identify and be treated as indicated for any clinical deterioration. Deep-vein thrombosis (DVT) and pulmonary embolism (PE) are common complications post-stroke and prophylactic measures should be utilized.

Patients who are screened as being unsafe to swallow should remain nil by mouth and receive non-oral feeding via a nasogastric tube if this is in keeping with the patient's wishes. An early detailed assessment by a speech and language therapist is essential for patient safety.

These treatments are time dependent and organized stroke care enables clinicians to respond quickly and efficiently. However, improved outcomes were associated with stroke units prior to these interventions being available.

Palliative care services can provide valuable input for complex cases and support a discharge home. Stroke unit teams have the skills and expertise to provide high-quality care.

Rehabilitation assessments are required to be performed as soon as the patient can participate safely in the assessment. Rehabilitation assessments are designed to identify and aim to maximize a patient's adaptive recovery by addressing specific impairments (e.g., weakness), activity limitation (eg difficulty walking), restricted social participation (e.g., less contact with friends) and overall quality of life. Rehabilitation should be personalized, taking into account not only the problems resulting from stroke but also comorbidities and the patient's views and preferences.

Some problems are very apparent, but others are only identified after careful assessment, so screening tools should be routinely used – especially for cognitive and mood disorders. The nature, implications, and treatment of problems due to stroke should be explained to patients and their families, who should be regularly updated and involved in decision making. Training should be offered to families, especially for communication and cognitive problems.

Discharge Planning The plan of care will include initial discharge planning for continuing care and treatment based on needs, condition and prognosis of the patient. Patient and family members (or identified significant others) are involved in the planning of care, including discharge plan.

2. WARRANTY

2.1 Any documented error or defect in the Work will be rectified by the vendor within a reasonable period of time, at the vendor’s sole cost.

3. INVOICES AND PAYMENT

Invoice shall be submitted after delivery and acceptance. Payments shall be made via EFT (Electronic Fund Transfer) from the VA Financial Service Center upon receipt of a properly prepared invoice. At a minimum, all invoices shall include the following:

· Contract Number

· Purchase order number. Correct purchase order number which shall be issued by the Contracting Officer after the contract is awarded. Invoice without correct purchase order number shall be rejected and returned to the Contractor

· Item(s) covered

· Description of services

· Billing period

· Invoice number and date