ASC Quality Improvement & Program Management 2 — Questions and Answers
Question 1: Which metric is most directly used to evaluate the effectiveness of a Get With The Guidelines-Stroke program?
- Door-to-needle time under 60 minutes (Correct answer)
- Number of stroke beds available
- Average hospital length of stay for all patients
- Nurse-to-patient staffing ratios
Correct answer: Door-to-needle time under 60 minutes
Door-to-needle time under 60 minutes for tPA administration is the primary performance metric in GWTG-Stroke certification programs.
Question 2: A stroke coordinator notices that NIHSS documentation is missing for 20% of admitted stroke patients. The BEST first step in a QI approach is to:
- Implement mandatory re-education for all nurses immediately
- Conduct a root cause analysis to identify why documentation is being missed (Correct answer)
- Discipline the staff involved in incomplete charting
- Change the NIHSS requirement to only apply to severe strokes
Correct answer: Conduct a root cause analysis to identify why documentation is being missed
Root cause analysis identifies the underlying system or process failure before interventions are designed.
Question 3: In the PDSA cycle used for stroke QI, what does the 'Study' phase primarily involve?
- Planning the intervention and setting goals
- Implementing the change on a small scale
- Analyzing data to determine if the change produced improvement (Correct answer)
- Spreading the successful change organization-wide
Correct answer: Analyzing data to determine if the change produced improvement
The Study phase involves reviewing data collected during the Do phase to evaluate whether the intervention worked.
Question 4: Which of the following is a process measure rather than an outcome measure in stroke quality reporting?
- 30-day stroke mortality rate
- Percentage of ischemic stroke patients receiving antithrombotic therapy at discharge (Correct answer)
- Rate of symptomatic intracranial hemorrhage after tPA
- Functional independence at 90 days
Correct answer: Percentage of ischemic stroke patients receiving antithrombotic therapy at discharge
Antithrombotic therapy at discharge is a process measure reflecting adherence to a care step, not a patient outcome.
Question 5: Which organization administers the Primary Stroke Center certification program in the United States?
- Centers for Medicare & Medicaid Services (CMS)
- The Joint Commission (TJC) (Correct answer)
- American Heart Association (AHA)
- Institute for Healthcare Improvement (IHI)
Correct answer: The Joint Commission (TJC)
The Joint Commission administers PSC, TSC, and CSC certification programs for stroke centers.
Question 6: A stroke program is preparing for its first Comprehensive Stroke Center (CSC) certification survey. Which capability distinguishes a CSC from a Primary Stroke Center?
- Ability to administer IV tPA
- 24/7 availability of neurosurgery and neurointerventional services (Correct answer)
- Dedicated stroke nurse on call
- Stroke unit with telemetry monitoring
Correct answer: 24/7 availability of neurosurgery and neurointerventional services
CSCs must provide 24/7 neurosurgical and neuroendovascular capabilities, which exceed PSC requirements.
Question 7: When benchmarking a stroke program's DTN times against national data, what is the most appropriate data source for comparison?
- Internal historical data only
- AHA/ASA Get With The Guidelines-Stroke national registry (Correct answer)
- State health department mortality records
- Individual physician performance reviews
Correct answer: AHA/ASA Get With The Guidelines-Stroke national registry
GWTG-Stroke provides validated national benchmark data for DTN times and other stroke quality metrics.
ASC Quality Improvement & Program Management 2
Which metric is most directly used to evaluate the effectiveness of a Get With The Guidelines-Stroke program?