Is Your Stroke Certification Program on Target?

As we wrap up Stroke Awareness Month, we thought there would be value to talking about where the most recent findings are occurring in the Disease Specific Certification Process for Stroke. First, let us look at the latest statistics regarding stroke. Did you know according to the latest statistics:

  • Fifteen million people worldwide suffer strokes annually.
  • In 2010-2022, 16.9% of cardiovascular disease (CVD) deaths were stroke, while 75.6% were heart disease.
  • In 2020, 19.05 million people died globally from CVD, an increase of over 18 % from 2010.
  • In 2020, 207.1 per 100,000 people died from heart disease and stroke.

When we look at these statistics, it is obvious that we have a long way to go to prevent strokes. However, we also need to ensure that the care provided, utilizing the organization's clinical practice guidelines, is evidence-based and up to date.

The Joint Commission regularly analyzes standards compliance data to identify areas that result in the highest number of Requirements for Improvement (RFIs) in its certified programs. This data helps The Joint Commission identify trends and tailor education related to challenging standards. This data also provides Certified organizations the opportunity to conduct a deep dive into their organization's strategies to achieve compliance and ensure they are providing the best care possible.

Based upon data collected from the 687 certification surveys conducted in 2023 by The Joint Commission, the top five most frequently cited elements of performance (EPs) from Jan. 1-Dec. 31, 2023, for the stroke certification programs were:


  • The program is implemented through the use of clinical practice guidelines selected to meet the patient's needs.
  • EP 2: The assessment(s) and reassessment(s) are completed according to the patient's needs and clinical practice guidelines.


  • The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver or facilitate the delivery of clinical care.
  • EP 5: The program demonstrates evidence that it is following the clinical practice guidelines when providing care, treatment, and services.


  • The program addresses the patient's education needs.
  • EP 5: The program addresses the education needs of the patient regarding their disease or condition and care, treatment, and services.


  • The program is implemented through the use of clinical practice guidelines selected to meet the patient's needs.
  • EP 3: The program implements care, treatment, and services based on the patient's assessed needs.


  • The program initiates, maintains, and makes accessible a medical record for every patient.
  • EP 5: The medical record contains sufficient information to document the course and results of care, treatment, and services.

As you can see, the majority of  improvement opportunities are focused on the consistent use of the most current clinical practice guidelines (CPGs). The American Stroke Association is the premiere subject matter expert when seeking practice guidelines. They regularly post updates on their website along with a summary of the changes.  Hardwiring the review of updated clinical practice guidelines into the agenda for your Stroke Team meetings, could help your team quickly identify any changes to the CPGs and take action to adopt those changes.  We encourage organizations to place this as a standing agenda item on the meeting agenda.  Additionally, ensuring you have a member of your organization's clinical informatics team on your Stroke Team will also help ensure quick communication of changes that may be needed to your order sets.  Do not forget, that changes to the order sets must be approved by your Pharmacy & Therapeutics, Clinical Nursing Leadership and Medical Staff committees.

The second area that is often cited is addressing the patient's education needs related to their disease or condition.  We often see on mock surveys where patients are provided wonderful information about Stroke as a disease process, but the content is very generic.  For instance, the printed information may contain a list of the types of medications often prescribed, but not the specific medications being prescribed for the patient.  We also often see segmentation of the educational materials which may or may not be available to all of the care providers. Working with your Clinical Informatics team to ensure that all patient education content of the health record flows together to a consistent location where all clinicians can see what has been taught and the patients response to that education is essential.

In summary, ensure that your clinical practice guidelines are up-to-date and evidence-based. Are your assessments and reassessments reflective of your patient's needs? Ensure that your program addresses patient/family education related to those identified needs. Finally, ensure that your documentation reflects care, treatment, and services provided.  By addressing these Top 5 cited deficiencies you should be on you way to a successful survey. Are you ready?


Perspectives, May 2024

Joint Commission Online, May, 1, 2024

For questions or to learn more contact the C&A team at 704-573-4535 or email us at

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