| Green - Required | ||||||||||||
| Blue - Optional | ||||||||||||
| Modified question | Deleted question | New required question | New optional question | Current PCNASP Hospital Inventory Survey (0920-1108; exp. 9/30/2022) | Requested changes | |||||||
| Original Data element | Original question | Response options | Data element | Revised question | Response options | Change description | ||||||
| 1 | RUCA | What is your hospital’s Rural-Urban Commuting Area (RUCA) code? To determine this, navigate to the Rural Health Information Hub website (https://www.ruralhealthinfo.org/am-i-rural). Enter your hospital’s address in the search bar and click “locate”. Then click on the orange “run report” button in the map. Scroll down to find your hospital’s RUCA Code by census tract (e.g. 1.1) and provide this number for the inventory survey | Numeric response | RUCA | What is your hospital’s Rural-Urban Commuting Area (RUCA) code? To determine this, navigate to the Rural Health Information Hub website (https://www.ruralhealthinfo.org/am-i-rural). Enter your hospital’s address in the search bar and click “locate”. Then click on “Run Report” button in the map. Scroll down to “Rural Urban Commuting Areas (RUCAs) by census tract” to find your hospital’s RUCA Code (two digit number, e.g. 1.1, 1.0) and provide this number for the inventory survey. | Numeric response | Modification to add more instructions for clarity and accurate data. | |||||
| 1 | AISDsch | Total number of acute ischemic stroke discharges in the most recent calendar year | Numeric response | Optional question deleted as this is data is not core to the program | ||||||||
| 1 | TIADsch | Total number of TIA discharges in the most recent calendar year | Numeric response | Optional question deleted as this is data is not core to the program | ||||||||
| 1 | SAHDsch | Total number of subarachnoid hemorrhagic stroke discharges in the most recent calendar year | Numeric response | Optional question deleted as this is data is not core to the program | ||||||||
| 1 | ICHDsch | Total number of intracerebral hemorrhagic stroke discharges in the most recent calendar year | Numeric response | Optional question deleted as this is data is not core to the program | ||||||||
| 1 | SNSDsch | Total number of stroke (type unspecified) discharges in the most recent calendar year | Numeric response | Optional question deleted as this is data is not core to the program | ||||||||
| 1 | SAHAText | Text response for We admit or transfer depending on staff availability or other factors (please describe) | Text response | New required data element for text responses | ||||||||
| 1 | ICHAText | Text response for We admit or transfer depending on staff availability or other factors (please describe) | Text response | New required data element for text responses | ||||||||
| 1 | DysScrn | Dysphagia screening | Yes No |
Required question deleted to align with program activities and focus under new cooperative agreement. | ||||||||
| 1 | DschProt | Discharge planning protocols | Yes No |
Required question deleted to align with program activities and focus under new cooperative agreement. | ||||||||
| 1 | PostDscF | Post-discharge follow-up care protocols | Yes No |
Required question deleted to align with program activities and focus under new cooperative agreement. | ||||||||
| 1 | ContECG | Do all stroke patients receive continuous ECG monitoring for at least 24 hours during admission? | Yes No |
Required question deleted as information is not core to the program. Other questions have been modified to align with scientific advancements | ||||||||
| 1 | Neur_247 | If yes to (5), does your hospital have neurosurgical services available 24/7 (may be on-site or at a remote location)? | Always Sometimes Never |
Neur_247 | If yes to (4), does your hospital have neurosurgical services available 24/7 (may be on-site or at a remote location)? | Always Sometimes Rarely Never |
Modification to add response option for data clarity and response | |||||
| 1 | Neur_2hr | If never to (5a), does your hospital have neurosurgical services available within 2 hours of patient arrival (may be on-site or at a remote location)? | Always Sometimes Never |
Neur_2hr | If never to (4a), does your hospital have neurosurgical services available within 2 hours of patient arrival (may be on-site or at a remote location)? | Always Sometimes Rarely Never |
Modification to add response option for data clarity and response | |||||
| 1 | Neurint | Does your hospital have stroke neurointerventional capabilities? | Yes No |
Neurint | Does your hospital provide neurointerventional treatment/mechanical thrombectomy? | Yes No |
Modification to align with stroke care guidelines and provide clarity | |||||
| 1 | Neurint1 Neurint2 |
Does your hospital provide neurointerventional treatment for | Intra-arterial alteplase Catheter-based reperfusion/mechanical thrombectomy |
Required question deleted because information is already captured in modified above question. | ||||||||
| 1 | EMSPreN | Does pre-notification by EMS regarding a suspected stroke case lead to activation of the stroke team? | Always Sometimes Never No pre-notification |
EMSPreN | How often does pre-notification by EMS regarding a suspected stroke case lead to activation of the stroke team? | Always Sometimes Rarely Never No pre-notification |
Modification to provide clarity and add respnse option | |||||
| 1 | PreNProt | Does pre-notification lead to activation of written stroke care protocols (e.g. notification to pharmacy, “clearing” of CT scanner)? | Always Sometimes Never No pre-notification |
PreNProt | How often does pre-notification lead to activation of written stroke care protocols (e.g. notification to pharmacy, “clearing” of CT scanner)? | Always Sometimes Rarely Never No pre-notification |
Modification to provide clarity and add respnse option | |||||
| 1 | TranProt | Does your hospital have written protocols for stroke patients transferred to and from your hospital? | Yes No |
New required question to capture information on stroke patients that are transferred and understand hospital capacity in improving and streamlining care for these patients. | ||||||||
| 1 | EMS_Run | Does your hospital enter EMS run sheets into a Coverdell-specific in-hospital data collection tool (e.g., GWTG, state-based system)? | Always Sometimes Rarely Never |
EMS_Run | How often does your hospital upload any EMS data (electronically or manually) into stroke patient’s eHR? | Always Sometimes Rarely Never |
Modification to align with recent changes to data systems and capture data more relevant to the program. | |||||
| 1 | EMSFeed_1 EMSFeed_2 EMSFeed_3 EMSFeed_4 EMSFeed_5 |
If yes to (5), how is the feedback provided to EMS agencies? | Fax Phone In-person (for example, at a meeting or during a case review) Other (please specify): |
Required question deleted to reduce burden as data is not core to the program | ||||||||
| 1 | EMSFd_P1 EMSFd_P2 EMSFd_P3 EMSFd_P4 EMSFd_P5 |
If yes to (5), for what patient population is feedback provided? | Patients transported by EMS with a final diagnosis of stroke with pre-notification of possible stroke Patients transported by EMS with a final diagnosis of stroke without pre-notification of possible stroke Possible stroke patients for whom EMS pre-notified the hospital, regardless of the final diagnosis Unknown Other (please specify): |
Required question deleted to reduce burden as data is not core to the program | ||||||||
| 1 | Feed_FRQ | How often does your hospital provide feedback to EMS agencies? | Always Sometimes Rarely Never |
New required question to capture information on EMS feedback to measure improvement and hospital engagement in this area | ||||||||
| 1 | EMSCord | Does your hospital have an EMS coordinator? | Yes No |
Required question deleted as information in not core to program. | ||||||||
| 1 | EMSInt | [Optional] To what extent has the interaction between the ED and EMS providers changed during the past calendar year, compared to the prior calendar year, with respect to the following: a. Communication |
Substantial improvement Minimal improvements No improvement Minimal decline Substantial decline |
Optional question deleted as the evalution of these activites are assessed in other better aligned questions in the survey. | ||||||||
| 1 | EMSint_d | b. Data exchange | Substantial improvement Minimal improvements No improvement Minimal decline Substantial decline |
Optional question deleted as the evalution of these activites are assessed in other better aligned questions in the survey. | ||||||||
| TOC_S | Do you utilize a transition of care summary with stroke patients during discharge? (The National Transitions of Care Coalition (NTOCC) defines a transition of care summary as a method of communication between sending and receiving providers and patient/family/caregivers. Use of a transition of care summary has been proven to reduce readmission rates and decrease medical errors.) | Always Sometimes Rarely Never |
TOC_S | How often do you utilize a transition of care summary with stroke patients during discharge? (The National Transitions of Care Coalition (NTOCC) defines a transition of care summary as a method of communication between sending and receiving providers and patient/family/caregivers. Use of a transition of care summary has been proven to reduce readmission rates and decrease medical errors.) | Always Sometimes Rarely Never |
Modification for clarity | ||||||
| 1 | TOC_F | Does your hospital conduct post-discharge follow-up on patients discharged to home? | Yes No |
Required question deleted to align with program activities and focus under new cooperative agreement. | ||||||||
| 1 | TOC_FT | If yes to (2), how long after discharge does this follow-up typically take place? | 1-7 days 8-14 days 15-21 days 22-30 days >30 days |
Required question deleted to align with program activities and focus under new cooperative agreement. | ||||||||
| 1 | TOC_FL1 TOC_FL2 TOC_FL3 TOC_FL4 TOC_FL5 |
Do you follow-up with (select all that apply): | All patients discharged home A sample of patients discharged home Only cases that were treated with IV alteplase Only cases that were treated with IV alteplase and/or thrombectomy Other: (text) |
Required question deleted to align with program activities and focus under new cooperative agreement. | ||||||||
| 1 | RefTrack | Has your hospital implemented a system for tracking referrals provided to stroke patients to support their post hospital transition of care? | Yes, fully implemented Yes, partially implemented No referral tracking system |
New required question to capture data for program evaluation of post stroke hospital transitions | ||||||||
| 1 | TOC_res | Does your hospital utilize an inventory of community resources to make referrals for post-stroke needs? | Yes No |
TOC_res | How often does your hospital utilize an inventory of community resources to make referrals for post-stroke needs, including resources that can meet patients’ medical, social, and functional needs? | Always Sometimes Rarely Never |
Mofification to response options and the question to align with program focus and provide additional context for this area of stroke care | |||||
| 1 | Partnr_1 Partnr_2 Partnr_3 Partnr_4 Partnr_5 |
Has your hospital established partnerships with any of the following? Please count any that your hospital participates in or provides resources to as a partnership (provide an estimated number next to each): | ____ State or local stroke coalition ____ State or local stroke initiatives ____ State or local professional organizations ____ National stroke initiatives or organizations ____ Other (open text – provide number in parenthesis (eg. state coalition (2), national association (2)): |
New required question to capture data for program evaluation of stroke partnerships | ||||||||
| 1 | CPACHW | Does your hospital have a Collaborative Practice Agreement (CPA) in place that includes community health workers (CHWs)? | Yes No |
New required question to capture data for program evaluation of post stroke hospital transitions | ||||||||
| 1 | CPASOP | If yes to (5), specific to CHWs, does the CPA include a CHW scope of practice? | Yes No |
New required question to capture data for program evaluation of post stroke hospital transitions | ||||||||
| 1 | CPAComm | Does the CPA ensure that CHW scope of practice maintains CHWs’ connections to the community? | Yes No |
New required question to capture data for program evaluation of post stroke hospital transitions | ||||||||
| 1 | CPARefer | How often does your hospital utilize community health workers to refer stroke survivors to resources that can meet their medical, social, and functional needs post-discharge? | Always Sometimes Rarely Never Do not utilize community health workers |
New required question to capture data for program evaluation of post stroke hospital transitions | ||||||||
| 1 | NeurRes |
Does your hospital have the following residency or fellowship programs? a. Neurology |
Yes No |
NeurRes | Does your hospital have a residency or fellowship programs (neurology or other/residency fellowship)? | Yes No |
Modified question to consolidate two question that captured similar information | |||||
| 1 | OthRes | b. Other residency/ fellowship program | Yes No |
Required question deleted to align with modified question above | ||||||||
| 1 | JCPSC_1 JCPSC_2 JCPSC_3 JCPSC_4 JCPSC_5 JCPSC_6 JCPSC_7 |
Is your hospital currently certified as a Joint Commission Acute Stroke Ready Hospital (JC ASRH), Joint Commission Primary Stroke Center (JC PSC), Joint Commission Comprehensive Stroke Center (JC CSC), Joint Commission thrombectomy capable stroke center (TSC) or other similar organization such as Det Norske Veritas (DNV) or Healthcare Facilities Accreditation Program (HFAP)? (select all that apply) | JC ASRH JC PSC DNV PSC HFAP PSC JC CSC DNV CSC JC thrombectomy-capable stroke center (TSC) |
StrkCert | 2. Is your hospital currently certified as a Joint Commission Acute Stroke Ready Hospital (JC ASRH), Joint Commission Primary Stroke Center (JC PSC), Joint Commission Comprehensive Stroke Center (JC CSC), Joint Commission thrombectomy capable stroke center (TSC) or other similar organization such as Det Norske Veritas (DNV) or Healthcare Facilities Accreditation Program (HFAP)? | Yes No |
Modified question to consolidate the individual data captured into yes/no question. Also changed data element name. | |||||
| 1 | Desn_Y Desn_Reg Desn_No |
Does your state/county/region/locality have a stroke designation program? | Yes, state stroke designation program Yes, county/regional/local-level stroke designation No, there is no state/county/regional/local-level designation program |
Required question deleted because question is not core to the program. Relevant question on certification of hospital is capured elsewhere. | ||||||||
| 1 | StDesn1 StDesn2 StDesn3 StDesn4 |
If yes to (3), is your hospital currently designated by that entity as a stroke center or stroke capable/ready hospital? (select all that apply) | Stroke Center (State designation) Stroke Capable/Ready (State designation) Stroke Center (County/regional/local designation) Stroke Capable/Ready (County/regional/local designation) |
Required question deleted because question is not core to the program. Relevant question on certification of hospital is capured elsewhere. | ||||||||
| 1 | TeleStk1 TeleStk2 TeleStk3 |
[Optional] If yes to (4), what mode does the telemedicine consult take place? (select all that apply) | Telephone call Interactive video/videoconference Other (e.g., teleradiology), please specify: |
Optional question deleted because question is not core to the program. Relevant information on telestroke is capured elsewhere. | ||||||||
| 1 | TelCon1 TelCon2 TelCon3 |
[Optional] If yes to (5), what mode does the telemedicine consult take place? (select all that apply) | Telephone call Interactive video/videoconference Other (e.g., teleradiology), please specify: |
Optional question deleted because question is not core to the program. Relevant information on telestroke is capured elsewhere. | ||||||||
| 1 | CommEdu | [Optional] Does your hospital provide community education on stroke signs and symptoms and importance of calling 911? | Optional question deleted because question is no longer core to the program. | |||||||||
| 1 | DataAbs_1 DataAbs_2 DataAbs_3 DataAbs_4 DataAbs_5 DataAbs_6 |
Who is responsible for data abstraction? | Physician Stroke nursing staff/stroke team member Medical records staff QI department staff Other hospital staff (please specify): _____________ Outsourced |
Question no longer needed as this is not core the program and hospital capacity data. | ||||||||
| 1 | Abs_Mtd | What process is used for data abstraction? | Mostly or completely concurrent with care Mostly or completely retrospective Roughly equal-- data collected concurrent with care and retrospective |
Question no longer needed as this is not core the program and hospital capacity data. | ||||||||
| 1 | Sample | Does your hospital sample cases to abstract for data that is submitted to Coverdell? | Yes No |
Question no longer needed as this is not core the program and hospital capacity data. States determine sampling methods so this information is not needed at the CDC level. | ||||||||
| 1 | SampleDes | If yes to (4), please briefly describe your sampling method (e.g. following The Joint Commission’s requirements), including the percentage of cases that are sampled | Open text | Question no longer needed as this is not core the program and hospital capacity data. States determine sampling methods so this information is not needed at the CDC level. | ||||||||
| 1 | EHR | What electronic health record system does your hospital use for stroke cases? | Allscripts Centricity Cerner Computer Programs and Systems Inc (CPSI) eClinicalWorks Epic Systems McKesson Meditech NextGen Healthcare Other (please specify): |
Question has been removed and replaced with one that will capture data more relevant to the program and stroke data integration. | ||||||||
| 1 | HIE | Does your hospital contribute data to a state health information exchange (HIE)? | Yes No |
new question to replace previous question to capture relevant state level EHR data integration | ||||||||
| 1 | EHR_Use | Does your hospital use the EHR system and standardized clinical quality measures to track differences between populations at highest risk for stroke events compared to all stroke patients for any of the following? | Stroke risk factors Acute stroke care Referrals for post-stroke care |
New question to capture use of patient data to identify at risk groups to reduce rehabilitation and prevent strokes. | ||||||||
| 1 | DataQI_1 DataQI_2 DataQI_3 DataQI_4 DataQI_5 DataQI_6 DataQI_7 DataQI_8 |
G2. During the past 12 months, did your hospital conduct data-driven quality improvement initiatives (e.g. the Plan-Do-Study-Act model, small tests of change, lean, six-sigma) related to stroke care to address any of the following? | Use of Multidisciplinary Teams for Care Management Electronic Health Record (EHR) and Patient Tracking Systems Self-Management and Care Management Clinical Guidelines Clinical Decision Support and Protocols Patient Education Other (please specify) Did not do any data-driven quality improvement in the past 12 months |
New question for program evaluation of quality improvement to better align with scope and focus of program under new cooperative agreement | ||||||||
| DataText | Text response for G2. DataQI_7 if “Other” option selected | Text response | Data element to capture text resonse | |||||||||
| 1 | DataRPT1 DataRPT2 DataRPT3 DataRPT4 DataRPT5 DataRPT6 DataRPT7 |
Who receives data reports on your stroke quality of care? | Hospital CEO/ upper management Hospital Board Chief Nursing Officer (CNO) Stroke Team Physician Stroke Champion Chief of Medicine Other (please specify): |
Question removed as this is not core to the program and information will not be used in program evaluation. | ||||||||
| 1 | QI_Imp QI_Text |
How many systematic quality improvement interventions were implemented by hospital staff as a result of quality of care data reports? Please briefly describe each one (e.g. if there was one that was particularly successful, and if it addressed a specific problem). | Number Description |
Question removed as other questions (new and modified) help to capture the necessary information needed to evaluate program related quality improvement. | ||||||||
| 1 | Analyses | [Optional] In the most recent calendar year, have you run additional analyses (beyond what was required for reporting) on your hospital’s own stroke data? | Yes No |
Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPart | Did you participate in any QI activities (e.g. QI training, networking meetings, learning collaboratives) offered through the State health department Coverdell program? | Yes No |
Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPart_N | If yes to (1), how many? | numeric | Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPart_S | [Optional, but can be used for process and outcome performance measure (POPM) data collection] Has your stroke team implemented structured quality improvement strategies (e.g. PDSA (Plan-Do-Study-Act) cycles, small tests of change, lean, six-sigma) to improve quality of care in the most recent calendar year? |
Yes No |
Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPart_P | If yes to (2), Describe the problem(s) addressed | Text | Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPart_R | Briefly describe results | Text | Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPart_H | Was this a helpful way to address the problem? | Yes No |
Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPart_W | Why or why not? | Text | Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPart_C | What challenges did you encounter? | Text | Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPrt_PO | [Optional, but can be used for process and outcome performance measure (POPM) data collection] As a result of participating in the registry the most recent calendar year, what stroke policies or system changes has your hospital implemented? | Text | Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPrt_CH | Have you assessed the impact of any of these changes, for example, by examining changes in data/performance measures? | Yes No |
Optional question removed because evaluation of quaity improvement activities is captured elsewhere. | ||||||||
| 1 | QIPrt_BU | [Optional] To what extent do you have buy-in from upper management (i.e. hospital CEO/board/upper management) to implement stroke QI initiatives? | A great deal of support A fair amount of support Little support No support |
Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities. | ||||||||
| 1 | QIPrt_OT | [Optional] Do you have other QI initiatives that are not directly related to stroke care at your hospital? | Yes No |
Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities. | ||||||||
| 1 | QIPrt_IN | If yes to (5), are your stroke QI initiatives integrated with other QI initiatives in your hospital? | Yes No |
Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities. | ||||||||
| 1 | QIPrt_PR | If yes to (5), compared to other QI initiatives, how important/prioritized are QI initiatives around stroke? | Much more important A little more important Equally important A little less important A lot less important |
Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities. | ||||||||
| 1 | QIPrt_AF | If yes to (5), how do you think other hospital QI initiatives affect your stroke QI initiatives? | Complement Hinder Do not affect |
Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities. | ||||||||
| 1 | QI_Rslt | Did your hospital’s data-driven quality improvement initiatives lead to a change in hospital stroke policies or systems? | Yes, please describe. _________________________________ No Not applicable |
New question for program evaluation of quality improvement to better align with scope and focus of program under new cooperative agreement | ||||||||
| 1 | QI_Imprv | Did your hospital’s data-driven quality improvement initiatives lead to an improvement in a performance measure of care (e.g. door-to-needle time, proportion of eligible patients receiving IV tPA)? | Yes, please describe the improvement and the measure. __________________________ No Not applicable |
New question for program evaluation of quality improvement to better align with scope and focus of program under new cooperative agreement | ||||||||
| 10 | 47 | 15 | 0 | |||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |