Wisconsin Coverdell Stroke Program: Hospitals

All Wisconsin hospitals are invited to be part of the Wisconsin Coverdell Stroke Program. The aim of the program is to support the implementation of comprehensive stroke systems for individuals at highest risk for stroke events and to improve the quality of care for stroke patients across the continuum of care. Hospitals can choose to participate as a Partner or Champion Hospital.

Overview

The Participating Hospital Guide, P-01137 (PDF) explains the benefits, how to join, and activities of the Wisconsin Coverdell Stroke Program.

Stroke Care Partners Coverdell Program Support. Participating stroke care partners in the Wisconsin Coverdell Stroke Program receive multiple benefits, such as:

  • Access to “Building Blocks of a Stroke Program Toolkit”
  • Access to Hemispheres free online stroke education as resources are available
  • Free BE FAST community education materials
  • Networking opportunities with other Coverdell hospitals
  • Member of the Stroke Coordinators of WI
  • Member of the Coverdell Learning Collaborative 
  • Technical assistance to answer questions regarding stroke care and related activities
  • Collaboration with American Heart Association/American Stroke Association for technical assistance on data collection
  • Invitations to stroke education opportunities
  • Recognition on the state stroke program website
  • A press release template on being a Stroke Care Partner to use for local publicity
  • Coverdell Stroke Partner Agreement, F-01648 (PDF)

Champion Hospitals Coverdell Program Support. Participating Champion Hospitals in the Wisconsin Coverdell Stroke Program receive multiple benefits, such as:

  • Learning opportunities for stroke teams
  • Resources for stroke care quality improvement and community stroke education
  • Coordinated development of Coverdell-related abstracts and presentations (e.g., for professional meetings) when appropriate
  • Safe and secure management of all de-identified data submitted by the hospital
  • Maintain chart re-abstraction results according to Centers for Disease Control and Prevention standards for quality and security
  • Free development of annual agreement reports for each site to ensure your data quality remains high
  • Quarterly report cards of quality measures along the continuum of care which provide benchmark groups for comparison, and have established goals for each measure to assist in motivating and gauging progress
  • Facilitated peer-to-peer and mentoring opportunities between hospitals to share best practices
  • Coverdell Champion Agreement, F-01649 (PDF)

Coverdell Registry

The long-term outcomes of the Paul Coverdell National Acute Stroke Program are:

  1. Increased access to care and improved quality of care for stroke patients
  2. Decreased disparities in access to care and quality of care for populations at highest risk for stroke events

The following are Coverdell program strategies to achieve the long-term outcomes:

  1. Track and monitor clinical measures to improve data infrastructure across stroke systems of care
  2. Implement a team-based approach to enhance quality of care for those at highest risk for stroke events and stroke patients across systems of care
  3. Link community resources and clinical services that support those at highest risk for stroke events and stroke patients across systems of care

Wisconsin’s participation in the Coverdell Registry is facilitated by the Division of Public Health and MetaStar.

About the Registry Process

Participating hospitals enter and track stroke data using an online quality improvement tool where data is abstracted for 10 consensus measures. Measures were established by the Centers for Disease Control and Prevention (CDC) in collaboration with The Joint Commission and the American Heart Association/American Stroke Association based on evidence from multiple clinical trials in peer-reviewed journals. These provide the foundation for stroke care quality improvement in Wisconsin:

  • Venous Thromboembolism (VTE) Prophylaxis

  • Discharged on Antithrombotic Therapy

  • Anticoagulation Therapy for Atrial Fibrillation/Flutter

  • Thrombolytic Therapy

  • Antithrombotic Therapy by End of Hospital Day 2

  • Discharged on Statin Medication

  • Stroke Education

  • Assessed for Rehabilitation

  • Smoking Cessation Counseling

  • Dysphagia Screening

Champion Hospitals
  • Ascension All Saints Hospital

  • Ascension Columbia St. Mary's Milwaukee

  • Ascension Columbia St. Mary's Ozaukee

  • Ascension NE Wisconsin Mercy Campus

  • Ascension NE Wisconsin St. Elizabeth Campus

  • Ascension St. Francis Hospital

  • Ascension SE Wisconsin Hospital - Elmbrook Campus

  • Ascension SE Wisconsin Hospital - Franklin Campus

  • Ascension SE Wisconsin Hospital - St. Joseph's Campus

  • Aspirus Divine Savior

  • Aspirus Eagle River

  • Aspirus Iron River Hospital

  • Aspirus Ironwood Hospital

  • Aspirus Keweenaw Hospital

  • Aspirus Langlade Hospital

  • Aspirus Medford Hospital

  • Aspirus Merrill Hospital

  • Aspirus Ontonagon Hospital

  • Aspirus Plover Hospital

  • Aspirus Rhinelander Hospital

  • Aspirus Riverview Hospital and Clinics

  • Aspirus Stanley Hospital

  • Aspirus Stevens Point Hospital

  • Aspirus Tomahawk Hospital

  • Aspirus Wausau Hospital

  • Aurora BayCare Medical Center

  • Aurora Lakeland Medical Center

  • Aurora Medical Center Bay Area

  • Aurora Medical Center Grafton

  • Aurora Medical Center Kenosha

  • Aurora Medical Center Manitowoc County

  • Aurora Medical Center Mount Pleasant

  • Aurora Medical Center of Washington County

  • Aurora Medical Center Oshkosh

  • Aurora Medical Center Summit

  • Aurora Memorial Hospital of Burlington

  • Aurora St. Luke's Medical Center

  • Aurora St. Luke's South Shore

  • Aurora Sheboygan Medical Center

  • Aurora Sinai Medical Center

  • Aurora West Allis Medical Center

  • Bellin Memorial Hospital

  • Beloit Health System

  • Essentia Health-St. Mary's Hospital of Superior

  • Froedtert Hospital

  • Froedtert Menomonee Falls

  • Froedtert West Bend

  • Gundersen Health System

  • Gundersen Moundview Hospital and Clinics

  • Howard Young Medical Center (Aspirus)

  • Marshfield Medical Center Ladysmith

  • Mayo Clinic Health System Eau Claire

  • Mayo Clinic Health System - Franciscan Healthcare La Crosse

  • Mercy Hospital and Trauma Center, Janesville

  • Meriter UnityPoint

  • ProHealth Care Oconomowoc Memorial Hospital

  • ProHealth Care Waukesha Memorial Hospital

  • Sacred Heart Hospital of the Hospital Sisters of the Third Order of St. Francis

  • St. Mary’s Hospital Medical Center, Green Bay, Inc.

  • St. Nicholas Hospital of the Hospital Sisters of the Third Order of St. Francis

  • St. Vincent Hospital of the Hospital Sisters of the Third Order of St. Francis 

  • SSM Health St. Mary's Hospital - Janesville

  • SSM Health St. Mary's Hospital - Madison

  • The Richland Hospital

  • University of Wisconsin Hospital and Clinics

Partner Hospitals
  • Bellin Health Oconto Hospital and Clinics

  • Black River Memorial Hospital

  • Crossing Rivers Health

  • Mercy Walworth Hospital

  • Mile Bluff Medical Center

  • Stoughton Hospital

  • Upland Hills Health

Coverdell Learning Collaborative

The Coverdell Learning Collaborative (CLC) meets for 1.5 hours quarterly, either in-person or virtually. The meeting provides members the opportunity to network with fellow stroke coordinators as well as ask questions and share best practices. The meeting consists of:

  • Review blinded data across the stroke systems of care (SSoC) to identify areas where efficiency and quality of care can be improved
  • Discuss, explore, and share best practices on the role of community health workers and patient navigators in post-discharge care
  • Identify and create collaborative quality improvement initiatives for Plan-Do-Study-Act (PDSA) cycles
  • Update on EMS practices
  • Inform on stroke-related activities at the state level

Attendance is required at three of four (75 percent) of these meetings.

Performance Improvement Program

In support of the ongoing quality improvement efforts of participating hospitals, the CLC analyzes Wisconsin Coverdell Stroke Program aggregated hospital stroke data and discusses evidence-based practices and processes that are involved in achieving sustained high performance.

In March we met virtually via a Zoom meeting which was recorded for those who had a conflict. We acknowledged and celebrated the Stroke Coordinator with the fastest arrival to CT completion time. The coordinator shared QI efforts which assisted their site in reaching this high level of performance.

  • Fastest time to CT initiation in those stroke patients arriving <4.5 hours from Last Known Well for Q4 2021:
    • Aurora Medical Center of Washington County

We also acknowledged and supported the five hospitals with 100% defect-free care within the 10 Coverdell performance measures for Q4 2021.

  • Aspirus Medford Hospital and Clinics
  • Aurora Medical Center of Washington County
  • HSHS St. Mary’s Hospital Medical Center, Green Bay
  • ProHealth Care Oconomowoc Memorial Hospital
  • The Richland Hospital, Inc.

Another notable achievement identified by the Coverdell Learning Collaborative (CLC) belongs to the seven hospitals with 100% agreement and the sixteen hospitals with 99% agreement between two abstractors for the Q3 2021 agreement process. WI Coverdell was at 96% agreement for this process in Q3 2021 which ties as the highest we have been.

  • Hospitals who achieved 100% agreement:
    • Ascension Columbia St Mary's Ozaukee
    • Ascension NE Wisconsin Mercy Campus
    • Ascension NE Wisconsin St. Elizabeth Campus
    • Ascension SE Wisconsin Hospital - Elmbrook Campus
    • Ascension SE Wisconsin Hospital - St. Joseph Campus
    • HSHS St. Nicholas Hospital, Sheboygan 
    • Meriter UnityPoint
  • Hospitals who achieved 99% agreement:
    • Ascension All Saints
    • Ascension St. Francis Hospital
    • Aspirus Iron River Hospital
    • Aspirus Keweenaw Hospital
    • Aspirus Ontonagon Hospital
    • Aspirus Wausau Hospital
    • Aurora BayCare Medical Center
    • Aurora Lakeland Medical Center 
    • Aurora Medical Center Grafton
    • Aurora Memorial Hospital of Burlington
    • Aurora Medical Center Summit
    • Aurora St. Luke's Medical Center
    • Bellin Memorial Hospital
    • HSHS St. Mary’s Hospital Medical Center, Green Bay
    • Mercy Hospital and Trauma Center, Janesville
    • ThedaCare Regional Medical Center-Neenah

A PI focus for the CLC is the EMS Pre-notification measure. In Q4 2021 there were twelve hospitals who achieved 100%. 

  • Ascension NE Wisconsin - Mercy Campus
  • Aspirus Iron River Hospital and Clinics
  • Aspirus Medford Hospital and Clinics
  • Aspirus Ontonagon Hospital
  • Aspirus Riverview Hospital and Clinics
  • Aurora Medical Center Summit
  • HSHS Sacred Heart Hospital
  • HSHS St. Nicholas Hospital, Sheboygan
  • Mercy Hospital and Trauma Center, Janesville
  • ProHealth Care Oconomowoc Memorial Hospital
  • The Richland Hospital, Inc.
  • ThedaCare Regional Medical Center-Neenah

Stroke Coordinators of Wisconsin (SCOW)

The SCOW Committee meets quarterly. Any hospital in the state of Wisconsin or surrounding states that has an objective of improving stroke patient outcomes by promoting evidence-based care and quality initiatives may participate. Currently, over 95 hospitals have representation in the SCOW. The mission of the SCOW is to collaboratively improve the quality of stroke care and prevention in Wisconsin, where the goals are to identify quality improvement needs in the state and recognize a process for measuring and monitoring performance. Attendance in-person or virtually is recommended for Coverdell hospitals.

This forum is a great opportunity to:

  • Hear from outside speakers on a variety of stroke topics.

  • Learn from others in the areas of data collection, quality improvement initiatives, and stroke systems of care.

  • Gain insight on preparing for stroke center certification or recertification.

  • Network with stroke coordinator peers throughout Wisconsin.

The Stroke Coordinators of Wisconsin Committee has an advisory council that:

  • Provides leadership and oversees progress on meeting SCOW recommendations.

  • Develops meeting agendas based on the group’s interest and quality improvement priorities.

  • Assists in recruiting speakers.

Resources for Hospitals

Articles, Guidelines, and Conference Recordings
Process Documents
Maps
Community Stroke Education
Hospital Accreditation Services
Stroke Disease Specific Certified (DSC) Hospitals

There are two certifying bodies Wisconsin hospitals have utilized to certify their stroke programs. To find which hospitals are certified in stroke, follow these steps:

The resources presented on this web page are a sampling of available materials and do not necessarily constitute an endorsement by the Department of Health Services or the American Heart Association/American Stroke Association.


Logo for the Wisconsin Coverdell Stroke ProgramMore Information

Dot Bluma, BSN, RN, CPHQ
Stroke Project Specialist, MetaStar
dbluma@metastar.com

Last Revised: April 13, 2022