Are The Financial Tough Times Behind Us?

A new reality is upon us! Hospitals are experiencing unprecedented challenges in maintaining operations at a profitable level.

While hospitals had unprecedented financial losses during the initial period of COVID-19, federal relief funding from the Coronavirus Aid, Relief and Economic Security (CARES) Act, helped neutralize hospital financial losses. But during the first 8 months of 2022, hospitals in the US were still operating substantially below pre-pandemic levels and many were on track for their worst financial year in decades.1

Fast forward to 2023. Hospitals will continue to struggle. Relief funding has dwindled. Everyone is grappling with an exhausted workforce and staffing shortages. Contract labor has become a mainstay for many hospitals.2 Inflation has driven up the cost of pharmaceuticals and supplies. And volumes are still down.

Because of this you may be feeling increased pressure to manage your program with less. It may be more challenging to get resources to sustain or expand your stroke program. Your stroke volume may be down due to diversion caused by staffed bed shortages. And your length-of-stay may be climbing because post-acute facilities for your patients are at capacity.

As we ring in the new year, there is a foreboding of uncertainty ahead!

What can you do, as a stroke program leader, to help mitigate financial worries of your organization and support the hospital and/or system’s 2023 strategic priorities?

  • First, are you familiar with your organization’s budgeting practices? Do you know and understand your program’s budget and how it relates to other departments and the overall hospital budget? Often funds to support a stroke program are budgeted within several different departments, i.e., nursing, education, quality, marketing, etc. In this case, collaboration and negotiation with department leaders are needed to prioritize stroke program needs with other budget needs in these departments.
  • Second, do you understand the economics of your stroke program? It’s vitally important for stroke program leaders to understand how their organization looks at profitability of programs or service lines. What financial metrics do your financial decision-makers consider when making budget decisions or program investments? Find out how your program is currently performing in these metrics and how your program can favorably impact them in the coming year(s). If additional investments are needed, it’s important to formulate the “business-oriented case” (short-term and long-term) using these financial metrics along with the “quality-of-care case” to illustrate the overall return on investment.
  • Third, are your organization’s overarching strategic priorities for the upcoming year clearly defined for you? These may involve staff retention, volume growth, increased bed capacity, improved quality indicators, cost-reduction, length-of-stay reduction, readmission reduction, effective transitions of care, etc. It may be all of these!! It is important to bring your team together and determine where and how you can contribute to these priorities. In developing your action plan(s), include the value proposition for each stakeholder, or stakeholder group, and use this to gain support for initiatives that will help offset problems they are facing, i.e., staff retention, length-of-stay, transitions of care, etc.
  • Lastly, how will you gain support for your plan or initiatives? It will likely require presentations to various stakeholder groups. Think through each group and what questions they will want answered. Organize your presentation accordingly. As an example, I had an important meeting with executive leaders to present a neurosurgery business plan and I crafted my presentation with my usual approach – a story with a beginning and an end. The night before, I rearranged the presentation and started with the “end” of the story, e.g., the financial impacts of the plan. This addressed the “burning” question of the executive leadership and, while the full picture was important to them. I answered “the bottom line” question before they had to scoot out for another meeting.

In closing, we find that stroke program leaders often have not been exposed to the economics of their stroke program in their organization and may not be totally familiar with how financial and executive leaders view the profitability of their program.

In support of our mission to bring important resources to stroke program leaders, we have developed a webinar entitled, Acute Stroke Economics 101, that is available on-demand at: It is designed to equip stroke program leaders with a better understanding of acute stroke economics and how to talk with financial leaders. Key topics of the webinar include:

  • Key revenue and cost drivers in acute stroke hospitalizations
  • How program profitability is determined
  • Reimbursement for stroke care by various payers including Medicare MS-DRGs
  • Financial impact of regulatory programs to improve care
  • How program investments are viewed by finance leaders


1Kaufman, Hall & Associates, National Hospital Flash Report Sept 2022: (August 2022 Data, 900+ Hospitals)
2Jonathan Cantor, PhD; Christopher Whaley, PhD; Kosali Simon, PhD; et al. US health care workforce changes during the first and second years of the COVID-19 pandemic  JAMA Health Forum. 2022;3(2):e215217. doi:10.1001/jamahealthforum.2021.5217

Ensuring a Successful Neurointerventional Radiology (NIR) Tracer

As mechanical thrombectomy science evolved over the past decade, the neurointerventional (NIR) suite became a critical area for patient care and a focus of regulatory review for stroke certification.When assisting programs in seeking successful certification visits, we’ve noted a few common themes in need of attention in the NIR suite to ensure successful certification tracers. 

  • Staffing: There tends to be variation in how NIR suites are staffed across the nation in terms of number of staff, credentials of staff and roles of each staff member in the suite.  This is often more pronounced in organizations when the NIR suite is maintained separately from the cardiac catheterization suite.  Leadership should be aware of the differences and articulate how their model of staffing ensures patient safety while in the NIR suite.  Differences between how cardiac intervention cases and stroke intervention cases are staffed should be explored by leadership and easily explained if asked.  
  • Educational competencies: NIR suite leadership may manage education and competency assessment from several perspectives.  Companies with knowledge about devices frequently host educational talks or in-services for staff.  Content covered and attendance at in-services should be noted by NIR leadership and documented in staff files.  Information from device experts should be put

    into context for NIR staff by practitioners (e.g., physicians, advanced practice providers, stroke coordinators, lead technologists) so all staff are knowledgeable about how devices will be used in procedures at the organization.  Another great approach to NIR staff education is focusing on what staff should anticipate if an unexpected complication occurs during the case.  Discussion or even simulated cases of managing complications during procedures can help all room staff anticipate what is needed during a stressful event.  Finally, any staff managing patients with critical care needs in the NIR suite should have documented education and competencies related to critical care stroke management. 
  • Knowledge of performance improvement data: NIR staff should have knowledge of the program’s performance data and how they fit into the puzzle of fast and safe care.  This includes knowledge about the time from door to thrombolysis and mechanical thrombectomy times (first pass of device, recanalization time) and outcomes (TICI scores).  Staff should be articulate about how they ensure processes are followed to minimize delay and ensure safety.  Data should be readily available for staff, and they should be able to explain the information and why it matters to patient care.  
  • Management of critically ill patients: Some patients receiving care in the NIR suite are critically ill, such as patients with subarachnoid hemorrhage in the suite for intra-arterial management of cerebral vasospasm.  Roles and responsibilities of all staff in the room related to management of critical care needs including the external ventricular drain (EVD), intracranial pressure monitoring and management, vasopressors for blood pressure management, and mechanical ventilation should be clear. Documentation of frequent vital sign assessment, EVD monitoring and mechanical ventilation should also be clear in the medical record for patient tracers. Many traditional templates for the NIR or cardiac catheterization lab in electronic health records do not offer a place for documentation of these parameters and require editing to ensure complete documentation of monitoring.

Having an organized approach to these key areas will help to ensure a smooth certification review for your stroke program and will minimize the risk of findings on your next certification review.  Most importantly, it will ensure you are providing the best care for your patients.   

And as always, Stroke Challenges has several free resources including blogs on various stroke topics.  We also offer both e-books and on-demand webinar training on topics including how to put your best foot forward during your stroke program opening presentation for certification, mastering your data tracer and several helpful on-demand data management presentations and workshops.  Visit our website to see all that we offer!


Sarah Livesay, DNP, APRN, ACNP-BC, ACNS-BC

Debbie Hill, BS, FAHA

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Keeping Up!

As we turn to fall, we thought it might be helpful to compile a list of “go-to” resources for stroke program leaders to keep on hand.  Something about the change in season and the back-to-school atmosphere has me making lists and getting organized both in my personal and professional life.

Of course, stroke program leaders are familiar with The American Stroke Association.  However, several other professional organizations offer guidelines and other resources related to stroke care including the American Association of Neuroscience NursesAssociation of Neurovascular Clinicians, Society of Vascular and Interventional Neurology, and Neurocritical Care Society. Joining list-servs through these professional organizations or regional stroke coordinator groups is also helpful.

If you are looking to expand your knowledge about healthcare quality, several organizations offer resources for free or for a small fee.  The Institute for Healthcare Improvement offers several free resources on quality, and they offer the IHI Open School with multiple courses on healthcare quality and improvement.  The courses are either free or for a small fee depending on your organization’s affiliation with the IHI.  The Agency for Healthcare Research and Quality has a large repository of free resources, including basic healthcare quality information.  The AHRQ search engine searches multiple government sites and can be helpful when researching stroke quality indicators and large data sets on stroke mortality.  They also have a great resource to assess healthcare quality and disparities by state.  

If you need to brush up on your basic excel skills, Technology for Teachers and Students has a great excel basics video and an intermediate excel tutorial.  You can then apply those skills using the Spinnaker Health Care Solutions YouTube channel where you will find great short videos teaching key excel and data management skills using stroke data templates tailored to stroke program leader needs.  

If you want to stay current on regulatory changes, sign up for e-Alerts or Advisories from stroke program certification agencies.

Another way to be sure to get timely certification agency stroke program updates is to connect with someone in your regulatory department and make sure they know what you need. For Medicare (CMS) changes in reimbursement or coverage, connect with someone in your finance department and coordinate getting any changes that impact the stroke program.

And as always, Stroke Challenges has several free resources including blogs on various stroke topics.  We also offer both e-books and on-demand webinar training on topics including how to put your best foot forward during your stroke program opening presentation for certification, mastering your data tracer and several helpful on-demand data management presentations and workshops.  Visit our website to see all that we offer!


Sarah Livesay, DNP, APRN, FNCS, FAAN

Debbie Hill, BS, FAHA

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By now, we are sure you’ve seen the latest guidelines from the American Stroke Association on the management of spontaneous intracerebral hemorrhage published in May of 2022. 

Has your program taken the appropriate steps to review the guideline and update your order sets, guidelines and/or clinical pathways to reflect the changes? And how do you handle disparate practice amongst care providers or disagreement with the guidelines? 

The publishing of a significant new guidelines offers an opportunity to reflect on the role guidelines play in your program and how to systematically approach guideline review.  An organized approach ensures you are both optimizing the care of your patients using an evidence-based approach and success during your next stroke program review. 

Guidelines offer a synthesis of the studies published on a certain disease by experts in the field.  Over the past decade, many societies adopted new methodologies to generate guidelines intended to increase the rigor and minimize bias.  This has resulted in both improved guidelines and also changes in guideline recommendations as a result of more rigorous methodology.  However, one of my favorite sayings about guidelines is that they are supposed to be the beginning of the conversation, not the end.  Guidelines are intended to summarize the best evidence applied to the broadest population of individuals.  They are not meant to be rules that are applied indiscriminately to all patients.  Some patients may require a deviation from suggested care in a guideline because the care provider is individualizing care to that individual.  These situations are expected and appropriate, and documentation to justify the decision should be evident in the medical record. 

The best approach to a newly published guideline is to pull all resources (order sets, protocols, pathways, policies, etc) and compare new recommendations against program resources.  When the resource deviates from a published recommendation, this warrants a team discussion with key leaders in the program including physicians, advanced practice providers, nurses, pharmacists and program administrators.  The strength of the recommendation and evidence used to make the recommendation should be reviewed in the context of the population the program serves.  The team must make a decision to either follow the recommendation in the guideline and update program resources, or to deviate from the guideline.  If the choice is made to deviate when planning program resources, the contextual program reasons for the decision should be well documented in meeting minutes or somewhere similar.  Then, program documents should be updated accordingly.  However, providers may still individualize care to patients and should document the reasons why care may differ from program resources and why this is best for the patient. 

Using an organized approach to reviewing and applying clinical practice guidelines is a key skill of a stroke program leader and will minimize the risk of findings on your next certification review.  Most importantly, it will ensure you are providing the best program resources for providers to care for your patients.    


Sarah Livesay, DNP, APRN, ACNP-BC, CNS-BC

Debbie Hill, BS, FAHA

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Control charts employ statistics to help you gauge if your process measures require intervention.  They allow you to track the effects of a quality improvement measure on the data and to respond to multiple data points instead of just an unfortunate case or data point.  As a result, you review individual cases in relation to trends from other cases to decide if a process is working for your program or if it’s time for a change.  This tool allows you to analyze and react to trends rather than allowing the last challenging case to overinfluence your team discussions.

Timeliness data (e.g., time-to-thrombolytic, time-to-groin puncture, etc.) are perfect processes to monitor using control charts.  Surprisingly, few stroke programs use control charts.  This may be because it requires some statistical knowledge and excel spreadsheet skills.  But once you learn how to build a control chart using Excel, you can quickly convert your standard line graph into a control chart

We developed an Excel tool and training webinar to help you learn how to build and master control charts. We give you an Excel template already populated with the statistical formulas and “mock” data. The webinar walks you through building a control chart with the Excel template. You can also cut and paste your Stroke Log data into the Excel template and build a control chart displaying your own data! Learn more about the webinar here.

We offered this training in a virtual workshop in January and got some great feedback that we’d like to share with you:  

“The workshop was perfect. Very informative. I liked the fact that the spreadsheet had a built-in tab illustrating the formulas and the cells. Very easy to follow.”

“Very straightforward and easy to understand!”

“Easy to follow and understand! Excellent workshop!”

“I really liked all of this workshop.  I use these charts all the time but even the review of the basics was great. I never knew the difference between a histogram and bar chart.”

“Great job, very helpful information and relevant examples.” 

Thank you to Dale Strong at Spinnaker Health Care Solutions for collaborating with us to develop this webinar and to ABBVIE for sponsoring the live workshop.