105 CMR 130.1406
Quality Improvement Requirements for Stroke Services
(A) The facility shall implement and maintain an effective, data-driven quality assessment and
performance improvement program for the Primary Stroke Service.
(B) The facility shall collect and analyze data, as defined by the Department, on patients
presenting to the ED with acute stroke, to identify opportunities for improvement in the service.
(C) The facility shall submit data, in a manner defined by the Department, and in accordance
with protocols established by the Department in guidelines.