MjMO2n7( LBm6N.Hl#|oKP?lEF@L9ew,w\XpP{]8vxmtV}Or,kU{ `B7{"'Tf(DL[}ZEY 7'XoFo(|{%Jlv,_v}%DPnpoAucQGPy'YVJGXv:E j5(kts,?BcBKd?R . All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. Visit: . Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. 4 0 obj STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. For the purposes of this blog, since we are focusing specifically on stroke measures, there is only one stroke measure that is used for Accreditation purposes by both CMS and TJC: OP-23. Hospital Outpatient Quality Measure Stroke. In this post we are either referencing CMS or The Joint Commission as the Measure Stewards. >0SPJ*@6W/rq+ERY_X&14>k( STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. The ACM is a pass-fail measure at the individual patient level that asks whether an eligible patient has received all of the appropriate care for the condition for which he or she is being treated. CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. There are five major stroke measure sets. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. Regulatory/AccreditationExamples would include the Center for Medicare & Medicaid Services (CMS) required core measures (e.g., fibrinolytic therapy received within 30 minutes of emergency department (ED) arrival, aspirin at arrival) and documentation of Joint Commission standard achievement. The two sub-populations must be sampled independently from each other. You receive one consultant that you can call anytime with questions or concerns. endobj Brainstorm with your team to find ways to improve your hospital's treatment rates. 1 0 obj The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. CSTK-09 Arrival Time to Skin Puncture, 8. website belongs to an official government organization in the United States. CSTK-09 Arrival Time to Skin Puncture, 1. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. Data collection for STK-OP-1 will replace ASR-OP-2. Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. Time from symptom onset to stroke alert is delayed in in-hospital stroke. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. Especially if you use an EHR vendor right now, youll notice a huge difference. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The AMA does not directly or indirectly practice medicine or dispense medical services. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. Specifications Manual for Joint Commission National Quality Measures (v2021A1), Comprehensive Stroke (CSTK) Initial Patient Population, First Pass of a Mechanical Reperfusion Device, Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation, Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation, IV Alteplase Prior to IA or Mechanical Reperfusion Therapy, Initial Blood Glucose Value at Hospital Arrival, Initial Blood Pressure at Hospital Arrival, Initial Platelet Count at Hospital Arrival, NIHSS Score Documented Closest to IA Alteplase or MER Initiation, NIHSS Score Documented Closest to IV Alteplase Initiation, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time, Reason for Not Administering Nimodipine Treatment, Reason for Not Administering a Procoagulant Reversal Agent, Appendix E - Overview of Measure Information Form and Flowchart Formats, Cover Page for the Joint Commission Manual, Joint Commission Clinical Data Processing Flow, Joint Commission National Quality Measures Data Processing, Using the The Joint Commission's National Measure Specifications Manual, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH ), Hemorrhagic Transformation (Overall Rate), Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), Modified Rankin Score (mRS at 90 Days: Favorable Outcome), Rate of Rapid Effective Reperfusion From Hospital Arrival, Rate of Rapid Effective Reperfusion From Skin Puncture, All Records, Not collected for HBIPS-2 and HBIPS-3, All Records, Optional for HBIPS-2, HBIPS-3, All Records, Optional for All HBIPS Records. Using the quarterly sampling table for the Ischemic sub-population, the sample size required is 20% of this sub-population, or 79 cases for the quarter (twenty percent of 392 equals 78.4 rounded up to the next whole number equals 79). This Agreement will terminate upon notice if you violate its terms. ASR-OP-2c Ischemic Stroke; drip and ship4. 7272 Greenville Ave. STK-6 Discharged on Statin Medication12. Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> There are no Stroke eCQMs applicable or available for Certification purposes. Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 20% of this subpopulation or 25 cases for the month (20% of 123 equals 24.6 rounded to the next highest whole number equals 25). A hospitals ischemic stroke patient population size is 129 cases during March. Sometimes it works best to start small and build on success. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. STK-OP-1a Overall Rate (Not Reported2. Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% of the Initial Patient Population is required, Patient level data must be processed in order to submit your aggregate data. The Core Quality Measure Collaborative, led by the Americas Health Insurance Plans (AHIP) and its member plans Chief Medical Officers, leaders from CMS and the National Quality Forum (NQF), as well as national physician organizations, employers and consumers, worked hard to reach consensus on core performance measures. STK-OP-1 Door to Transfer to Another Hospital, 1. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. All rights reserved. The required sample size for the CSTK-01 measure is a minimum of 42 cases for the month (28 cases from Table 4 plus 14 cases from Table 5 equals 42). In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. Program details are found in Part 2. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. A single copy of these materials may be reprinted for noncommercial personal use only. STK-OP-1f Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO7. You, your employees and agents are authorized to use CPT only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. U.S. Government Rights Finally, I have listed a few more resources for you. Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. These core measure sets are a major step forward for alignment of quality measures between public and private payers and provides a framework upon which future efforts can be based. Since the program's start in 2003, over 2,000hospitals have entered more than 5million patient records into the Get With The Guidelines- Stroke database. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). Find more information on our content editorial process. Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. 690 0 obj <>stream Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. We keep you on track for your submission deadlines and ensure you dont miss critical dates. Here I have broken it into the inpatient measure set and the outpatient measure set. Get With The Guidelines- Stroke supports hospitals in many ways, including: Data submission and feedback reporting are performed using the American Heart Association's Get With The Guidelines Registry (IRP)(link opens in new window). Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. 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Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Measures for Acute Stroke Ready Center Certification, Measures for Primary Stroke Center Certification, Measures for Thrombectomy Capable Stroke Center Certification, Measures for Comprehensive Stroke Center Certification, eSTK-2 Discharged on Antithrombotic Therapy, eSTK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, eSTK-5 Antithrombotic Therapy by End of Hospital Day Two, ASR-IP-1 Thrombolytic Therapy: Inpatient Admission, ASR-IP-2 Antithrombotic Therapy By End of Hospital Day 2, ASR-IP-3 Discharged on Antithrombotic Therapy, ASR-OP-1 Thrombolytic Therapy: Drip and Ship, CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients, CSTK-02 Modified Rankin Score (mRS) at 90 Days, CSTK-03 Severity Measurement Performed for SAH and ICH Patients, CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH), CSTK-06 Nimodipine Treatment Administered, CSTK-08 Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade, CSTK-10 Modified Rankin Score (mRS) at 90 Days: Favorable Outcome, CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival, CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture, STK-1 Venous Thromboembolism (VTE) Prophylaxis, STK-2 Discharged on Antithrombotic Therapy, STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-5 Antithrombotic Therapy By End of Hospital Day Two, STK-OP-1 Door to Transfer to Another Hospital, STK-VOL-1 Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy. endobj Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. endobj The American Heart Association is a qualified 501(c)(3) tax-exempt organization. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> I hope this high-level overview was helpful and can be a reference for you. 671 0 obj <>/Filter/FlateDecode/ID[<8968A4F338E55446928FCF4A155C4BC8>]/Index[646 45]/Info 645 0 R/Length 114/Prev 86415/Root 647 0 R/Size 691/Type/XRef/W[1 2 1]>>stream The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. STK-10 Assessed for Rehabilitation. Core measures are based on the most common condition's hospitals see, such as acute myocardial infarction (AMI), heart failure (HF), pneumonia, surgical care, children's asthma care, venous thromboembolism (VTE), stroke, and more. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. Stroke Core Stroke Measures As a Certified Stroke Center the stroke committee would like to provide physicians with updates on how we are performing on the stroke performance and quality measures. This is a big year for Quality. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 1-800-AHA-USA-1 These measures include aggressive use of medications, such as antithrombotics, anticoagulation therapy, deep vein thrombosis prophylaxis, cholesterol-reducing drugs and smoking cessation, all aimed at reducing death and disability and improving the lives of stroke patients. This content does not have an Arabic version. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. Numerous published studies demonstrate the program's success in improving patient outcomes. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. % 2021; 97: . The core measurescan be found at: http://www.qualityforum.org/cqmc/. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 37 cases are sampled. Stroke Core Measure - About Us - Mayo Clinic , . endobj For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Learn about the development and implementation of standardized performance measures. Claims-Based Measures by Category Claims-Based Patient Safety Measures for 2022 Claims-Based Mortality Measures for 2022 Claims-Based Coordination of Care Measures for 2022 2 0 obj Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. You can decide how often to receive updates. This began in Fiscal Year (FY) 2014. Find more information on our content editorial process. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. Stroke (STK) (v2021B) Home Stroke (STK) Release Notes: Measure Information Form Version 2021B Stroke (STK) On this page: Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements Related Materials Initial Patient Population Algorithm Stroke (STK) Initial Patient Population Algorithm Narrative STK-4 Thrombolytic Therapy10. The CQMC is a diverse coalition of health care leaders representing over 75 consumer groups, medical associations, health insurance providers, purchasers and other quality stakeholders, all working together to develop and recommend core sets of measures by clinical area to assess and improve the quality of health care in America. Measure ID # Measure Short Name OP-23 . The reduction of LDL cholesterol, through lifestyle modification and drug therapy when appropriate, is recommended for the prevention of recurrent ischemic stroke, heart attack, and other major vascular events. Submission of aggregate data is still required. The American Medical Association does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The required quarterly sample is 45 cases. Using the monthy sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 14 cases for the month. All rights reserved. The next measure set we review is abbreviated ASR-IP/OP. Chart-abstracted measures specificationsScreen Reader Text. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. They also could require other measures. 4 0 obj We help you select and set up measures that make sense based on your hospitals situation. This post is a guide to understanding the differences between the five major stroke measure sets. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. This Agreement will terminate upon notice if you violate its terms. STK-8 Stroke Education18. CPT is provided as is without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Contact Us, Hours Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. A hospitals Ischemic sub-population is 100 during the first quarter. Early rehabilitation interventions initiated following stroke can enhance the recovery process and minimize functional disability. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. In the Hospital Inpatient VBP Program Final Rule, CMS adopted the 30-day mortality measures for acute myocardial infarction (AMI), heart failure (HF), and pneumonia* under the Outcome domain.