Start STK Initial Patient Population logic sub-routine. 2 0 obj All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Submission of aggregate data is still required. The Centers for Medicare & Medicaid Services (CMS) has posted the electronic clinical quality measure ( eCQM) specifications for the 2021 reporting period for Eligible Hospitals and Critical Access Hospitals, and the 2021 performance period for Eligible Professionals and Eligible Clinicians. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. Nozzle assembly is comprehensively flow tested to measure flow rate, leak and seat condition to validate injection consistency. The Differences Between The 5 Major Stroke Measure Sets, Thrombolytic Therapy: Inpatient Admission, Antithrombotic Therapy By End of Hospital Day 2, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship), CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only, CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), 1. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. All rights reserved. *7.`"}K3t;qBEN]1F"9V>7[?)] CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. Numerous published studies demonstrate the program's success in improving patient outcomes. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. Return to Clinical Data Processing Flow in the Data Processing section. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. Pets and Your Health / Healthy Bond for Life, La Iniciativa Nacional de Control de la Hipertensin, Contact your local Get With The Guidelines, Get With The Guidelines Data Request Form. So, Ive attempted to structure it in a way that will be a reference for you. The required quarterly sample size would be 100% of the patient population or 5 cases for the quarter, No sampling; 100% Initial Patient Population required. 10960 Grantchester Way, Suite 520Columbia, MD 21044. Through the use of a multi-stakeholder process, the Collaborative promotes alignment and harmonization of measure use and collection across payers in both the public and private sectors. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. Hospitals now have one place to submit both chart-abstracted and eCQM data. The core measurescan be found at: http://www.qualityforum.org/cqmc/. Stroke is a leading cause of serious, long-term disability in the United States. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 42 cases for the quarter. Designed to be meaningful to patients, consumers, and physicians, the alignment of these core measure sets will aid in: CMS believes that by reducing burden on providers and focusing quality improvement on key areas across payers, quality of care can be improved for patients more effectively and efficiently. CSTK-09 Arrival Time to Skin Puncture, 8. STK-2 Discharged on Antithrombotic Therapy5. A hospitals Hemorrhagic sub-population is 316 during February. Set the Initial Patient Population Reject Case Flag to equal Yes. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. 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. This content does not have an Arabic version. Today, the Core Quality Measures Collaborative (CQMC) released four updated core measure sets covering specific clinical areas as part of its mission to provide useful quality metrics as the nation's health care system moves from one that pays based on volume of services to one that pays for value. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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. Return to Clinical Data Processing Flow in the Data Processing section. A hospitals ischemic stroke patient population size is 70 cases during March. Closed on Sundays. 1-800-242-8721 Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this Agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. 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). Initial Population: Inpatient hospitalizations for patients age 18 and older . a set of re-specified measures in 2019, which were updated in 2021. Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. Honestly though Stroke Outpatient versus Outpatient Stroke. Here I have broken it into the inpatient measure set and the outpatient measure set. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Hospital Outpatient Quality Measure Stroke. endobj 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. <> Include the patient in the Initial Patient Population for the appropriate measures. >0SPJ*@6W/rq+ERY_X&14>k( Contact Us, Hours This post is a guide to understanding the differences between the five major stroke measure sets. CSTK-05 Hemorrhagic Transformation, 1. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. Test your ideas. *All health/medical information on this website has been reviewed and approved by the American Heart Association, based on scientific research and American Heart Association guidelines. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. We can make a difference on your journey to provide consistently excellent care for each and every patient. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5 @/K6jPw*sfoqW}"3v}qCmqytT_.NnwT*_kL?hokU^dU2h=>tLi Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. 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. Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI : Scan Interpretation Within 45 minutes of ED Arrival: 2012 . Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. STK-OP-1b Hemorrhagic Strok3. All rights reserved. Find more information on our content editorial process. These updated core sets are a result of months of consensus-based review and deliberation among the groups 75+ multi-stakeholder member organizations, evaluating hundreds of existing quality measures against the CQMCs rigorous criteria. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 20% of this subpopulation or 78 cases for the quarter (20% of 392 equals 78.4 rounded to the next highest whole number equals 78). decreased providers collection burden and cost. Secure .gov websites use HTTPSA But hospitals see benefits as well. Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. 4 0 obj % There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. endobj Measures that include patient and/or caregiver engagement Adult Recommended Core Measures Controlling High Blood Pressure Use of High-Risk Medications in the Elderly Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Use of Imaging Studies for Low Back Pain Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 67 cases are sampled. . A hospitals Ischemic sub-population is 100 during the first quarter. with acute ischemic stroke in the hospital setting will submit this measure. 3= recommended; the outcome measure has good psychometric . %PDF-1.4 % Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received If the Length of Stay is less than or equal to 120 days, continue processing and proceed to ICD-10-CM Principal Diagnosis Code Check. At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). The six measures are: . Unauthorized use prohibited. The required monthly sample is 60 cases. January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. 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. Share sensitive information only on official, secure websites. Once a patient is qualified, he/she moves to the second part of the algorithm which tells you which sub-population he/she falls into. A hospitals Hemorrhagic sub-population is 100 during the first quarter. The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. STK-10 Assessed for Rehabilitation, Measures for TJC Comprehensive Stroke Center Certification, 1. 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. Learn about the "gold standard" in quality. The CMS Measure Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to promote healthcare quality and quality improvement. CMIT searches all fields in the inventory and is not case-sensitive. https:// A hospitals hemorrhagic stroke patient population size is 295 cases during March. STK-1 Venous Thromboembolism (VTE Prophylaxis)4. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). Below are the list of Stroke measures by Certification Program. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. Sixty (60) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. TARGET: STROKE MEASURE Door to IV rt-PA in 60 minutes (Historic-Quality): Percent of ischemic stroke patients receiving IV t-PA at your hospital who are treated within 60 minutes after triage (ED arrival). Measure 6a is new and is being pilot tested in 2009. In addition, the public may compare specific healthcare organizations' results on Core Measures at the Measures for TJC Acute Stroke Ready Center Certification, 1. Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. REMINDER: Stroke is now a Core Measure for CMS!!! A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. STK-6 Discharged on Statin Medication12. By not making a selection you will be agreeing to the use of our cookies. Using the quarterly sampling table for the Hemorrhagic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. 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 . The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. Percent of ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. Measure Type: InpatientNumber of Measures Included: 8Certification Requirement: The Joint Commissions Primary Stroke Certification, Anticoagulation Therapy for Atrial Fibrillation/Flutter, Antithrombotic Therapy By End of Hospital Day Two. endobj 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. Eisenberg Patient Safety and Quality Award, Bernard J. 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. endstream endobj startxref Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the (AMA is not recommending their use. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. Set the Initial Patient Population Reject Case Flag to equal Yes. *** AHRQ is the measure steward for the survey instrument in the Adult Core Set (NQF #0006) and NCQA is the developer of the survey administration protocol. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. 690 0 obj <>stream An antithrombotic agent is a drug that reduces the formation of blood clots. STK-5 Antithrombotic Therapy By End of Hospital Day Two16. A hospitals ischemic stroke patient population size is 129 cases during March. Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. 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. There are no Stroke eCQMs applicable or available for Certification purposes. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> *{o7@FNhR/ Of FSRMC patients treated with tPA, a clot-dissolver, or who underwent a procedure to retrieve a blood clot, 2.4% experienced complications, compared to the national average complication rate of 6.8%. 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Reports, http://www.qualityforum.org/CQMC_Core_Sets.aspx. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. The American Medical Association reserves all rights to approve any license with any Federal agency. Patients admitted to the hospital for inpatient acute care are included in the CSTK-2 Ischemic Stroke With IV t-PA, IA t-PA, or MER subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1 AND ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a OR Table 8.1b, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. The following are Stroke eCQMs used by The Joint Commission. %PDF-1.5 STK-4 Thrombolytic Therapy10. You can decide how often to receive updates. The required quarterly sample sizes for each sub-population would be 79 and 5. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. This is a big year for Quality. CMS is already using measures from the each of the core sets. CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. 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 The final clinical diagnosis is used to identify the measure population. *Note: There are additional measures needed to fulfill this certification. STK-8 Stroke Education13. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. STK-4 Thrombolytic Therapy15. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Medisolv Can HelpThis is a big year for Quality. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. To develop the core measure sets the Collaborative split into workgroups and reviewed measures currently in use by CMS and health plans as well as measures endorsed by NQF for the individual measure sets. Specifications Manual for Joint Commission National Quality Measures (v2021B), Stroke (STK) Initial Patient Population Algorithm Narrative, Anticoagulation Therapy Prescribed at Discharge, Antithrombotic Therapy Administered by End of Hospital Day 2, Antithrombotic Therapy Prescribed at Discharge, Education Addresses Activation of Emergency Medical System, Education Addresses Follow-up After Discharge, Education Addresses Medication Prescribed at Discharge, Education Addresses Risk Factors for Stroke, Education Addresses Warning Signs and Symptoms of Stroke, IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival, Reason for Extending the Initiation of IV Alteplase, Reason for No VTE Prophylaxis Hospital Admission, Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2, Reason for Not Prescribing Statin Medication at Discharge, Statin Medication Prescribed at Discharge, 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, Anticoagulation Therapy for Atrial Fibrillation/Flutter, Antithrombotic Therapy By End of Hospital Day Two, 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.

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