STK-1 Venous Thromboembolism (VTE Prophylaxis)4. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. 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 measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). Drive performance improvement using our new business intelligence tools. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. >0SPJ*@6W/rq+ERY_X&14>k( Statin drugs are medications used to reduce serum level of lipids such as cholesterol. In the specifications manual, Version 2021B, it is in Section 7: Joint Commission National Quality Measures Data Processing, Joint Commission Stroke Measures table: https://manual.jointcommission.org/releases/TJC2021B/TransmissionChapterTJC.html. 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). We help you select and set up measures that make sense based on your hospitals situation. Centers for Medicare and Medicaid Services Measures Inventory Tool Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture11. %PDF-1.7 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. The Pathfinder Core Rulebook includes: More than 600 pages of game rules, advice, character options, treasure, and more for players and Game Masters! The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. 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. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. Arrhythmia means that the heart's normal beating rhythm is interrupted. stream Measures for TJC Acute Stroke Ready Center Certification, 1. The goal is to quickly get rid of any blood clot(s) to restore function to the area that is impacted by a stroke, such as the brain. TJC is adding three additional measures beginning with July 1, 2021 discharges.Certification Requirement: The Joint Commissions Primary Stroke Certification, Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible **ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, Measure Type: OutpatientNumber of Measures Included: 1 process measureAccreditation Requirement: CMS Outpatient Quality Reporting program. At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. CMS will go through a public notice and comment rule-making for implementation of these core sets and looks forward to public input on the measures included in these core measure sets. CSTK-05 Hemorrhagic Transformation, 1. Patient Age, in years, is equal to the Admission Date minus the Birthdate. Percent of ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. https://manual.jointcommission.org/releases/TJC2021B/TransmissionChapterTJC.html, The Joint Commission (ASR-IP, ASR-OP, PSC, TSC, CSC), program comparison sheet with guidelines of certification requirements, Centers for Medicare & Medicaid Services (CMS), The Joint Commission Stroke Certification Programs Program Concept Comparison, Specifications Manual for Joint Commission National Quality Measures (version 2021B), Acute Stroke Ready Hospital Certification (ASRH), Standardized Performance Measures for Acute Stroke Ready Hospitals, Primary Stroke Center Certification (PSC), Standardized Performance Measures for Primary Stroke Centers, Comprehensive Stroke Center Certification (CSC), Standardized Performance Measures for Comprehensive Stroke Centers, Standardized Performance Measures for Thrombectomy-Capable Stroke Centers, Using the New Opioid eCQM to Improve Prescribing Practices and Patient Care, 2021 Quality Reporting Deadlines Calendar, 2023 Promoting Interoperability Requirements, A Guide to The Joint Commissions New Health Equity Requirements, Hospital eCQM Results Are In: A Review of the January 2023 Care Compare Refresh, [Download] 2021 Hospital IQR Program Requirements, [Download] Hybrid Measure Implementation Guide, Hemorrhagic Transformation (Overall Rate), 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, Ischemic Stroke with Procedure (Thrombolytic Therapy or Mechanical endovascular therapy). 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. STK-6 Discharged on Statin Medication9. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. 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. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. endstream endobj startxref STK-5 Antithrombotic Therapy By End of Hospital Day Two8. website belongs to an official government organization in the United States. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. PDF Hospital Outpatient Quality Reporting Stroke Measure Set - RWHC The AMA does not directly or indirectly practice medicine or dispense medical services. 3 0 obj Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. An official website of the United States government They are responsible for making the necessary updates to the measure and for informing NQF (National Quality Forum) about any changes that are made to the measure on an annual basis. *** 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. *Note: There are additional measures needed to fulfill this certification. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. PDF Core Measures: The Nurse's Role - r N ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. 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). The most common signs and symptoms of HF are shortness of breath on exertion; orthopnea; weight gain with edema in the feet, legs, or lower back; fatigue; and weakness. STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**4. https:// Stroke is a leading cause of serious, long-term disability in the United States. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. An antithrombotic is a medication that prevents blood clots. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. 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. Studies at this time suggest that antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity. The Measure Steward refers to the organization that is responsible for providing the required measure information for the measure maintenance process that occurs approximately every three years. There are no Stroke eCQMs applicable or available for Certification purposes. CSTK-09a Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who are transferred from another hospital and undergo endovascular treatment2. Stroke Quality Scores | Duke Health Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. STK-5 Antithrombotic Therapy By End of Hospital Day Two11. We help you measure, assess and improve your performance. STK-6 Discharged on Statin Medication12. To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. Using the quarterly 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 45 cases for the quarter (20% of 223 equals 44.6 rounded to the next highest whole number equals 45). <>>> January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. Patients admitted to the hospital for inpatient acute care are included in the CSTK 3-Hemorrhagic Stroke subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.2, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. ) The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. Its a nightmare trying to keep straight this wide range of acronym-filled information. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. 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. 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 nations health care system moves from one that pays based on volume of services to one that pays for value. Set the Initial Patient Population Reject Case Flag to equal Yes. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. x[o ?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU 1 0 obj STK-8 Stroke Education18. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population. Medisolv Can HelpThis is a big year for Quality. endobj 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. Stroke | UofL Health 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. Start STK Initial Patient Population logic sub-routine. Refine processes and protocols to ensure they are in line with the guidelines. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 17 cases are sampled. }J We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. This content does not have an Arabic version. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. A hospitals ischemic stroke patient population size is 70 cases during March. Heres a good reference document in case you get confused. 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. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time The required quarterly sample sizes for each sub-population would be 79 and 5. 4 0 obj Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. Program details are found in Part 2. The guiding principles used by the Collaborative in developing the core measure sets are that they be meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost. Hospital Core Measures Defined - ESO endobj CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. 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. Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 11 cases are sampled. So, Ive attempted to structure it in a way that will be a reference for you. Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. A hospitals Ischemic sub-population is 5 patients during February. Stroke Core Measure Data | Fort Sanders Regional Medical Center, a Data collection for STK-OP-1 will replace ASR-OP-2. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . There are five major stroke measure sets. 2023 Medisolv, Inc. All Rights Reserved. Below are the list of Stroke measures by Certification Program. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. 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. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. Clinical Performance Measures for Stroke Rehabilitation: Performance Researchers also have the opportunity to conduct investigator-led research projects using data from the Get With The Guidelines- Stroke program. PDF Hospital OQR Quality Measures and Timelines for CY 2021 Payment The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. A hospitals ischemic stroke patient population size is 200 cases during the second quarter. The following links provide you with information available on past, present and future versions of the specification manuals, including release notes, measure information forms, data dictionaries, missing and invalid data, population and sampling, data transmission, tools and resources, and appendices. 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. %PDF-1.4 % <> Test your ideas. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. STK-8 Stroke Education13. 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 Using the quarterly sampling table for the Hemorrhagic 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). There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, physicians and other clinicians, and policymakers. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation. Download Get With The Guidelines- Stroke fact sheets and forms here. Medisolv can help you along the way. 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. Implementing International Standards of Practice in A Low Resource CSTK-05 Hemorrhagic Transformation, 1. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. STK-4 Thrombolytic Therapy15. This post is a guide to understanding the differences between the five major stroke measure sets. STK-5 Antithrombotic Therapy By End of Hospital Day Two16. STK-4 Thrombolytic Therapy7. TARGET: STROKE MEASURE 1-800-AHA-USA-1 Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. Contact Us, Hours Initial Population: Inpatient hospitalizations for patients age 18 and older . PDF Quality ID #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. ASR-OP-2b Hemorrhagic Stroke3. STK-2 Discharged on Antithrombotic Therapy13. hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! CPT only copyright 2019 American Medical Association. endobj The Ischemic sub-population has 392 patients per quarter, which requires a 20% sample size, or 79 cases (twenty percent of 392 equals 78.4 rounded to the next highest whole number equals 79).
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