*{o7@FNhR/ In addition, the public may compare specific healthcare organizations' results on Core Measures at the You can decide how often to receive updates. We can make a difference on your journey to provide consistently excellent care for each and every patient. This Agreement will terminate upon notice if you violate its terms. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. 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. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. %PDF-1.7 stream Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. endobj The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. 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). STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. There are no Stroke eCQMs applicable or available for Certification purposes. 1 0 obj CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. Below are the list of Stroke measures by Certification Program. Use the month and day portion of admission date and birthdate to yield the most accurate age. website belongs to an official government organization in the United States. 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. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. CPT is a registered trademark of the American Medical Association. Include the patient in the Initial Patient Population for the appropriate measures. CSTK-06 Nimodipine Treatment Administered6. The following are the list of required chart-abstracted stroke measures for each certification program. 7272 Greenville Ave. 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. Numerous published studies demonstrate the program's success in improving patient outcomes. This content does not have an English version. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 7 cases are sampled. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. 4 0 obj 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. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. Here is a diagram that outlines the submission differences. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Data Source: American Heart Association Get With The Guidelines stroke database. STK-2 Discharged on Antithrombotic Therapy13. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. 2018 - 2021. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. A hospitals Ischemic sub-population is 100 during the first quarter. 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 treatment, CSTK-09b Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who present directly to your hospital and undergo endovascular treatment, Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH ), 2. <> Monday - Friday: 7 a.m. 7 p.m. CT Initial Population: Inpatient hospitalizations for patients age 18 and older . A hospitals ischemic stroke patient population size is 200 patients during the second quarter. TARGET: STROKE MEASURE Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. https:// STK-1 Venous Thromboembolism (VTE Prophylaxis)7. STK-6 Discharged on Statin Medication17. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. In addition, stroke rehabilitation incorporates prevention and treatment of medical and mental health complications such as aspiration pneumonia, soft-tissue contractures, decubitus ulcers, infection, deep vein thrombosis (DVT), malnourishment, and depression. 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . The AMA does not directly or indirectly practice medicine or dispense medical services. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. 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. February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. 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). ( Sometimes it works best to start small and build on success. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA is a third party beneficiary to this Agreement. x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) 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. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. I also included the complete list of measures required for each certification. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 3 0 obj ASR-OP-2b Hemorrhagic Stroke3. 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 Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. 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. STK-4 Thrombolytic Therapy15. Using the notice and public comment rule-making process, CMS also intends to implement new core measures across applicable Medicare quality programs as appropriate, while eliminating redundant measures that are not part of the core set. 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 . Heres how you know. Calculate the Length of Stay. Saturday: 9 a.m. - 5 p.m. CT STK-5 Antithrombotic Therapy By End of Hospital Day Two11. A hospitals ischemic stroke patient population size is 70 cases during March. 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. 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. Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). endobj Its a nightmare trying to keep straight this wide range of acronym-filled information. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. Assemble your multidisciplinary team to determine roles and processes for entering patient data. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. Q2 (April 1-June 30); Q3 (July 1-September 30); Q4 (October 1-December 31); Q1 . Share sensitive information only on official, secure websites. There are five major stroke measure sets. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Comprehensive Stroke Arrival Time to Skin Puncture, Comprehensive Stroke Post Thrombolysis Revascularization Rate, Comprehensive Stroke Timeliness of IV Thrombolytic Therapy, Advertising and sponsorship opportunities, Percent of ischemic and hemorrhagic stroke patients who received venous thromboembolism (VTE) prophylaxis the day of or the day after hospital admission. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. Ready to get started with CMIT 2.0? a set of re-specified measures in 2019, which were updated in 2021. 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . 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 All rights reserved. CSTK-09b Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who present directly to your hospital and undergo endovascular treatment, 6. Start STK Initial Patient Population logic sub-routine. We help troubleshoot technical and clinical issues to improve your measures. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. 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. Find more information on our content editorial process. A hospitals hemorrhagic stroke patient population size is 129 cases during March. 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. 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. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. 2 0 obj Remember that changes do not have to be large. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. STK-OP-1f Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO7. 3 0 obj 1 0 obj This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. The required quarterly sample is 60 cases. An antithrombotic is a medication that prevents blood clots. Neurology. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 20% of this subpopulation or 26 cases for the month (20% of 129 equals 25.8 rounded to the next highest whole number equals 26). Unauthorized use prohibited. 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. Submission of aggregate data is still required. If the Patient Age is less than 18 years, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ %PDF-1.4 % Twenty (20) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. STK-8 Stroke Education13. STK-OP-1a Overall Rate (Not Reported2. 4 0 obj The core measurescan be found at: http://www.qualityforum.org/cqmc/. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). In the final section, I review the way this information is submitted to The Joint Commission and CMS. Find the exact resources you need to succeed in your accreditation journey. So, Ive attempted to structure it in a way that will be a reference for you. The following table identifies the population . To submit a research proposal for the Get With The Guidelines- Stroke program, email a completed Get With The Guidelines Data Request Form (download) to [emailprotected]. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. The psychometric properties of the measures are reviewed using a modified EDGE (Evidence Database to Guide Effectiveness) template (a format recommended by the APTA EDGE task force). Sixty (60) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. A hospitals ischemic stroke patient population size is 7 cases during March. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. endobj . The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. Return to Clinical Data Processing Flow in the Data Processing section. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation. It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5 @/K6jPw*sfoqW}"3v}qCmqytT_.NnwT*_kL?hokU^dU2h=>tLi 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. Ongoing monitoring by the Collaborative of the use of these measures will enable modifications of measure sets, as needed and based on lessons learned, including minimizing unintended consequences and selection of new measures as better measures become available. x[o ?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU 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. Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. Drive performance improvement using our new business intelligence tools. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Heres a good reference document in case you get confused. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Nozzle assembly is comprehensively flow tested to measure flow rate, leak and seat condition to validate injection consistency. Set expectations for your organization's performance that are reasonable, achievable and survey-able. A single copy of these materials may be reprinted for noncommercial personal use only. 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. Percent of ischemic stroke patients who received antithrombotic therapy by the end of hospital day two. 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. Domain-specific outcomes for stroke clinical trials: what the modified Rankin isn't ranking. If the ICD-10-CM Principal Diagnosis Code is on Table 8.1, the patient is in the first Ischemic Stroke sub-population and is eligible to be sampled for the first STK sub-population. Patients admitted to the hospital for inpatient acute care are included in the CSTK 1-Ischemic Stroke Without Procedure subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. CSTK-02 Modified Rankin Score (mRS at 90 Days)3. Using the monthly sampling table for the Hemorrhagic sub-population, the sample size required is 20% of this sub-population, or 46 cases for the quarter (twenty percent of 228 equals 45.6 rounded up to the next whole number equals 46). We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Here are some resources to help you get started: JoAnne Marino is a Registered Nurse that is currently working as a Senior Clinical Consultant for Medisolv helping clients with the ENCOR Hospital Abstracted Measures. Measure 6a is new and is being pilot tested in 2009. The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. 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. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . Using the monthly sampling table for the Ischemic sub-population, the sample size is less than the minimum required monthly sample size, so 100% of this sub-population is sampled. >ob=AOtVt. STK-1 Venous Thromboembolism (VTE Prophylaxis)4. Patient education should include information about the event (e.g., cause, treatment, and risk factors), the role of various medications or strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Quarterly sampling for the two combined populations for Joint Commission certification purposes. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. %PDF-1.5 Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. means youve safely connected to the .gov website. 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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.