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. Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. All rights reserved. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)7. 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. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. Test your ideas. Hospitals now have one place to submit both chart-abstracted and eCQM data. CSTK-09 Arrival Time to Skin Puncture, 1. The required quarterly sample size for the CSTK-01 measure is a minimum of 84 cases (42 cases from Table 1 plus 42 cases from Table 2 equals 84). 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. REMINDER: Stroke is now a Core Measure for CMS!!! 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. CMS is already using measures from the each of the core sets. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Saturday: 9 a.m. - 5 p.m. CT Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. Dude JA, Lohse KR, Cramer SC, Worrall BB; GPAS Collaboration Phenotyping Core. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. a set of re-specified measures in 2019, which were updated in 2021. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. Refine processes and protocols to ensure they are in line with the guidelines. They also could require other measures. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. endstream endobj 647 0 obj <>/Metadata 18 0 R/Pages 644 0 R/StructTreeRoot 24 0 R/Type/Catalog/ViewerPreferences<>>> endobj 648 0 obj <>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 1/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 649 0 obj <>stream The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received The American Medical Association reserves all rights to approve any license with any Federal agency. <>>> Comprehensive Core Stroke Measures were developed for the management of both ischemic and hemorrhagic stroke patients in hospitals equipped with clinical expertise, infrastructure, and specialized neurointerventional and imaging services needed to provide a higher level of stroke care. Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 28 cases for the month. Official websites use .govA The two sub-populations must be sampled independently from each other. 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 ASR-OP-2b Hemorrhagic Stroke3. The core measurescan be found at: http://www.qualityforum.org/cqmc/. Time from symptom onset to stroke alert is delayed in in-hospital stroke. 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. Heres how you know. 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). <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. 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. Start STK Initial Patient Population logic sub-routine. Twenty (20) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. The change in the performance measure requirements for Acute Stroke Ready Hospitals, (i.e., STK-OP-1 replacing ASR-OP-2 effective with discharges on and after July 1, 2021) can be found in several places. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. 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. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Heart Attack), Pneumonia, and Surgical Site Infection prevention. 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. Its a nightmare trying to keep straight this wide range of acronym-filled information. % *Note: Significant changes to this measure set begin July 1, 2021. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . 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. 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. %PDF-1.5 See how our expertise and rigorous standards can help organizations like yours. Learn how working with the Joint Commission benefits your organization and community. STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. Assemble your multidisciplinary team to determine roles and processes for entering patient data. Measure ID # Measure Short Name OP-23 . A hospitals ischemic stroke patient population size is 129 cases during March. Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Measure Information 2021 Reporting Period; CMS eCQM ID: CMS71v10 Short Name: STK-3 NQF Number: Not Applicable Description: Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge. TARGET: STROKE MEASURE 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). 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. hbspt.cta._relativeUrls=true;hbspt.cta.load(491484, '41fd9d46-8610-4a5f-a135-c143fe55a31f', {"useNewLoader":"true","region":"na1"}); By JoAnne Marino April 30, 2021 Regulatory Updates: Hospital. This is increasingly important as the health care system moves towards value-based reimbursement models. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. <> Heres a good reference document in case you get confused. 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. Unauthorized use prohibited. Please see link below for more information. % The required quarterly sample is 45 cases. The listed denominator criteria are used to identify the intended patient population. You receive one consultant that you can call anytime with questions or concerns. 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. The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. If the Length of Stay is greater than 120 days, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). We help troubleshoot technical and clinical issues to improve your measures. Much like we saw how cases fall into their respective sub-populations with CSTK, cases for STK use the same criteria when determining which sub-population a case will qualify for. Remember that changes do not have to be large. 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. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. 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. 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 Finally, I have listed a few more resources for you. 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. Using the quarterly 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 quarterly sample size, so 100% of the subpopulation or all 19 cases are sampled. All rights reserved. Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. 1-800-AHA-USA-1 2 0 obj 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). Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . 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 responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. 2 0 obj 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. By not making a selection you will be agreeing to the use of our cookies. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. A hospitals ischemic stroke patient population size is 7 cases during March. Percent of ischemic stroke patients with an LDL greater than or equal to 70 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge. Medisolv Can HelpThis is a big year for Quality. Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. Sign up to get the latest information about your choice of CMS topics. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. STK-6 Discharged on Statin Medication12. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. 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. Create your baseline by entering 30 records into the Patient Management Tool. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. uz'*\08 DLli_{5:G}M=}nS`M6C'{AREuw%~NM5Ydam\[\_#$ s8S@ AE"4u0qwCmWN N`h,bp``+bv\~B9M A hospitals hemorrhagic stroke patient population size is 392 cases during the second quarter. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 7 cases are sampled. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. TARGET: STROKE MEASURE Door to IV rt-PA in 60 minutes (Historic-Quality): Percent of ischemic stroke patients receiving IV t-PA at your hospital who are treated within 60 minutes after triage (ED arrival). The following are the list of required chart-abstracted stroke measures for each certification program. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. <> 4 0 obj Arrhythmia means that the heart's normal beating rhythm is interrupted. website belongs to an official government organization in the United States. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. This post is a guide to understanding the differences between the five major stroke measure sets. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. In the specifications manual, Version 2021B, it is in Section 7: Joint Commission National Quality Measures Data Processing, Joint Commission Stroke Measures table: https://manual.jointcommission.org/releases/TJC2021B/TransmissionChapterTJC.html. STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**4. x[6 >tK(E4.z~bK[K6IL[Ev9$g8oon_G|&"JLEE DFowJEM/7^G7Zt]kv\}{\](6t~fFKHVY4#o}Q1ps 2)bO}eYOcfY[7YO_b;x%k)ZJE,Tx[p53^\BH\T,uFN'gI8JP^fD*VbIgWb 4*nO4>nEHlE<4VujSs.i[_i]@gjBq?yrY5r>||x\n#bi\O#_5mHXG_@0-`=[05L$Ae[BvzWR?y'1XV%^m#. A hospitals Hemorrhagic sub-population is 316 during February. A hospital may choose to use a larger sample size than is required. 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. A hospitals ischemic stroke patient population size is 70 cases during March. This consensus core set was further discussed by all Collaborative members before being finalized. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. Patient Age, in years, is equal to the Admission Date minus the Birthdate. STK-4 Thrombolytic Therapy15. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. Stroke Core Measure - About Us - Mayo Clinic , . Comprehensive Stroke (CSTK) (v2021A1) Home Comprehensive Stroke (CSTK) Comprehensive Stroke (CSTK) On this page: Comprehensive Stroke (CSTK) Initial Patient Population Monthly Sampling Sample Size Examples Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements Statin drugs are medications used to reduce serum level of lipids such as cholesterol. 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. 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). CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. 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 It is important to always refer to the latest edition. decreased providers collection burden and cost. A hospitals Ischemic sub-population is 316 during January. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. The next measure set we review is abbreviated ASR-IP/OP. 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 . 2018 - 2021. Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features!