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. Start STK Initial Patient Population logic sub-routine. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. 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). 2 0 obj 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. In addition, TJC established the Certification Measure Information Process (CMIP) tool where hospitals must manually enter their certification data for the program certifications we reviewed above (ASR, PSC, TSC and CSC). 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Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Measures for Acute Stroke Ready Center Certification, Measures for Primary Stroke Center Certification, Measures for Thrombectomy Capable Stroke Center Certification, Measures for Comprehensive Stroke Center Certification, eSTK-2 Discharged on Antithrombotic Therapy, eSTK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, eSTK-5 Antithrombotic Therapy by End of Hospital Day Two, ASR-IP-1 Thrombolytic Therapy: Inpatient Admission, ASR-IP-2 Antithrombotic Therapy By End of Hospital Day 2, ASR-IP-3 Discharged on Antithrombotic Therapy, ASR-OP-1 Thrombolytic Therapy: Drip and Ship, CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients, CSTK-02 Modified Rankin Score (mRS) at 90 Days, CSTK-03 Severity Measurement Performed for SAH and ICH Patients, CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH), CSTK-06 Nimodipine Treatment Administered, CSTK-08 Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade, CSTK-10 Modified Rankin Score (mRS) at 90 Days: Favorable Outcome, CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival, CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture, STK-1 Venous Thromboembolism (VTE) Prophylaxis, STK-2 Discharged on Antithrombotic Therapy, STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-5 Antithrombotic Therapy By End of Hospital Day Two, STK-OP-1 Door to Transfer to Another Hospital, STK-VOL-1 Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy. 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. Using the quarterly sampling table for the ischemic 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). Commercial health plans are rolling out the core measures as part of their contract cycle. PDF California EMS System Core Quality Measures Instruction Manual Calculate the Length of Stay. Heres how you know. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid 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). website belongs to an official government organization in the United States. IQR Measures - Centers for Medicare & Medicaid Services Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. <> This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. 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, Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. This content does not have an Arabic version. CMIT searches all fields in the inventory and is not case-sensitive. STK-OP-1a Overall Rate (Not Reported2. The American Medical Association reserves all rights to approve any license with any Federal agency. Stroke Core Measure - About Us - Mayo Clinic , . PDF Core Measures: The Nurse's Role - r N 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. ASR OP-2 Door to Transfer to Another Hospital **RETIRED Effective July 1, 2021**, 1. Clinical Performance Measures for Stroke Rehabilitation: Performance Set the Initial Patient Population Reject Case Flag to equal No. Refine processes and protocols to ensure they are in line with the guidelines. *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. You receive one consultant that you can call anytime with questions or concerns. REMINDER: Stroke is now a Core Measure for CMS!!! <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> ) Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. 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. 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. 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. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. 10960 Grantchester Way, Suite 520Columbia, MD 21044. 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. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. STK-5 Antithrombotic Therapy By End of Hospital Day Two11. The American Medical Association reserves all rights to approve any license with any Federal agency. 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. 2021; 96:e1812-e1822 . <> 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 . PDF STROKE - American Heart Association The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Share sensitive information only on official, secure websites. Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients Sometimes it works best to start small and build on success. 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 . Diesel Fuel Injector - 2004.5-2007 Ford 6.0L Power Stroke 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 measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). 646 0 obj <> endobj The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. 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. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). <> Find the exact resources you need to succeed in your accreditation journey. https:// Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. A hospitals Hemorrhagic sub-population is 3 patients during January. Finally, I have listed a few more resources for you. The numerator options included in this CSM special February 2021 Motor planning after stroke CSM special January 2021 January 2021 Stroke SIG and CSM 2 January 2021 Stroke SIG and CSM January 2021, Locomotor Podcast - Intensity and stepping. endobj Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Using the quarterly sampling table for the Ischemic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. Disclaimer of Warranties and Liabilities. We help you measure, assess and improve your performance. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. Unauthorized use prohibited. >ob=AOtVt. This is a big year for Quality. ASR-OP-2c Ischemic Stroke; drip and ship4. The following are Stroke eCQMs used by The Joint Commission. A hospitals ischemic stroke patient population size is 200 cases during the second 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 treatment2. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form(PDF). Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. 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. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. This began in Fiscal Year (FY) 2014. May 2021 Measure ID# Measure Short Name Measure Description STK-1 Venous Thromboembolism (VTE) This measure captures the proportion of ischemic or hemorrhagic Prophylaxis stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. Return to Clinical Data Processing Flow in the Data Processing section. PDF Hospital Outpatient Quality Reporting Stroke Measure Set - RWHC Hospitals report on these measures quarterly or monthly, and compliance can affect TJC accreditation and CMS . We help you select and set up measures that make sense based on your hospitals situation. (

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