The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. We help you measure, assess and improve your performance. This item requires a Core Return or Core Charge. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. The following are the list of required chart-abstracted stroke measures for each certification program. Finally, I have listed a few more resources for you. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. 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). Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. sI An official website of the United States government 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. 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. If the Principal Diagnosis code falls on Table 8.1 it will be placed in the Ischemic Stroke, or sub-pop 1 and if it has a Principal Diagnosis code that falls on Table 8.2, then it will be placed in the Hemorrhagic Stroke or sub-pop-2. STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. 4 0 obj STK-1 Venous Thromboembolism (VTE Prophylaxis)7. But hospitals see benefits as well. 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. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. The listed denominator criteria are used to identify the intended patient population. Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. Core measures are based on the most common condition's hospitals see, such as acute myocardial infarction (AMI), heart failure (HF), pneumonia, surgical care, children's asthma care, venous thromboembolism (VTE), stroke, and more. All rights reserved. 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). Percent of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well. Measure ID # Measure Short Name OP-23 . % We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. Using the monthly sampling table for the Ischemic 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). <> Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. Medisolv can help you along the way. <> You can decide how often to receive updates. <> We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). <>>> Set the Initial Patient Population Reject Case Flag to equal No. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. Time from symptom onset to stroke alert is delayed in in-hospital stroke. ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. CSTK-09 Arrival Time to Skin Puncture, 1. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Medisolv can help you along the way. 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. n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. See our editorial policies and staff. Learn how working with the Joint Commission benefits your organization and community. Download Get With The Guidelines- Stroke fact sheets and forms here. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> STK-6 Discharged on Statin Medication17. Part 1: A review of the different stroke measure sets. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. 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 This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. Test your ideas. U.S. Government Rights The final clinical diagnosis is used to identify the measure population. endstream endobj startxref You can download it or email it to yourself to help you remember. A hospitals Hemorrhagic sub-population is 3 patients during January. Start STK Initial Patient Population logic sub-routine. 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. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. 2 0 obj 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. 3 0 obj Stroke is a leading cause of serious, long-term disability in the United States. A hospitals ischemic stroke patient population size is 200 patients during March. Hospitals report on these measures quarterly or monthly, and compliance can affect TJC accreditation and CMS . STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. 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. CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. Domain-specific outcomes for stroke clinical trials: what the modified Rankin isn't ranking. Mayo Clinic does not endorse any of the third party products and services advertised. Saturday: 9 a.m. - 5 p.m. CT The following are Stroke chart abstracted measures used by The Joint Commission. ASR-OP-2c Ischemic Stroke; drip and ship4. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. endobj Statin drugs are medications used to reduce serum level of lipids such as cholesterol. Part 2: A review of the different stroke certifications. This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. Heres how you know. CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. Set expectations for your organization's performance that are reasonable, achievable and survey-able. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. 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. We keep you on track for your submission deadlines and ensure you dont miss critical dates. An antithrombotic is a medication that prevents blood clots. %PDF-1.4 % CSTK-05 Hemorrhagic Transformation, 1. ruTv?U J4lUBex(a8{g$CHj ~>-z I&8:+hlvM(XdvY;D|BOl,Yu'D> YR9Gbl6GrJ8'},^V)\i/0 Gg:} >!81I88{'swe )I6v#{$&YymLyn\tl S3r6.o?x@q$_1A=U$H3%QUx . You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. This Agreement will terminate upon notice if you violate its terms. Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment. The following table identifies the population . <> You can use the words "AND" and "OR" along . decreased providers collection burden and cost. 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. endobj Medisolv Can HelpThis is a big year for Quality. 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. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. Remember that changes do not have to be large. The required quarterly sample sizes for each sub-population would be 79 and 5. All rights reserved. CSTK-06 Nimodipine Treatment Administered6. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. *Note: There are additional measures needed to fulfill this certification. U.S. Government Rights Find evidence-based sources on preventing infections in clinical settings. Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). .gov Chart-abstracted measures specificationsScreen Reader Text. 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 Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. 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). CQMC will release four additional updated core measure sets and two new core measure sets over the coming months. A hospitals ischemic stroke patient population size is 129 cases during March. This Agreement will terminate upon notice if you violate its terms. 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. Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. There are no Stroke eCQMs applicable or available for Certification purposes. endobj Find more information on our content editorial process. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. >0SPJ*@6W/rq+ERY_X&14>k( They also could require other measures. Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . A hospitals Ischemic sub-population is 316 during January. ( The median number of Adult Core Set measures reported by states is 22.5 measures for FFY 2019, up from 20 measures reported for FFY 2018 and 17 measures for FFY 2017. lock endobj STK-2 Discharged on Antithrombotic Therapy5. 2023 American Heart Association, Inc. All rights reserved. The coalition was convened in 2015 by Americas Health Insurance Providers (AHIP) and the Centers for Medicare & Medicaid Services (CMS) and is housed at the National Quality Forum (NQF). Initial Population: Inpatient hospitalizations for patients age 18 and older . 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. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Neurology. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. A hospitals hemorrhagic stroke patient population size is 17 cases during March. Learn about the development and implementation of standardized performance measures. Assemble your multidisciplinary team to determine roles and processes for entering patient data. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. This content does not have an Arabic version. hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ STK-2 Discharged on Antithrombotic Therapy8. A hospitals hemorrhagic stroke patient population size is 129 cases during March. 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.