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. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. 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. PDF California EMS System Core Quality Measures Instruction Manual The American Heart Association is a qualified 501(c)(3) tax-exempt organization. STK-6 Discharged on Statin Medication9. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 42 cases for the quarter. Assemble your multidisciplinary team to determine roles and processes for entering patient data. 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. STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. 1 0 obj 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. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). 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). 3 0 obj These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. Calculate Patient Age. Closed on Sundays. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. *Note: Significant changes to this measure set begin July 1, 2021. 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. 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. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. Anticoagulation Therapy for Atrial Fibrillation/Flutter means youve safely connected to the .gov website. Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. The Centers for Medicare & Medicaid Services (CMS) has posted the electronic clinical quality measure ( eCQM) specifications for the 2021 reporting period for Eligible Hospitals and Critical Access Hospitals, and the 2021 performance period for Eligible Professionals and Eligible Clinicians. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. 1-800-242-8721 You receive one consultant that you can call anytime with questions or concerns. A hospitals ischemic stroke patient population size is 200 patients during March. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. 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. Arrhythmia means that the heart's normal beating rhythm is interrupted. ASR-IP-3: Discharged on Antithrombotic Therapy4. 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). 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. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 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. 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 Stroke Core Measure - About Us - Mayo Clinic , . View them by specific areas by clicking here. <> Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients 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. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. An official website of the United States government A hospitals ischemic stroke patient population size is 495 cases during the second quarter. The ACM is a pass-fail measure at the individual patient level that asks whether an eligible patient has received all of the appropriate care for the condition for which he or she is being treated. ASR OP-2 Door to Transfer to Another Hospital **RETIRED Effective July 1, 2021**, 1. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . 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. Development of Stroke Performance Measures | Stroke The numerator options included in this {8Dm.;JHTBXEXh^^^.Y)oH 6K;ANf!;*#.\1\c"1cKE. 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. 1 0 obj STK-1 Venous Thromboembolism (VTE Prophylaxis)12. The two Measure Stewards (CMS and TJC) require hospitals to submit their chart-abstracted data in two different ways. This consensus core set was further discussed by all Collaborative members before being finalized. website belongs to an official government organization in the United States. 1 0 obj Measure 6a is new and is being pilot tested in 2009. Get With The Guidelines - Stroke Overview - American Heart Association Joint Commission Clinical Measures. 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 ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. 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. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. 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. endobj STK-8 Stroke Education10. The CMS Measure Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to promote healthcare quality and quality improvement. Measure Type: OutpatientNumber of Measures Included: There are five process measures (youll see one additional measure listed below that is not reported and one additional measure that is retired starting with July 1, 2021 discharges). CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. All rights reserved. ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. ) hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . 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 Set the Initial Patient Population Reject Case Flag to equal No. STK-4 Thrombolytic Therapy15. STK-OP-1b Hemorrhagic Strok3. 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 . 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). We keep you on track for your submission deadlines and ensure you dont miss critical dates. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time Sixty (60) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. *7.`"}K3t;qBEN]1F"9V>7[?)] 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. 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). 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. 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 Perfect Care Report identifies patients that received perfect care. There are five major stroke measure sets. All rights reserved. TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. This means the patient passed every measure they qualified for. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. It is important to always refer to the latest edition. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. PDF Quality ID #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy 2023 American Heart Association, Inc. All rights reserved. ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). 2023 Medisolv, Inc. All Rights Reserved. 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 TARGET: STROKE MEASURE CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. %PDF-1.4 % The AMA is a third party beneficiary to this Agreement. Create your baseline by entering 30 records into the Patient Management Tool. A hospitals hemorrhagic stroke patient population size is 60 cases during March. ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. 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. Stroke (STK) (v2021B) Q2 (April 1-June 30); Q3 (July 1-September 30); Q4 (October 1-December 31); Q1 . A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. Unauthorized use prohibited. Nozzle assembly is comprehensively flow tested to measure flow rate, leak and seat condition to validate injection consistency. . 4 0 obj Dallas, TX 75231, Customer Service 4 0 obj Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. CSTK-02 Modified Rankin Score (mRS at 90 Days)3. ( Find more information on our content editorial process. CSTK-09 Arrival Time to Skin Puncture, 1. 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). Find evidence-based sources on preventing infections in clinical settings. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. 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). 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 . 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. STK-10 Assessed for Rehabilitation, Measures for TJC Comprehensive Stroke Center Certification, 1. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. Find the exact resources you need to succeed in your accreditation journey. *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. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. Core Measures | CMS - Centers for Medicare & Medicaid Services The AMA does not directly or indirectly practice medicine or dispense medical services. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. Test your ideas. This post is a guide to understanding the differences between the five major stroke measure sets. Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. 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. n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! 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). Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. Return to Clinical Data Processing Flow in the Data Processing section. 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. Medisolv Can HelpThis is a big year for Quality. Stroke Core Measure - About Us - Mayo Clinic ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. 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. x[o ?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU But hospitals see benefits as well. Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. >0SPJ*@6W/rq+ERY_X&14>k( What is wrong with these people making it so complicated for us? STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Stroke is a leading cause of serious, long-term disability in the United States. There are no Stroke eCQMs applicable or available for Certification purposes. StrokEdge - neuropt.org A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. You can use the words "AND" and "OR" along . The required monthly sample is 60 cases. }J 2021; 96:e1812-e1822 . stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). 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. 2022 Hospital IQR Requirements - Medisolv STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. A hospitals ischemic stroke patient population size is 129 cases during March. Pets and Your Health / Healthy Bond for Life, La Iniciativa Nacional de Control de la Hipertensin, Contact your local Get With The Guidelines, Get With The Guidelines Data Request Form. This Agreement will terminate upon notice if you violate its terms. CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. 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). I hope this high-level overview was helpful and can be a reference for you. Hospitals report on these measures quarterly or monthly, and compliance can affect TJC accreditation and CMS . 2 0 obj CPT only copyright 2019 American Medical Association. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. 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. 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). All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. Return to Clinical Data Processing Flow in the Data Processing section. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. 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). A hospitals hemorrhagic stroke patient population size is 295 cases during March. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Medisolv can help you along the way. a set of re-specified measures in 2019, which were updated in 2021. 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.