Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. <>>> 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. <> 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. STK-2 Discharged on Antithrombotic Therapy5. endobj The final clinical diagnosis is used to identify the measure population. CSTK-06 Nimodipine Treatment Administered6. Here I have broken it into the inpatient measure set and the outpatient measure set. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. The American Medical Association reserves all rights to approve any license with any Federal agency. We develop and implement measures for accountability and quality improvement. Below are the list of Stroke measures by Certification Program. The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. This content does not have an English version. A single copy of these materials may be reprinted for noncommercial personal use only. CSTK-03 Severity Measurement Performed for SAH and ICH Patients (Overall Rate)3. 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. The following are Stroke eCQMs used by The Joint Commission. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. Medisolv Can HelpThis is a big year for Quality. 4 0 obj Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. STK-10 Assessed for Rehabilitation, Measures for TJC Comprehensive Stroke Center Certification, 1. Saturday: 9 a.m. - 5 p.m. CT A hospitals ischemic stroke patient population size is 7 cases during March. 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 Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. You can download it or email it to yourself to help you remember. uz'*\08 DLli_{5:G}M=}nS`M6C'{AREuw%~NM5Ydam\[\_#$ s8S@ AE"4u0qwCmWN N`h,bp``+bv\~B9M 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. Heart Attack), Pneumonia, and Surgical Site Infection prevention. Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. 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. Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. 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. 3 0 obj Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. *** AHRQ is the measure steward for the survey instrument in the Adult Core Set (NQF #0006) and NCQA is the developer of the survey administration protocol. A hospitals ischemic stroke patient population size is 129 cases during March. There are no Stroke eCQMs applicable or available for Certification purposes. website belongs to an official government organization in the United States. A hospitals hemorrhagic stroke patient population size is 392 cases during the second quarter. STK-6 Discharged on Statin Medication9. Honestly though Stroke Outpatient versus Outpatient Stroke. In this post we are either referencing CMS or The Joint Commission as the Measure Stewards. What is wrong with these people making it so complicated for us? See our editorial policies and staff. 1 0 obj By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. {8Dm.;JHTBXEXh^^^.Y)oH 6K;ANf!;*#.\1\c"1cKE. Learn about the development and implementation of standardized performance measures. 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. There are five major stroke measure sets. 1 0 obj Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. A hospitals Hemorrhagic sub-population is 3 patients during January. a set of re-specified measures in 2019, which were updated in 2021. *7.`"}K3t;qBEN]1F"9V>7[?)] This means the patient passed every measure they qualified for. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. %PDF-1.4 % Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. A hospitals Ischemic sub-population is 5 patients during the first quarter. endobj Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. 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 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. This item requires a Core Return or Core Charge. A hospital may choose to use a larger sample size than is required. CPT only copyright 2019 American Medical Association. Patients admitted to the hospital for inpatient acute care are included in the CSTK 3-Hemorrhagic Stroke subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.2, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. Core Measure Data as of 3/2/2022. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. 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). Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. The listed denominator criteria are used to identify the intended patient population. The Perfect Care Report identifies patients that received perfect care. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. Initial Population: Inpatient hospitalizations for patients age 18 and older . Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. Learn how working with the Joint Commission benefits your organization and community. 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. Disclaimer of Warranties and Liabilities. 2021). A hospitals ischemic stroke patient population size is 37 cases during the second quarter. A hospitals Ischemic sub-population is 5 patients during February. Commercial health plans are rolling out the core measures as part of their contract cycle. You can decide how often to receive updates. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. Heres a good reference document in case you get confused. 1-800-242-8721 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. Its a nightmare trying to keep straight this wide range of acronym-filled information. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Medisolv can help you along the way. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> I hope this high-level overview was helpful and can be a reference for you. Data Source: American Heart Association Get With The Guidelines stroke database. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. A hospitals Hemorrhagic sub-population is 100 during the first quarter. 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. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. 4 0 obj 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 following are Stroke chart abstracted measures used by The Joint Commission. 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. 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. .gov Part 2: A review of the different stroke certifications. 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]. 3= recommended; the outcome measure has good psychometric . The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 2. 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. I also included the complete list of measures required for each certification. 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. Measure ID # Measure Short Name OP-23 . Numerous published studies demonstrate the program's success in improving patient outcomes. A hospitals ischemic stroke patient population size is 200 cases during the second quarter. *Note: There are additional measures needed to fulfill this certification. Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. https:// This is a big year for Quality. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). Submission of aggregate data is still required. We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). The most common signs and symptoms of HF are shortness of breath on exertion; orthopnea; weight gain with edema in the feet, legs, or lower back; fatigue; and weakness. Chart-abstracted measures specificationsScreen Reader Text. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. The following table identifies the population . 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. February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)7. Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Ready to get started with CMIT 2.0? ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. Stroke Core Stroke Measures As a Certified Stroke Center the stroke committee would like to provide physicians with updates on how we are performing on the stroke performance and quality measures. 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. See how our expertise and rigorous standards can help organizations like yours. Set expectations for your organization's performance that are reasonable, achievable and survey-able. 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. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. Secure .gov websites use HTTPSA *{o7@FNhR/ Start STK Initial Patient Population logic sub-routine. STK-OP-1 Door to Transfer to Another Hospital, 1. Using the quarterly sampling table for the Ischemic 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). STK-8 Stroke Education10. 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. 2 0 obj 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. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. ASR-OP-2c Ischemic Stroke; drip and ship4. U.S. Government Rights *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. STK-1 Venous Thromboembolism (VTE Prophylaxis)12. Download Get With The Guidelines- Stroke fact sheets and forms here. means youve safely connected to the .gov website. STK-OP-1b Hemorrhagic Strok3. Refine processes and protocols to ensure they are in line with the guidelines. Find more information on our content editorial process. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time }J Remember that changes do not have to be large. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. STK-OP-1f Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO7. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. 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. The two Measure Stewards (CMS and TJC) require hospitals to submit their chart-abstracted data in two different ways. 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. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Assemble your multidisciplinary team to determine roles and processes for entering patient data. The AMA is a third party beneficiary to this Agreement. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. You can use the words "AND" and "OR" along . hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji Especially if you use an EHR vendor right now, youll notice a huge difference. Return to Clinical Data Processing Flow in the Data Processing section. A hospital may choose to use a larger sample size than is required. A hospitals hemorrhagic stroke patient population size is 60 cases during March. Learn about the "gold standard" in quality. CSTK-05 Hemorrhagic Transformation, 1. The Differences Between The 5 Major Stroke Measure Sets, Thrombolytic Therapy: Inpatient Admission, Antithrombotic Therapy By End of Hospital Day 2, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship), CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only, CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), 1. 2023 American Heart Association, Inc. All rights reserved. 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. 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. Hospitals report on these measures quarterly or monthly, and compliance can affect TJC accreditation and CMS . Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. Researchers also have the opportunity to conduct investigator-led research projects using data from the Get With The Guidelines- Stroke program. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. The six measures are: . It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received To address this problem, the Centers for Medicare & Medicaid Services (CMS), commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations, and consumers worked together through the Core Quality Measures Collaborative to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible. 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. Joint Commission Clinical Measures. Learn more about the communities and organizations we serve. STK-2 Discharged on Antithrombotic Therapy13. Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge.

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