We can make a difference on your journey to provide consistently excellent care for each and every patient. STK-8 Stroke Education18. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. 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). A hospitals ischemic stroke patient population size is 129 cases during March. JoAnne has a background in Quality Management and has been working with hospitals on their Core Measures compliance with CMS and The Joint Commission since 2008. CSTK-05 Hemorrhagic Transformation, 1. 2021). Monthly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 228 during March. This section includes the measure type (inpatient vs outpatient), the number of measures in the set, which certification the measure set is a part of, a list of the measures in the set and the associated algorithm. %%EOF 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. An antithrombotic agent is a drug that reduces the formation of blood clots. 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). A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. endobj ) Each measure includes patients from one or more categories. Download Get With The Guidelines- Stroke fact sheets and forms here. 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. The following links provide you with information available on past, present and future versions of the specification manuals, including release notes, measure information forms, data dictionaries, missing and invalid data, population and sampling, data transmission, tools and resources, and appendices. website belongs to an official government organization in the United States. A hospitals ischemic stroke patient population size is 70 cases during March. 646 0 obj <> endobj Calculate Patient Age. Test your ideas. The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. *{o7@FNhR/ These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. This began in Fiscal Year (FY) 2014. Official websites use .govA See how our expertise and rigorous standards can help organizations like yours. Saturday: 9 a.m. - 5 p.m. CT Hospitals now have one place to submit both chart-abstracted and eCQM data. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. 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. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. 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. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. This Agreement will terminate upon notice if you violate its terms. Source: Medisolv Perfect Care Report (eff. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> x[o ?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, physicians and other clinicians, and policymakers. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. The final clinical diagnosis is used to identify the measure population. Using the monthly 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 25 cases for the month (20% of 123 equals 24.6 rounded to the next highest whole number equals 25). Core Rulebook (disambiguation) This is a disambiguation page; that is, one that points to other pages that might otherwise have the same name.Pathfinder 2E.Expand your capabilities by selecting general feats that improve your statistics or give you. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. 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. *Note: There are additional measures needed to fulfill this certification. 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. STK-OP-1f Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO7. Chart Abstracted Measures for Certification. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. Start STK Initial Patient Population logic sub-routine. Share sensitive information only on official, secure websites. 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 QualityResearch@heart.org. 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. The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. This means the patient passed every measure they qualified for. STK-4 Thrombolytic Therapy10. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. The six measures are: . For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form(PDF). Medisolv can help you along the way. CMIT searches all fields in the inventory and is not case-sensitive. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. 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. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Using the monthly sampling table for the hemorrhagic 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). CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. 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. Closed on Sundays. The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. STK-4 Thrombolytic Therapy7. The numerator options included in this 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. Measure Type: InpatientNumber of Measures Included: 3 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Measure Type: OutpatientNumber of Measures Included: 2 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Door to Transfer to Another Hospital**RETIRED Effective July 1, 2021**, Note: All Joint Commission certified acute stroke ready hospitals, as well as those seeking initial certification, will be required to collect the STK-OP-1 Door to Transfer to Another Hospital measure for discharges on and after July 1, 2021. Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Stroke Core Measure - About Us - Mayo Clinic , . Visit: . Heres a good reference document in case you get confused. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. Disclaimer of Warranties and Liabilities. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Learn about the development and implementation of standardized performance measures. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. 3= recommended; the outcome measure has good psychometric . 3 0 obj Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 84 cases for the quarter. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Joint Commission Clinical Measures. 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. stream Statin drugs are medications used to reduce serum level of lipids such as cholesterol. This post is a guide to understanding the differences between the five major stroke measure sets. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. %PDF-1.7 You can decide how often to receive updates. STK-1 Venous Thromboembolism (VTE Prophylaxis)4. 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. The following are Stroke eCQMs used by The Joint Commission. 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). CSTK-09 Arrival Time to Skin Puncture, 8. We help troubleshoot technical and clinical issues to improve your measures. % A hospitals Hemorrhagic sub-population is 100 during the first quarter. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. 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. <> 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 . Submission of aggregate data is still required. 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. Fifty (50) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. Include the patient in the Initial Patient Population for the appropriate measures. 4 0 obj . endobj STK-5 Antithrombotic Therapy By End of Hospital Day Two11. Medisolv can help you along the way. 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). ASR-OP-2b Hemorrhagic Stroke3. The guiding principles used by the Collaborative in developing the core measure sets are that they be meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost. CSTK-09 Arrival Time to Skin Puncture, 1. Patient Age, in years, is equal to the Admission Date minus the Birthdate. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. Monday - Friday: 7 a.m. 7 p.m. CT 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. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. 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). U.S. Government Rights STK-1 Venous Thromboembolism (VTE Prophylaxis)12. A hospitals ischemic stroke patient population size is 200 patients during the second quarter. Set the Initial Patient Population Reject Case Flag to equal Yes. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time A hospitals Ischemic sub-population is 316 during January. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> with acute ischemic stroke in the hospital setting will submit this measure. 7272 Greenville Ave. For the purposes of this blog, since we are focusing specifically on stroke measures, there is only one stroke measure that is used for Accreditation purposes by both CMS and TJC: OP-23. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. lock CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. 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. Dallas, TX 75231, Customer Service STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. endobj 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. 2 0 obj Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. This is increasingly important as the health care system moves towards value-based reimbursement models. Calculate the Length of Stay. The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. There are no Stroke eCQMs applicable or available for Certification purposes. <>/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. The required monthly sample is 60 cases. A hospitals Ischemic sub-population is 5 patients during the first quarter. % CSM CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)7. <> Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. STK-2 Discharged on Antithrombotic Therapy5. In this post we are either referencing CMS or The Joint Commission as the Measure Stewards. Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. 2021; 96:e1812-e1822 . A hospitals hemorrhagic stroke patient population size is 129 cases during March. STK-10 Assessed for Rehabilitation. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). By not making a selection you will be agreeing to the use of our cookies. 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. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. Measure 6a is new and is being pilot tested in 2009. STK-OP-1b Hemorrhagic Strok3. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. or 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).

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