See our editorial policies and staff. Include the patient in the Initial Patient Population for the appropriate measures. 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. STK-10 Assessed for Rehabilitation, Measures for TJC Comprehensive Stroke Center Certification, 1. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. We develop and implement measures for accountability and quality improvement. In the Hospital Inpatient VBP Program Final Rule, CMS adopted the 30-day mortality measures for acute myocardial infarction (AMI), heart failure (HF), and pneumonia* under the Outcome domain. Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. 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. Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. 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. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. TJC is adding three additional measures beginning with July 1, 2021 discharges.Certification Requirement: The Joint Commissions Primary Stroke Certification, Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible **ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, Measure Type: OutpatientNumber of Measures Included: 1 process measureAccreditation Requirement: CMS Outpatient Quality Reporting program. CSTK-05 Hemorrhagic Transformation, 1. Especially if you use an EHR vendor right now, youll notice a huge difference. a set of re-specified measures in 2019, which were updated in 2021. Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. Domain-specific outcomes for stroke clinical trials: what the modified Rankin isn't ranking. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Data collection for STK-OP-1 will replace ASR-OP-2. The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. Measures for TJC Acute Stroke Ready Center Certification, 1. <> 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. CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. You can decide how often to receive updates. 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. Stroke | The Joint Commission In addition, stroke rehabilitation incorporates prevention and treatment of medical and mental health complications such as aspiration pneumonia, soft-tissue contractures, decubitus ulcers, infection, deep vein thrombosis (DVT), malnourishment, and depression. CMS is already using measures from the each of the core sets. Stroke Corner - Education - neuropt.org This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. Hospital Outpatient Quality Measure Stroke. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. STK-OP-1a Overall Rate (Not Reported2. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. Pathfinder 2e core rulebook pdf - qlu.lesthetiquecusago.it ( 1-800-242-8721 Find the exact resources you need to succeed in your accreditation journey. 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). Honestly though Stroke Outpatient versus Outpatient Stroke. PDF STROKE - American Heart Association Core Measures | CMS - Centers for Medicare & Medicaid Services Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. 2 0 obj Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. 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. 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). 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. Remember that changes do not have to be large. STK-6 Discharged on Statin Medication17. 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). Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 67 cases are sampled. But hospitals see benefits as well. We can make a difference on your journey to provide consistently excellent care for each and every patient. 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). *Note: There are additional measures needed to fulfill this certification. The CQMC is a diverse coalition of health care leaders representing over 75 consumer groups, medical associations, health insurance providers, purchasers and other quality stakeholders, all working together to develop and recommend core sets of measures by clinical area to assess and improve the quality of health care in America. hbspt.cta._relativeUrls=true;hbspt.cta.load(491484, '41fd9d46-8610-4a5f-a135-c143fe55a31f', {"useNewLoader":"true","region":"na1"}); By JoAnne Marino April 30, 2021 Regulatory Updates: Hospital. 3 0 obj Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. If the ICD-10-CM Principal Diagnosis Code is on Table 8.1, the patient is in the first Ischemic Stroke sub-population and is eligible to be sampled for the first STK sub-population. Finally, I have listed a few more resources for you. CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. Learn about the priorities that drive us and how we are helping propel health care forward. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. STK-8 Stroke Education18. stream 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. 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). Saturday: 9 a.m. - 5 p.m. CT STK-8 Stroke Education10. . Domain-Specific Outcome Measures in Clinical Trials of Therapies Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. 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). Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. U.S. Government Rights 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. Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. CQMC will release four additional updated core measure sets and two new core measure sets over the coming months. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Set expectations for your organization's performance that are reasonable, achievable and survey-able. endobj Neurology. A hospitals Ischemic sub-population is 5 patients during the first quarter. An injection of TPA is usually given through a vein in the arm within the first three hours. 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. Anticoagulation Therapy for Atrial Fibrillation/Flutter >ob=AOtVt. Regulatory/AccreditationExamples would include the Center for Medicare & Medicaid Services (CMS) required core measures (e.g., fibrinolytic therapy received within 30 minutes of emergency department (ED) arrival, aspirin at arrival) and documentation of Joint Commission standard achievement. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 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 subpopulation, the sample size required is 28 cases for the month. 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). REMINDER: Stroke is now a Core Measure for CMS!!! CSTK-06 Nimodipine Treatment Administered6. There are five major stroke measure sets. 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. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). PDF Hospital OQR Quality Measures and Timelines for CY 2021 Payment Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. 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). 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. ASR-OP-2b Hemorrhagic Stroke3. Commercial health plans are rolling out the core measures as part of their contract cycle. To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. Find more information on our content editorial process. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. Nozzle assembly is comprehensively flow tested to measure flow rate, leak and seat condition to validate injection consistency. 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. 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. Program details are found in Part 2. CPT is a registered trademark of the American Medical Association. Drive performance improvement using our new business intelligence tools. CSM Create your baseline by entering 30 records into the Patient Management Tool. 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. 1 0 obj All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. 3 0 obj Data Source: American Heart Association Get With The Guidelines stroke database. The goal is to quickly get rid of any blood clot(s) to restore function to the area that is impacted by a stroke, such as the brain. CMIT searches all fields in the inventory and is not case-sensitive. Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . The CSTK Initial Patient Population is unique in that it is comprised of three distinct subpopulations: ischemic stroke patients who do not undergo a reperfusion therapy (i.e., procedure), ischemic stroke patients who undergo a reperfusion therapy (IV t-PA, IA t-PA, or mechanical endovascular reperfusion (MER) therapy), and hemorrhagic stroke patients. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. or 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. A hospitals Hemorrhagic sub-population is 3 patients during January. Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. Section 3. Measuring Emergency Department Performance 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-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. All rights reserved. Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). Core Measure Data as of 3/2/2022. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. An antithrombotic agent is a drug that reduces the formation of blood clots. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. Using the notice and public comment rule-making process, CMS also intends to implement new core measures across applicable Medicare quality programs as appropriate, while eliminating redundant measures that are not part of the core set. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Download Get With The Guidelines- Stroke fact sheets and forms here. endobj Set the Initial Patient Population Reject Case Flag to equal No. lock 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. These updated core sets are a result of months of consensus-based review and deliberation among the groups 75+ multi-stakeholder member organizations, evaluating hundreds of existing quality measures against the CQMCs rigorous criteria. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. 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. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. Using the monthly 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. 2018 - 2021. https:// A hospitals ischemic stroke patient population size is 7 cases during March. Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. A hospitals Hemorrhagic sub-population is 316 during February. A hospitals ischemic stroke patient population size is 70 cases during March. An official website of the United States government 3 0 obj CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. It is important to always refer to the latest edition. 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-10 Assessed for Rehabilitation. endstream endobj startxref CPT only copyright 2019 American Medical Association. STK-2 Discharged on Antithrombotic Therapy5. 2023 American Heart Association, Inc. All rights reserved. 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. The following are the list of required chart-abstracted stroke measures for each certification program. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. 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 The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. The following table identifies the population . 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. n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/!