Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. 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). This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. The American Medical Association reserves all rights to approve any license with any Federal agency. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. <> We help you measure, assess and improve your performance. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. Measure ID # Measure Short Name OP-23 . Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. 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. endobj 7272 Greenville Ave. Chart-abstracted measures specificationsScreen Reader Text. Here are some resources to help you get started: JoAnne Marino is a Registered Nurse that is currently working as a Senior Clinical Consultant for Medisolv helping clients with the ENCOR Hospital Abstracted Measures. Create your baseline by entering 30 records into the Patient Management Tool. Stroke is a leading cause of serious, long-term disability in the United States. But hospitals see benefits as well. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. 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). Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). 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. <> 1-800-242-8721 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. . 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. Program details are found in Part 2. 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. A hospital may choose to use a larger sample size than is required. STK-OP-1 Door to Transfer to Another Hospital, 1. Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Calculate Patient Age. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. A hospitals Ischemic sub-population is 316 during January. %PDF-1.5 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. x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) 4 0 obj Time from symptom onset to stroke alert is delayed in in-hospital stroke. Share sensitive information only on official, secure websites. CPT only copyright 2019 American Medical Association. Much like we saw how cases fall into their respective sub-populations with CSTK, cases for STK use the same criteria when determining which sub-population a case will qualify for. 690 0 obj <>stream 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. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Set the Initial Patient Population Reject Case Flag to equal Yes. Especially if you use an EHR vendor right now, youll notice a huge difference. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Measures for Acute Stroke Ready Center Certification, Measures for Primary Stroke Center Certification, Measures for Thrombectomy Capable Stroke Center Certification, Measures for Comprehensive Stroke Center Certification, eSTK-2 Discharged on Antithrombotic Therapy, eSTK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, eSTK-5 Antithrombotic Therapy by End of Hospital Day Two, ASR-IP-1 Thrombolytic Therapy: Inpatient Admission, ASR-IP-2 Antithrombotic Therapy By End of Hospital Day 2, ASR-IP-3 Discharged on Antithrombotic Therapy, ASR-OP-1 Thrombolytic Therapy: Drip and Ship, CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients, CSTK-02 Modified Rankin Score (mRS) at 90 Days, CSTK-03 Severity Measurement Performed for SAH and ICH Patients, CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH), CSTK-06 Nimodipine Treatment Administered, CSTK-08 Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade, CSTK-10 Modified Rankin Score (mRS) at 90 Days: Favorable Outcome, CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival, CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture, STK-1 Venous Thromboembolism (VTE) Prophylaxis, STK-2 Discharged on Antithrombotic Therapy, STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-5 Antithrombotic Therapy By End of Hospital Day Two, STK-OP-1 Door to Transfer to Another Hospital, STK-VOL-1 Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy. The AMA does not directly or indirectly practice medicine or dispense medical services. 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 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. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. 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: 2012 . 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. A hospitals hemorrhagic stroke patient population size is 60 cases during March. This content does not have an Arabic version. Anticoagulation therapy is a course of drug therapy in which medications are administered to a patient to slow the rate at which the patient's blood clots. Set the Initial Patient Population Reject Case Flag to equal No. % sI 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 primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. CSTK-02 Modified Rankin Score (mRS at 90 Days)3. Eleven (11) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. 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. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. ) 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. STK-4 Thrombolytic Therapy10. *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. A hospitals ischemic stroke patient population size is 70 cases during March. 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. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). 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. 10960 Grantchester Way, Suite 520Columbia, MD 21044. Through the use of a multi-stakeholder process, the Collaborative promotes alignment and harmonization of measure use and collection across payers in both the public and private sectors. Nozzle assembly is comprehensively flow tested to measure flow rate, leak and seat condition to validate injection consistency. 2 0 obj CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. 2023 American Heart Association, Inc. All rights reserved. 1 0 obj Here I have broken it into the inpatient measure set and the outpatient measure set. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. 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. % ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. 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. Dude JA, Lohse KR, Cramer SC, Worrall BB; GPAS Collaboration Phenotyping Core. I also included the complete list of measures required for each certification. 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 3= recommended; the outcome measure has good psychometric . The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. Here is a diagram that outlines the submission differences. Measures for TJC Acute Stroke Ready Center Certification, 1. The two Measure Stewards (CMS and TJC) require hospitals to submit their chart-abstracted data in two different ways. 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. This Agreement will terminate upon notice if you violate its terms. Closed on Sundays. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. Heres a good reference document in case you get confused. lock decreased providers collection burden and cost. The required quarterly sample is 45 cases. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. This item requires a Core Return or Core Charge. Learn more about the communities and organizations we serve. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. 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. 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. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e.
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