3= recommended; the outcome measure has good psychometric . STK-4 Thrombolytic Therapy10. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. You can use the words "AND" and "OR" along . Major causes of HF are coronary artery disease, high blood pressure, and diabetes. endstream endobj startxref 7272 Greenville Ave. ASR-OP-2b Hemorrhagic Stroke3. .gov 2018 - 2021. The required quarterly sample sizes for each sub-population would be 79 and 5. The core measurescan be found at: http://www.qualityforum.org/cqmc/. The two sub-populations must be sampled independently from each other. 4 0 obj 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. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. Sometimes it works best to start small and build on success. We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. 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. If the Length of Stay is greater than 120 days, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. 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. Below are the list of Stroke measures by Certification Program. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 42 cases for the quarter. Hospitals report on these measures quarterly or monthly, and compliance can affect TJC accreditation and CMS . 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. Download Get With The Guidelines- Stroke fact sheets and forms here. Comprehensive Stroke (CSTK) (v2021A1) Home Comprehensive Stroke (CSTK) Comprehensive Stroke (CSTK) On this page: Comprehensive Stroke (CSTK) Initial Patient Population Monthly Sampling Sample Size Examples Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements 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. *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. Measures for TJC Acute Stroke Ready Center Certification, 1. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. I also included the complete list of measures required for each certification. stream lock There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Of FSRMC patients treated with tPA, a clot-dissolver, or who underwent a procedure to retrieve a blood clot, 2.4% experienced complications, compared to the national average complication rate of 6.8%. Commercial health plans are rolling out the core measures as part of their contract cycle. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. 2021; 97: . Medisolv can help you along the way. A hospitals Hemorrhagic sub-population is 100 during the first quarter. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Test your ideas. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. Quarterly sampling for the two combined populations for Joint Commission certification purposes. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. 2 0 obj Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. Researchers also have the opportunity to conduct investigator-led research projects using data from the Get With The Guidelines- Stroke program. 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. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. Using the quarterly 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. See our editorial policies and staff. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. %%EOF Calculate Patient Age. These core measure sets are a major step forward for alignment of quality measures between public and private payers and provides a framework upon which future efforts can be based. A hospitals Hemorrhagic sub-population is 3 patients during January. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. Find the exact resources you need to succeed in your accreditation journey. 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. This began in Fiscal Year (FY) 2014. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. In this post we are either referencing CMS or The Joint Commission as the Measure Stewards. <> Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. 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 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. REMINDER: Stroke is now a Core Measure for CMS!!! 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ But hospitals see benefits as well. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). 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. Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients They also could require other measures. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation. The numerator options included in this The required quarterly sample is 45 cases. Chart Abstracted Measures for Certification. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. The listed denominator criteria are used to identify the intended patient population. 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). This means the patient passed every measure they qualified for. 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. 646 0 obj <> endobj TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. Find more information on our content editorial process. 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. Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . 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. All rights reserved. Hospital Outpatient Quality Measure Stroke. 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. This post is a guide to understanding the differences between the five major stroke measure sets. Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. Dallas, TX 75231, Customer Service 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 annual Acute Care Hospital Quality Improvement Program Measures reference guide provides a comparison of measures for five Centers for Medicare & Medicaid Services (CMS) acute care hospital quality improvement programs, including the: Hospital IQR Program Hospital Value-Based Purchasing (VBP) Program Promoting Interoperability Program R,A`=N T$gZq,AW@0H#`.K#AJk_~}~Dc7?o=0T,qp{"+&y8N^-9yG-W +~ZY(DA[xvc2EGJv;P.Q12`3'o0f}ahq+ci;")i EmNW`0}d\K?QD-ki'e1ACa%i^\|.I$a-4>b(L A hospitals hemorrhagic stroke patient population size is 129 cases during March. CPT is a registered trademark of the American Medical Association. A hospitals Ischemic sub-population is 5 patients during the first quarter. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. 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, 6. 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. %PDF-1.5 Set the Initial Patient Population Reject Case Flag to equal Yes. *7.`"}K3t;qBEN]1F"9V>7[?)] Here I have broken it into the inpatient measure set and the outpatient measure set. TARGET: STROKE MEASURE CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. STK-4 Thrombolytic Therapy15. Medisolv Can HelpThis is a big year for Quality. 1-800-AHA-USA-1 x[6 >tK(E4.z~bK[K6IL[Ev9$g8oon_G|&"JLEE DFowJEM/7^G7Zt]kv\}{\](6t~fFKHVY4#o}Q1ps 2)bO}eYOcfY[7YO_b;x%k)ZJE,Tx[p53^\BH\T,uFN'gI8JP^fD*VbIgWb 4*nO4>nEHlE<4VujSs.i[_i]@gjBq?yrY5r>||x\n#bi\O#_5mHXG_@0-`=[05L$Ae[BvzWR?y'1XV%^m#. STK-OP-1 Door to Transfer to Another Hospital, 1. All rights reserved. Initial Population: Inpatient hospitalizations for patients age 18 and older . Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 20% of this subpopulation or 78 cases for the quarter (20% of 392 equals 78.4 rounded to the next highest whole number equals 78). ruTv?U J4lUBex(a8{g$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 . Sixty (60) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. 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). >ob=AOtVt. STK-4 Thrombolytic Therapy7. Patient Age, in years, is equal to the Admission Date minus the Birthdate. Program details are found in Part 2. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 37 cases are sampled. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. They are responsible for making the necessary updates to the measure and for informing NQF (National Quality Forum) about any changes that are made to the measure on an annual basis. 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. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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). Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. This is increasingly important as the health care system moves towards value-based reimbursement models. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. 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). CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. 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 6a is new and is being pilot tested in 2009. CPT is a registered trademark of the American Medical Association. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. 4 0 obj 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. 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. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. Part 2: A review of the different stroke certifications. *Note: Significant changes to this measure set begin July 1, 2021. STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. 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. CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture11. Stroke (STK) (v2021B) Home Stroke (STK) Release Notes: Measure Information Form Version 2021B Stroke (STK) On this page: Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements Related Materials Initial Patient Population Algorithm Stroke (STK) Initial Patient Population Algorithm Narrative We help you measure, assess and improve your performance. You can decide how often to receive updates. stream By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. A hospital may choose to use a larger sample size than is required. 1 0 obj STK-5 Antithrombotic Therapy By End of Hospital Day Two11. Please see link below for more information. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. 2021). A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. 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. The Ischemic sub-population has 392 patients per quarter, which requires a 20% sample size, or 79 cases (twenty percent of 392 equals 78.4 rounded to the next highest whole number equals 79). Understanding Stroke Measure Sets - f.hubspotusercontent30.net %PDF-1.4 % Data collection for STK-OP-1 will replace ASR-OP-2. 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. ASR OP-2 Door to Transfer to Another Hospital **RETIRED Effective July 1, 2021**, 1.