The Core Quality Measure Collaborative, led by the Americas Health Insurance Plans (AHIP) and its member plans Chief Medical Officers, leaders from CMS and the National Quality Forum (NQF), as well as national physician organizations, employers and consumers, worked hard to reach consensus on core performance measures. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. *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. %PDF-1.5 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. 10960 Grantchester Way, Suite 520Columbia, MD 21044. Stroke Core Measure - About Us - Mayo Clinic , . 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. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. 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). The AMA is a third party beneficiary to this Agreement. CSM special February 2021 Motor planning after stroke CSM special January 2021 January 2021 Stroke SIG and CSM 2 January 2021 Stroke SIG and CSM January 2021, Locomotor Podcast - Intensity and stepping. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. Especially if you use an EHR vendor right now, youll notice a huge difference. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). 4 0 obj Part 1: A review of the different stroke measure sets. A hospitals Ischemic sub-population is 100 during the first quarter. Data collection for STK-OP-1 will replace ASR-OP-2. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). A hospital may choose to use a larger sample size than is required. Nozzle assembly is comprehensively flow tested to measure flow rate, leak and seat condition to validate injection consistency. CPT only copyright 2019 American Medical Association. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. Saturday: 9 a.m. - 5 p.m. CT Calculate the Length of Stay. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. Especially if you use an EHR vendor right now, youll notice a huge difference. Hospitals report on these measures quarterly or monthly, and compliance can affect TJC accreditation and CMS . CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. Set the Initial Patient Population Reject Case Flag to equal Yes. This post is a guide to understanding the differences between the five major stroke measure sets. You can download it or email it to yourself to help you remember. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> %PDF-1.4 % Set expectations for your organization's performance that are reasonable, achievable and survey-able. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. Visit: . At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. The two sub-populations must be sampled independently from each other. Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time 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. endobj Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . 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 CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. Submission of aggregate data is still required. Using the quarterly sampling table for the Ischemic sub-population, the sample size required is 20% of this sub-population, or 79 cases for the quarter (twenty percent of 392 equals 78.4 rounded up to the next whole number equals 79). Dallas, TX 75231, Customer Service CPT only copyright 2019 American Medical Association. <> 1 0 obj 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. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). Q2 (April 1-June 30); Q3 (July 1-September 30); Q4 (October 1-December 31); Q1 . Refine processes and protocols to ensure they are in line with the guidelines. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. CSTK-09 Arrival Time to Skin Puncture, 8. 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. 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). 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. 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. CSTK-06 Nimodipine Treatment Administered6. CSTK-05 Hemorrhagic Transformation, 1. 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. 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. 2021; 97: . STK-2 Discharged on Antithrombotic Therapy8. 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. Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients Pets and Your Health / Healthy Bond for Life, La Iniciativa Nacional de Control de la Hipertensin, Contact your local Get With The Guidelines, Get With The Guidelines Data Request Form. 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. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. 2 0 obj A hospitals ischemic stroke patient population size is 495 cases during the second quarter. The two Measure Stewards (CMS and TJC) require hospitals to submit their chart-abstracted data in two different ways. Using the monthly sampling table for the ischemic 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). A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. endobj 3 0 obj You receive one consultant that you can call anytime with questions or concerns. View them by specific areas by clicking here. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. U.S. Government Rights There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. A hospitals Ischemic sub-population is 5 patients during the first quarter. <>>> 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. STK-6 Discharged on Statin Medication9. 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. Time from symptom onset to stroke alert is delayed in in-hospital stroke. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. 2 0 obj 2023 American Heart Association, Inc. All rights reserved. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Heres a good reference document in case you get confused. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. lock Start STK Initial Patient Population logic sub-routine. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. CSTK-02 Modified Rankin Score (mRS at 90 Days)3. We develop and implement measures for accountability and quality improvement. . endobj Data Source: American Heart Association Get With The Guidelines stroke database. 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. MjMO2n7( LBm6N.Hl#|oKP?lEF@L9ew,w\XpP{]8vxmtV}Or,kU{ `B7{"'Tf(DL[}ZEY 7'XoFo(|{%Jlv,_v}%DPnpoAucQGPy'YVJGXv:E j5(kts,?BcBKd?R . STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. A hospitals Ischemic sub-population is 316 during January. 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. A hospitals ischemic stroke patient population size is 200 patients during March. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. }J 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). Test your ideas. 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 . Unauthorized use prohibited. sI REMINDER: Stroke is now a Core Measure for CMS!!! 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. Contact Us, Hours x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) Find out about the current National Patient Safety Goals (NPSGs) for specific programs. A hospitals Hemorrhagic sub-population is 3 patients during January. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. Here I have broken it into the inpatient measure set and the outpatient measure set. Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation. Calculate Patient Age. 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. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. A hospitals Hemorrhagic sub-population is 316 during February. In the specifications manual, Version 2021B, it is in Section 7: Joint Commission National Quality Measures Data Processing, Joint Commission Stroke Measures table: https://manual.jointcommission.org/releases/TJC2021B/TransmissionChapterTJC.html. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. All rights reserved. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 19 cases are sampled. National Center 3= recommended; the outcome measure has good psychometric . Set the Initial Patient Population Reject Case Flag to equal Yes. Chart Abstracted Measures for Certification. TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. CSTK-05 Hemorrhagic Transformation, 1. 646 0 obj <> endobj CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 2. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB Measures that include patient and/or caregiver engagement Adult Recommended Core Measures Controlling High Blood Pressure Use of High-Risk Medications in the Elderly Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Use of Imaging Studies for Low Back Pain ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. The following table identifies the population . % To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). stream This content does not have an English version. Disclaimer of Warranties and Liabilities. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. The American Medical Association does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. Of FSRMC patients treated with tPA, a clot-dissolver, or who underwent a procedure to retrieve a blood clot, 2.4% experienced complications, compared to the national average complication rate of 6.8%. STK-4 Thrombolytic Therapy7. Percent of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well. There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, physicians and other clinicians, and policymakers. R,A`=N T$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 All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. STK-8 Stroke Education13. STK-10 Assessed for Rehabilitation. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. 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. See our editorial policies and staff. Secure .gov websites use HTTPSA Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. All rights reserved. A hospitals ischemic stroke patient population size is 200 cases during the second quarter. Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. 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). STK-6 Discharged on Statin Medication12. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. >ob=AOtVt. 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. Medisolv can help you along the way. *Note: Significant changes to this measure set begin July 1, 2021. hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! 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. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. A hospitals ischemic stroke patient population size is 7 cases during March. 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). 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). You can use the words "AND" and "OR" along . STK-OP-1f Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO7. Core measures are based on the most common condition's hospitals see, such as acute myocardial infarction (AMI), heart failure (HF), pneumonia, surgical care, children's asthma care, venous thromboembolism (VTE), stroke, and more. 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. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. Return to Clinical Data Processing Flow in the Data Processing section. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). STK-8 Stroke Education10. This item requires a Core Return or Core Charge. 0 CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. The required quarterly sample is 60 cases. 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). CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture11. ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. By not making a selection you will be agreeing to the use of our cookies. The required quarterly sample size for the CSTK-01 measure is a minimum of 84 cases (42 cases from Table 1 plus 42 cases from Table 2 equals 84). 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. 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. 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 American Medical Association reserves all rights to approve any license with any Federal agency. 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. 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.