This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. 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). 4 0 obj Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. 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 A hospitals ischemic stroke patient population size is 200 patients during March. }J All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 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). Drive performance improvement using our new business intelligence tools. 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. Studies at this time suggest that antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity. Fifty (50) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the (AMA is not recommending their use. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. A hospitals hemorrhagic stroke patient population size is 392 cases during the second quarter. CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. In the final section, I review the way this information is submitted to The Joint Commission and CMS. 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. Below are the list of Stroke measures by Certification Program. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. 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. *7.`"}K3t;qBEN]1F"9V>7[?)] 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. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. 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. 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. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. website belongs to an official government organization in the United States. uz'*\08 DLli_{5:G}M=}nS`M6C'{AREuw%~NM5Ydam\[\_#$ s8S@ AE"4u0qwCmWN N`h,bp``+bv\~B9M Learn about the "gold standard" in quality. Download Get With The Guidelines- Stroke fact sheets and forms here. 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. In addition, the public may compare specific healthcare organizations' results on Core Measures at the 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. Chart Abstracted Measures for Certification. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. A hospitals ischemic stroke patient population size is 129 cases during March. All rights reserved. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. 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. 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. I also included the complete list of measures required for each certification. 3 0 obj 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 . 2023 Medisolv, Inc. All Rights Reserved. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. The American Medical Association reserves all rights to approve any license with any Federal agency. https:// ASR-IP-3: Discharged on Antithrombotic Therapy4. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. 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. %PDF-1.4 % 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. Official websites use .govA 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. Set the Initial Patient Population Reject Case Flag to equal Yes. 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. Chart-abstracted measures specificationsScreen Reader Text. Find more information on our content editorial process. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. Return to Clinical Data Processing Flow in the Data Processing section. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. ASR OP-2 Door to Transfer to Another Hospital **RETIRED Effective July 1, 2021**, 1. National Center The Centers for Medicare & Medicaid Services (CMS) has posted the electronic clinical quality measure ( eCQM) specifications for the 2021 reporting period for Eligible Hospitals and Critical Access Hospitals, and the 2021 performance period for Eligible Professionals and Eligible Clinicians. Refine processes and protocols to ensure they are in line with the guidelines. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment. We help you measure, assess and improve your performance. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. To develop the core measure sets the Collaborative split into workgroups and reviewed measures currently in use by CMS and health plans as well as measures endorsed by NQF for the individual measure sets. REMINDER: Stroke is now a Core Measure for CMS!!! 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. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. >0SPJ*@6W/rq+ERY_X&14>k( Especially if you use an EHR vendor right now, youll notice a huge difference. 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 Medisolv can help you along the way. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. 2021; 97: . The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). STK-OP-1 Door to Transfer to Another Hospital, 1. Percent of ischemic stroke patients who received antithrombotic therapy by the end of hospital day two. 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. stream 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). The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. The required monthly sample is 60 cases. 2018 - 2021. Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. Monday - Friday: 7 a.m. 7 p.m. CT We keep you on track for your submission deadlines and ensure you dont miss critical dates. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 2. 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). Ready to get started with CMIT 2.0? Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). The American Medical Association reserves all rights to approve any license with any Federal agency. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. A hospitals ischemic stroke patient population size is 7 cases during March. Researchers also have the opportunity to conduct investigator-led research projects using data from the Get With The Guidelines- Stroke program. CSTK-05 Hemorrhagic Transformation, 1. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. >ob=AOtVt. Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Medisolv Can HelpThis is a big year for Quality. A hospitals ischemic stroke patient population size is 200 patients during the second quarter. Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . Here I have broken it into the inpatient measure set and the outpatient measure set. February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. The two sub-populations must be sampled independently from each other. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. lock The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. 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. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time . For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**4. Its a nightmare trying to keep straight this wide range of acronym-filled information. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. 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. Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. endobj CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. STK-6 Discharged on Statin Medication17. Learn about the priorities that drive us and how we are helping propel health care forward. TARGET: STROKE MEASURE Door to IV rt-PA in 60 minutes (Historic-Quality): Percent of ischemic stroke patients receiving IV t-PA at your hospital who are treated within 60 minutes after triage (ED arrival). Early rehabilitation interventions initiated following stroke can enhance the recovery process and minimize functional disability. 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. Time from symptom onset to stroke alert is delayed in in-hospital stroke. 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-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. The Measure Steward refers to the organization that is responsible for providing the required measure information for the measure maintenance process that occurs approximately every three years. 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 required quarterly sample size would be 100% of the patient population or 5 cases for the quarter, No sampling; 100% Initial Patient Population required. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. 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.

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