A hospitals Hemorrhagic sub-population is 100 during the first quarter. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. means youve safely connected to the .gov website. CMS is already using measures from the each of the core sets. 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. 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. STK-8 Stroke Education18. The Pathfinder Core Rulebook includes: More than 600 pages of game rules, advice, character options, treasure, and more for players and Game Masters! Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. 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 Medisolv can help you along the way. The following are Stroke chart abstracted measures used by The Joint Commission. We keep you on track for your submission deadlines and ensure you dont miss critical dates. ASR-IP-3: Discharged on Antithrombotic Therapy4. We can make a difference on your journey to provide consistently excellent care for each and every patient. An official website of the United States government An injection of TPA is usually given through a vein in the arm within the first three hours. 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. Measures for TJC Acute Stroke Ready Center Certification, 1. ASR OP-2 Door to Transfer to Another Hospital **RETIRED Effective July 1, 2021**, 1. A single copy of these materials may be reprinted for noncommercial personal use only. Return to Clinical Data Processing Flow in the Data Processing section. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. Part 1: A review of the different stroke measure sets. Unauthorized use prohibited. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. The most common signs and symptoms of HF are shortness of breath on exertion; orthopnea; weight gain with edema in the feet, legs, or lower back; fatigue; and weakness. The required quarterly sample sizes for each sub-population would be 79 and 5. The following links provide you with information available on past, present and future versions of the specification manuals, including release notes, measure information forms, data dictionaries, missing and invalid data, population and sampling, data transmission, tools and resources, and appendices. A hospital may choose to use a larger sample size than is required. 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. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. 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 measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). 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. The American Medical Association reserves all rights to approve any license with any Federal agency. ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. Joint Commission Clinical Measures. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. Core Measure Data as of 3/2/2022. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. A hospitals hemorrhagic stroke patient population size is 60 cases during March. 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. 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. 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. Find more information on our content editorial process. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. website belongs to an official government organization in the United States. 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. This section includes the measure type (inpatient vs outpatient), the number of measures in the set, which certification the measure set is a part of, a list of the measures in the set and the associated algorithm. 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 . 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. ASR-OP-2b Hemorrhagic Stroke3. .gov STK-6 Discharged on Statin Medication17. %PDF-1.5
Heres how you know. Ready to get started with CMIT 2.0? U.S. Government Rights Learn how working with the Joint Commission benefits your organization and community. Twenty (20) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. 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. Set the Initial Patient Population Reject Case Flag to equal Yes. 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. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). Program details are found in Part 2. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. endobj
Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. Eleven (11) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. Mayo Clinic does not endorse any of the third party products and services advertised. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. Finally, I have listed a few more resources for you. 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. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. CSTK-05 Hemorrhagic Transformation, 1. CPT is a registered trademark of the American Medical Association. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). 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. To submit a research proposal for the Get With The Guidelines - Stroke program, email a completed Get With The Guidelines Data Request Form (download) to QualityResearch@heart.org. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. Sometimes it works best to start small and build on success. <>
STK-4 Thrombolytic Therapy7. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). STK-1 Venous Thromboembolism (VTE Prophylaxis)12. This consensus core set was further discussed by all Collaborative members before being finalized. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. 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%. 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. Especially if you use an EHR vendor right now, youll notice a huge difference. An antithrombotic agent is a drug that reduces the formation of blood clots. Saturday: 9 a.m. - 5 p.m. CT I hope this high-level overview was helpful and can be a reference for you. endobj
STK-6 Discharged on Statin Medication9. 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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. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. Stroke is a leading cause of serious, long-term disability in the United States. By not making a selection you will be agreeing to the use of our cookies. A hospitals Ischemic sub-population is 5 patients during February. Here is a diagram that outlines the submission differences. Each measure includes patients from one or more categories. 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. U.S. Government Rights 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ A hospitals ischemic stroke patient population size is 495 cases during the second quarter. Data Source: American Heart Association Get With The Guidelines stroke database. Using the monthy sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 14 cases for the month. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. TJC is adding three additional measures beginning with July 1, 2021 discharges.Certification Requirement: The Joint Commissions Primary Stroke Certification, Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible **ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, Measure Type: OutpatientNumber of Measures Included: 1 process measureAccreditation Requirement: CMS Outpatient Quality Reporting program. Brainstorm with your team to find ways to improve your hospital's treatment rates. We help you select and set up measures that make sense based on your hospitals situation. }J A hospitals hemorrhagic stroke patient population size is 17 cases during March. 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. x[o
?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU 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. 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). Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. Specifications Manual for Joint Commission National Quality Measures (v2021A1), Comprehensive Stroke (CSTK) Initial Patient Population, First Pass of a Mechanical Reperfusion Device, Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation, Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation, IV Alteplase Prior to IA or Mechanical Reperfusion Therapy, Initial Blood Glucose Value at Hospital Arrival, Initial Blood Pressure at Hospital Arrival, Initial Platelet Count at Hospital Arrival, NIHSS Score Documented Closest to IA Alteplase or MER Initiation, NIHSS Score Documented Closest to IV Alteplase Initiation, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time, Reason for Not Administering Nimodipine Treatment, Reason for Not Administering a Procoagulant Reversal Agent, 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, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH ), Hemorrhagic Transformation (Overall Rate), Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), Modified Rankin Score (mRS at 90 Days: Favorable Outcome), Rate of Rapid Effective Reperfusion From Hospital Arrival, Rate of Rapid Effective Reperfusion From Skin Puncture, 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.