stroke core measures 2021

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. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. endstream endobj startxref CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Hospital Outpatient Quality Measure Stroke. View them by specific areas by clicking here. We develop and implement measures for accountability and quality improvement. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. Calculate the Length of Stay. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. The next measure set we review is abbreviated ASR-IP/OP. So, Ive attempted to structure it in a way that will be a reference for you. n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. The core measurescan be found at: http://www.qualityforum.org/cqmc/. endobj Hospitals now have one place to submit both chart-abstracted and eCQM data. The American Medical Association reserves all rights to approve any license with any Federal agency. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. . OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time ruTv?U J4lUBex(a8{g$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 . 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. Find more information on our content editorial process. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. Patient Age, in years, is equal to the Admission Date minus the Birthdate. A hospitals ischemic stroke patient population size is 129 cases during March. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. CSTK-06 Nimodipine Treatment Administered6. Set the Initial Patient Population Reject Case Flag to equal No. Medisolv can help you along the way. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5 @/K6jPw*sfoqW}"3v}qCmqytT_.NnwT*_kL?hokU^dU2h=>tLi 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. All rights reserved. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. 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. 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). A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. CPT is a registered trademark of the American Medical Association. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). CSM 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. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. 3 0 obj Ongoing monitoring by the Collaborative of the use of these measures will enable modifications of measure sets, as needed and based on lessons learned, including minimizing unintended consequences and selection of new measures as better measures become available. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. Using the quarterly sampling table for the Ischemic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. 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. Submission of aggregate data is still required. uz'*\08 DLli_{5:G}M=}nS`M6C'{AREuw%~NM5Ydam\[\_#$ s8S@ AE"4u0qwCmWN N`h,bp``+bv\~B9M Monday - Friday: 7 a.m. 7 p.m. CT Ready to get started with CMIT 2.0? <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> lock "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. A hospitals Ischemic sub-population is 5 patients 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. 1 0 obj A hospitals ischemic stroke patient population size is 200 patients during the second quarter. 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. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. 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. Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. A hospitals Ischemic sub-population is 5 patients during the first quarter. x[o ?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. A hospitals hemorrhagic stroke patient population size is 129 cases during March. stream Comprehensive Core Stroke Measures were developed for the management of both ischemic and hemorrhagic stroke patients in hospitals equipped with clinical expertise, infrastructure, and specialized neurointerventional and imaging services needed to provide a higher level of stroke care. Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. 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. sI Medisolv can help you along the way. STK-OP-1a Overall Rate (Not Reported2. .gov hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ If the Principal Diagnosis code falls on Table 8.1 it will be placed in the Ischemic Stroke, or sub-pop 1 and if it has a Principal Diagnosis code that falls on Table 8.2, then it will be placed in the Hemorrhagic Stroke or sub-pop-2. stream Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. The American Medical Association reserves all rights to approve any license with any Federal agency. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. 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. 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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. Stroke Core Stroke Measures As a Certified Stroke Center the stroke committee would like to provide physicians with updates on how we are performing on the stroke performance and quality measures. This Agreement will terminate upon notice if you violate its terms. Use the month and day portion of admission date and birthdate to yield the most accurate age. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 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. 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 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). Get more information about cookies and how you can refuse them by clicking on the learn more button below. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. Calculate Patient Age. 2 0 obj 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. endobj 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). Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. 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. 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. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. STK-6 Discharged on Statin Medication9. 2023 American Heart Association, Inc. All rights reserved. Learn about the development and implementation of standardized performance measures. 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 [emailprotected]. STK-OP-1 Door to Transfer to Another Hospital, 1. CSTK-05 Hemorrhagic Transformation, 1. 1 0 obj 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . Sixty (60) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. <> 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 Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. JoAnne has a background in Quality Management and has been working with hospitals on their Core Measures compliance with CMS and The Joint Commission since 2008. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). What is wrong with these people making it so complicated for us? 3= recommended; the outcome measure has good psychometric . A hospitals Ischemic sub-population is 316 during January. In the final section, I review the way this information is submitted to The Joint Commission and CMS. Part 2: A review of the different stroke certifications. 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 Nozzle assembly is comprehensively flow tested to measure flow rate, leak and seat condition to validate injection consistency. This Agreement will terminate upon notice if you violate its terms. TARGET: STROKE MEASURE CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. By not making a selection you will be agreeing to the use of our cookies. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. Share sensitive information only on official, secure websites. Create your baseline by entering 30 records into the Patient Management Tool. hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received 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 . Set the Initial Patient Population Reject Case Flag to equal Yes. 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. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. Chart-abstracted measures specificationsScreen Reader Text. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. 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#. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. 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. The two sub-populations must be sampled independently from each other. The AMA does not directly or indirectly practice medicine or dispense medical services. Measure Type: InpatientNumber of Measures Included: 3 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Measure Type: OutpatientNumber of Measures Included: 2 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Door to Transfer to Another Hospital**RETIRED Effective July 1, 2021**, Note: All Joint Commission certified acute stroke ready hospitals, as well as those seeking initial certification, will be required to collect the STK-OP-1 Door to Transfer to Another Hospital measure for discharges on and after July 1, 2021. Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. Find evidence-based sources on preventing infections in clinical settings. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . The required sample size for the CSTK-01 measure is a minimum of 42 cases for the month (28 cases from Table 4 plus 14 cases from Table 5 equals 42). Learn how working with the Joint Commission benefits your organization and community. 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. Using the monthly sampling table for the Hemorrhagic 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). 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). Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. 10960 Grantchester Way, Suite 520Columbia, MD 21044. 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.

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