The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). A hospitals Hemorrhagic sub-population is 316 during February. The Perfect Care Report identifies patients that received perfect care. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. The listed denominator criteria are used to identify the intended patient population. The required quarterly sample is 60 cases. % Hospitals report on these measures quarterly or monthly, and compliance can affect TJC accreditation and CMS . 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]. A hospitals ischemic stroke patient population size is 129 cases during March. Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. A hospitals Hemorrhagic sub-population is 100 during the first quarter. We can make a difference on your journey to provide consistently excellent care for each and every patient. TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. A hospital may choose to use a larger sample size than is required. Percent of ischemic stroke patients with an LDL greater than or equal to 70 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge. Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. https:// <> 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. 3= recommended; the outcome measure has good psychometric . It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. 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. 10960 Grantchester Way, Suite 520Columbia, MD 21044. Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. U.S. Government Rights 3 0 obj If the Length of Stay is less than or equal to 120 days, continue processing and proceed to ICD-10-CM Principal Diagnosis Code Check. These measures include aggressive use of medications, such as antithrombotics, anticoagulation therapy, deep vein thrombosis prophylaxis, cholesterol-reducing drugs and smoking cessation, all aimed at reducing death and disability and improving the lives of stroke patients. endobj 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. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. website belongs to an official government organization in the United States. 1-800-242-8721 Stroke is a leading cause of serious, long-term disability in the United States. STK-2 Discharged on Antithrombotic Therapy13. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. 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. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form(PDF). Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. decreased providers collection burden and cost. 2023 Medisolv, Inc. All Rights Reserved. STK-2 Discharged on Antithrombotic Therapy5. stream These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). You can decide how often to receive updates. A hospitals Hemorrhagic sub-population is 3 patients during the first 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). Set the Initial Patient Population Reject Case Flag to equal Yes. Refine processes and protocols to ensure they are in line with the guidelines. 4 0 obj 671 0 obj <>/Filter/FlateDecode/ID[<8968A4F338E55446928FCF4A155C4BC8>]/Index[646 45]/Info 645 0 R/Length 114/Prev 86415/Root 647 0 R/Size 691/Type/XRef/W[1 2 1]>>stream 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. 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. A hospitals Hemorrhagic sub-population is 3 patients during January. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. 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. The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. *{o7@FNhR/ Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. 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. 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. The required quarterly sample sizes for each sub-population would be 79 and 5. CSTK-09a Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who are transferred from another hospital and undergo endovascular treatment2. The ACM is a pass-fail measure at the individual patient level that asks whether an eligible patient has received all of the appropriate care for the condition for which he or she is being treated. <> 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. Sometimes it works best to start small and build on success. 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%. 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. Learn about the priorities that drive us and how we are helping propel health care forward. Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. 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). 2 0 obj You can download it or email it to yourself to help you remember. Here are some resources to help you get started: JoAnne Marino is a Registered Nurse that is currently working as a Senior Clinical Consultant for Medisolv helping clients with the ENCOR Hospital Abstracted Measures. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Medisolv can help you along the way. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 20% of this subpopulation or 26 cases for the month (20% of 129 equals 25.8 rounded to the next highest whole number equals 26). Studies suggest that antithrombotic therapy should be prescribed at hospital discharge following an ischemic stroke to reduce stroke mortality and morbidity. Remember that changes do not have to be large. 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. Measure Information 2021 Reporting Period; CMS eCQM ID: CMS71v10 Short Name: STK-3 NQF Number: Not Applicable Description: Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge. CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. <> 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#. Visit: . 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). Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. This post is a guide to understanding the differences between the five major stroke measure sets. Heres how you know. 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 nations health care system moves from one that pays based on volume of services to one that pays for value. Chart-abstracted measures specificationsScreen Reader Text. STK-OP-1b Hemorrhagic Strok3. 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. 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-5 Antithrombotic Therapy By End of Hospital Day Two11. Drive performance improvement using our new business intelligence tools. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)7. Use the month and day portion of admission date and birthdate to yield the most accurate age. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). Return to Clinical Data Processing Flow in the Data Processing section. The AMA does not directly or indirectly practice medicine or dispense medical services. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB stream Set the Initial Patient Population Reject Case Flag to equal No. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. There are five major stroke measure sets. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. 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. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. Part 2: A review of the different stroke certifications. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> *7.`"}K3t;qBEN]1F"9V>7[?)] ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5 @/K6jPw*sfoqW}"3v}qCmqytT_.NnwT*_kL?hokU^dU2h=>tLi 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. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. Commercial health plans are rolling out the core measures as part of their contract cycle. Secure .gov websites use HTTPSA The final clinical diagnosis is used to identify the measure population. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. May 2021 Measure ID# Measure Short Name Measure Description STK-1 Venous Thromboembolism (VTE) This measure captures the proportion of ischemic or hemorrhagic Prophylaxis stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. CMIT searches all fields in the inventory and is not case-sensitive. 2021). 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. 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. Please see link below for more information. Here is a diagram that outlines the submission differences. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. 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. This Agreement will terminate upon notice if you violate its terms. Medisolv can help you along the way. The following table identifies the population . Data Source: American Heart Association Get With The Guidelines stroke database. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. CPT only copyright 2019 American Medical Association. The reduction of LDL cholesterol, through lifestyle modification and drug therapy when appropriate, is recommended for the prevention of recurrent ischemic stroke, heart attack, and other major vascular events. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. An official website of the United States government Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 84 cases for the quarter. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. STK-8 Stroke Education10. endstream endobj startxref CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. Official websites use .govA 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. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. 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. ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. Share sensitive information only on official, secure websites. *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. 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 <>>> 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. Disclaimer of Warranties and Liabilities. An antithrombotic agent is a drug that reduces the formation of blood clots. STK-4 Thrombolytic Therapy10. Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). Domain-specific outcomes for stroke clinical trials: what the modified Rankin isn't ranking. An injection of TPA is usually given through a vein in the arm within the first three hours. ASR-OP-2c Ischemic Stroke; drip and ship4. Disclaimer of Warranties and Liabilities. The six measures are: . The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. *Note: There are additional measures needed to fulfill this certification. .gov 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 Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. STK-4 Thrombolytic Therapy7. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. 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. 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 CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. 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. A hospitals ischemic stroke patient population size is 295 cases during March. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population.
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