Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. 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. The numerator options included in this <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. View them by specific areas by clicking here. 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. Hospital Outpatient Quality Measure Stroke. 1 0 obj
means youve safely connected to the .gov website. 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#. We can make a difference on your journey to provide consistently excellent care for each and every patient. CSM The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. 646 0 obj
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Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). stream
STK-OP-1a Overall Rate (Not Reported2. Set expectations for your organization's performance that are reasonable, achievable and survey-able. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. 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. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. If the Patient Age is less than 18 years, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. The American Medical Association reserves all rights to approve any license with any Federal agency. Sign up to get the latest information about your choice of CMS topics. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. STK-6 Discharged on Statin Medication12. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. This Agreement will terminate upon notice if you violate its terms. An injection of TPA is usually given through a vein in the arm within the first three hours. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Comprehensive Stroke Arrival Time to Skin Puncture, Comprehensive Stroke Post Thrombolysis Revascularization Rate, Comprehensive Stroke Timeliness of IV Thrombolytic Therapy, Advertising and sponsorship opportunities, Percent of ischemic and hemorrhagic stroke patients who received venous thromboembolism (VTE) prophylaxis the day of or the day after hospital admission. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. 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 Nozzle assembly is comprehensively flow tested to measure flow rate, leak and seat condition to validate injection consistency.
For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. An official website of the United States government 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. A hospitals ischemic stroke patient population size is 200 patients during the second quarter. 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. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. This means the patient passed every measure they qualified for. Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. All rights reserved. The guiding principles used by the Collaborative in developing the core measure sets are that they be meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost. Chart Abstracted Measures for Certification. 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. Clinical Performance Measures for Stroke Rehabilitation: Performance %%EOF
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. Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). <>/Metadata 285 0 R/ViewerPreferences 286 0 R>>
STK-8 Stroke Education18. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. Set the Initial Patient Population Reject Case Flag to equal Yes. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. National Center Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. endstream
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Stroke Corner - Education - neuropt.org Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. Include the patient in the Initial Patient Population for the appropriate measures. This Agreement will terminate upon notice if you violate its terms. 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. This is increasingly important as the health care system moves towards value-based reimbursement models. Recommended Core Measures | CMS Secure .gov websites use HTTPSA 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. . CSTK-02 Modified Rankin Score (mRS at 90 Days)3. <>>>
. Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. Disclaimer of Warranties and Liabilities. 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. ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Return to Clinical Data Processing Flow in the Data Processing section. 1-800-242-8721 4 0 obj
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Core Measure Data as of 3/2/2022. Centers for Medicare and Medicaid Services Measures Inventory Tool Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. STK-4 Thrombolytic Therapy7. Dallas, TX 75231, Customer Service Initial Population: Inpatient hospitalizations for patients age 18 and older . endobj
Find out about the current National Patient Safety Goals (NPSGs) for specific programs. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. REMINDER: Stroke is now a Core Measure for CMS!!! The CMS Measure Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to promote healthcare quality and quality improvement. Core Measures - Nursing On Point Much like we saw how cases fall into their respective sub-populations with CSTK, cases for STK use the same criteria when determining which sub-population a case will qualify for. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture11. Hospital Core Measures Defined - ESO Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. Measure ID # Measure Short Name OP-23 . ASR-OP-2b Hemorrhagic Stroke3. Fifty (50) 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 sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. Especially if you use an EHR vendor right now, youll notice a huge difference. Learn about the "gold standard" in quality. In the Hospital Inpatient VBP Program Final Rule, CMS adopted the 30-day mortality measures for acute myocardial infarction (AMI), heart failure (HF), and pneumonia* under the Outcome domain. 2 0 obj
All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Implementing International Standards of Practice in A Low Resource m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB 2021; 97: . I also included the complete list of measures required for each certification. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Ready to get started with CMIT 2.0? These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. 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. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. *** AHRQ is the measure steward for the survey instrument in the Adult Core Set (NQF #0006) and NCQA is the developer of the survey administration protocol. It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. endobj
Monday - Friday: 7 a.m. 7 p.m. CT Below are the list of Stroke measures by Certification Program. 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 . 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). Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. TARGET: STROKE MEASURE Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 42 cases for the quarter. 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. Stroke - Diagnosis and treatment - Mayo Clinic CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. The final clinical diagnosis is used to identify the measure population. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. 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 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). STK-1 Venous Thromboembolism (VTE Prophylaxis)4. x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4(
L`yXS7?b!0@qp) The core measurescan be found at: http://www.qualityforum.org/cqmc/. Commercial health plans are rolling out the core measures as part of their contract cycle. Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . PDF Understanding Stroke Measure Sets - f.hubspotusercontent30.net 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). 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). The two Measure Stewards (CMS and TJC) require hospitals to submit their chart-abstracted data in two different ways. ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). The listed denominator criteria are used to identify the intended patient population. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. 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. 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. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form(PDF). sI CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. Unauthorized use prohibited. PDF Hospital OQR Quality Measures and Timelines for CY 2021 Payment CPT is a registered trademark of the American Medical Association. Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment. 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. A hospitals hemorrhagic stroke patient population size is 17 cases during March. PDF Hospital Outpatient Quality Reporting Stroke Measure Set - RWHC stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). Program details are found in Part 2. This content does not have an Arabic version. 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. 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. 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. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals.