The two sub-populations must be sampled independently from each other. The American Medical Association reserves all rights to approve any license with any Federal agency. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. Source: Medisolv Perfect Care Report (eff. Using the quarterly 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. 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. We help you measure, assess and improve your performance. Twenty (20) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. This Agreement will terminate upon notice if you violate its terms. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received This item requires a Core Return or Core Charge. 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. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
Clinical Measures Outcomes | Cleveland Clinic Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . STK-OP-1b Hemorrhagic Strok3. 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. 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). Set the Initial Patient Population Reject Case Flag to equal Yes. Visit: . <>/Metadata 285 0 R/ViewerPreferences 286 0 R>>
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. STK-10 Assessed for Rehabilitation. 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. At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). Comprehensive Stroke (CSTK) (v2021A1) Home Comprehensive Stroke (CSTK) Comprehensive Stroke (CSTK) On this page: Comprehensive Stroke (CSTK) Initial Patient Population Monthly Sampling Sample Size Examples Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements 1 0 obj
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Stroke - Diagnosis and treatment - Mayo Clinic STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. Measures for TJC Acute Stroke Ready Center Certification, 1. 646 0 obj
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STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**4.
PDF 2021 Core Set of Adult Health Care Quality Measures for - Medicaid 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. Include the patient in the Initial Patient Population for the appropriate measures. %%EOF
You can use the words "AND" and "OR" along . 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. They also could require other measures. . n01Qf
i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. 3= recommended; the outcome measure has good psychometric . Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture.
Core Measures - Nursing On Point The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers.
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. 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. CPT only copyright 2019 American Medical Association. 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. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. 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. Chart-abstracted measures specificationsScreen Reader Text. 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. A hospitals ischemic stroke patient population size is 295 cases during March. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. Assemble your multidisciplinary team to determine roles and processes for entering patient data. STK-2 Discharged on Antithrombotic Therapy13. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. 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. 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. We can make a difference on your journey to provide consistently excellent care for each and every patient. Learn how working with the Joint Commission benefits your organization and community.
Stroke | The Joint Commission 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. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time 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. 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. 10960 Grantchester Way, Suite 520Columbia, MD 21044. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. For the purposes of this blog, since we are focusing specifically on stroke measures, there is only one stroke measure that is used for Accreditation purposes by both CMS and TJC: OP-23. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. 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 . Calculate the Length of Stay.
Stroke Core Measure - About Us - Mayo Clinic Updated eCQM Specifications and eCQM Materials for 2021 Reporting Now Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. 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. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. Learn about the priorities that drive us and how we are helping propel health care forward. 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-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)7. See how our expertise and rigorous standards can help organizations like yours. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. 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. Set the Initial Patient Population Reject Case Flag to equal Yes. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. 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. Set the Initial Patient Population Reject Case Flag to equal No. Each measure includes patients from one or more categories. 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. 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? )
PDF California EMS System Core Quality Measures Instruction Manual *{o7@FNhR/
PDF Understanding Stroke Measure Sets - f.hubspotusercontent30.net promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. This content does not have an English version. %
Create your baseline by entering 30 records into the Patient Management Tool. Stroke Core Measure - About Us - Mayo Clinic , . Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 17 cases are sampled. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. endobj
The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. Mayo Clinic does not endorse any of the third party products and services advertised. stream
Remember that changes do not have to be large. The listed denominator criteria are used to identify the intended patient population. The Core Quality Measure Collaborative, led by the Americas Health Insurance Plans (AHIP) and its member plans Chief Medical Officers, leaders from CMS and the National Quality Forum (NQF), as well as national physician organizations, employers and consumers, worked hard to reach consensus on core performance measures. *** 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. STK-4 Thrombolytic Therapy10. 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. Return to Clinical Data Processing Flow in the Data Processing section. CPT is provided as is without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. %PDF-1.4
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The core measurescan be found at: http://www.qualityforum.org/cqmc/. Unauthorized use prohibited. 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 Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. An antithrombotic is a medication that prevents blood clots. Closed on Sundays. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. 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. 2 0 obj
Quarterly sampling for the two combined populations for Joint Commission certification purposes. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. 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. Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. The required quarterly sample is 45 cases. Measure Type: InpatientNumber of Measures Included: 8Certification Requirement: The Joint Commissions Primary Stroke Certification, Anticoagulation Therapy for Atrial Fibrillation/Flutter, Antithrombotic Therapy By End of Hospital Day Two. 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. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month.
PDF CMCS Informational Bulletin - Medicaid.gov We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. <>
This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. A hospitals hemorrhagic stroke patient population size is 17 cases during March.
PDF Core Measures: The Nurse's Role - r N Using the monthly sampling table for the Ischemic sub-population, the sample size is less than the minimum required monthly sample size, so 100% of this sub-population is sampled. Regulatory/AccreditationExamples would include the Center for Medicare & Medicaid Services (CMS) required core measures (e.g., fibrinolytic therapy received within 30 minutes of emergency department (ED) arrival, aspirin at arrival) and documentation of Joint Commission standard achievement. CPT is a registered trademark of the American Medical Association. Percent of ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.
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]. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter. Arrhythmia means that the heart's normal beating rhythm is interrupted. A hospitals Hemorrhagic sub-population is 3 patients during January. hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji
This began in Fiscal Year (FY) 2014. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. 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. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5
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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.
Comprehensive Stroke (CSTK) (v2021A1) - Performance Measurement Network A modified sampling procedure is required for hospitals performing quarterly sampling for STK. In addition, the public may compare specific healthcare organizations' results on Core Measures at the Joint Commission Clinical Measures.
Anticoagulation Therapy for Atrial Fibrillation/Flutter 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). 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . https:// 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 cases during the second quarter. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). STK-8 Stroke Education13. website belongs to an official government organization in the United States. In this post we are either referencing CMS or The Joint Commission as the Measure Stewards. This Agreement will terminate upon notice if you violate its terms. CSTK-09 Arrival Time to Skin Puncture, 8. 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 CPT is a registered trademark of the American Medical Association. endobj
Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes.
So, Ive attempted to structure it in a way that will be a reference for you. A hospitals Ischemic sub-population is 316 during January.
StrokEdge - neuropt.org The following are Stroke eCQMs used by The Joint Commission. Researchers also have the opportunity to conduct investigator-led research projects using data from the Get With The Guidelines- Stroke program.
PDF Stroke Core Stroke Measures - University of Florida decreased providers collection burden and cost. 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. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset.