stroke core measures 2021stroke core measures 2021

endobj 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 Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospitals Hemorrhagic sub-population is 100 during the first quarter. 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. Return to Clinical Data Processing Flow in the Data Processing section. Honestly though Stroke Outpatient versus Outpatient Stroke. Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 20% of this subpopulation or 45 cases for the quarter (20% of 223 equals 44.6 rounded to the next highest whole number equals 45). So, Ive attempted to structure it in a way that will be a reference for you. <>>> Include the patient in the Initial Patient Population for the appropriate measures. CPT is a registered trademark of the American Medical Association. Find the exact resources you need to succeed in your accreditation journey. 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. stream Create your baseline by entering 30 records into the Patient Management Tool. Calculate the Length of Stay. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. 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). Find more information on our content editorial process. means youve safely connected to the .gov website. hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! 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). CMIT searches all fields in the inventory and is not case-sensitive. The following are Stroke eCQMs used by The Joint Commission. 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 receive one consultant that you can call anytime with questions or concerns. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. View them by specific areas by clicking here. 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. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. TARGET: STROKE MEASURE Door to IV rt-PA in 60 minutes (Historic-Quality): Percent of ischemic stroke patients receiving IV t-PA at your hospital who are treated within 60 minutes after triage (ED arrival). A hospitals ischemic stroke patient population size is 295 cases during March. 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. website belongs to an official government organization in the United States. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ CSTK-05 Hemorrhagic Transformation, 1. 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. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Official websites use .govA The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. An antithrombotic agent is a drug that reduces the formation of blood clots. 2018 - 2021. Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> STK-OP-1a Overall Rate (Not Reported2. The CSTK Initial Patient Population is unique in that it is comprised of three distinct subpopulations: ischemic stroke patients who do not undergo a reperfusion therapy (i.e., procedure), ischemic stroke patients who undergo a reperfusion therapy (IV t-PA, IA t-PA, or mechanical endovascular reperfusion (MER) therapy), and hemorrhagic stroke patients. STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 2. The Differences Between The 5 Major Stroke Measure Sets, Thrombolytic Therapy: Inpatient Admission, Antithrombotic Therapy By End of Hospital Day 2, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship), CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only, CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), 1. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. 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. 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. Start STK Initial Patient Population logic sub-routine. Heres how you know. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. %PDF-1.5 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 ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. 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. Share sensitive information only on official, secure websites. 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. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. In addition, TJC established the Certification Measure Information Process (CMIP) tool where hospitals must manually enter their certification data for the program certifications we reviewed above (ASR, PSC, TSC and CSC). A hospitals ischemic stroke patient population size is 70 cases during March. We help troubleshoot technical and clinical issues to improve your measures. 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 . 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. Initial Population: Inpatient hospitalizations for patients age 18 and older . Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Numerous published studies demonstrate the program's success in improving patient outcomes. This means the patient passed every measure they qualified for. .gov A hospitals ischemic stroke patient population size is 200 patients during the second quarter. A hospitals ischemic stroke patient population size is 129 cases during March. In the final section, I review the way this information is submitted to The Joint Commission and CMS. Remember that changes do not have to be large. Disclaimer of Warranties and Liabilities. 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. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. CPT only copyright 2019 American Medical Association. We develop and implement measures for accountability and quality improvement. 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. 4 0 obj Part 2: A review of the different stroke certifications. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Secure .gov websites use HTTPSA This content does not have an Arabic version. 3 0 obj A hospitals hemorrhagic stroke patient population size is 392 cases during the second quarter. The AMA does not directly or indirectly practice medicine or dispense medical services. 2 0 obj The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. This is a big year for Quality. Use the month and day portion of admission date and birthdate to yield the most accurate age. Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 11 cases are sampled. This began in Fiscal Year (FY) 2014. %PDF-1.5 Medisolv Can HelpThis is a big year for Quality. STK-2 Discharged on Antithrombotic Therapy5. An official website of the United States government Chart-abstracted measures specificationsScreen Reader Text. 4 0 obj >ob=AOtVt. 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. A hospitals Hemorrhagic sub-population is 316 during February. A hospitals Ischemic sub-population is 5 patients during February. 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 Understanding Stroke Measure Sets - f.hubspotusercontent30.net Learn about the development and implementation of standardized performance measures. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received 1-800-242-8721 STK-6 Discharged on Statin Medication12. Monday - Friday: 7 a.m. 7 p.m. CT with acute ischemic stroke in the hospital setting will submit this measure. Q2 (April 1-June 30); Q3 (July 1-September 30); Q4 (October 1-December 31); Q1 . Download Get With The Guidelines- Stroke fact sheets and forms here. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% of the Initial Patient Population is required, Patient level data must be processed in order to submit your aggregate data. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. All rights reserved. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. Patient Age, in years, is equal to the Admission Date minus the Birthdate. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. or The final clinical diagnosis is used to identify the measure population. This content does not have an English version. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. }J CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Each measure includes patients from one or more categories. lock TARGET: STROKE MEASURE 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. The next measure set we review is abbreviated ASR-IP/OP. The core measurescan be found at: http://www.qualityforum.org/cqmc/. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Dallas, TX 75231, Customer Service *{o7@FNhR/ Learn about the "gold standard" in quality. This consensus core set was further discussed by all Collaborative members before being finalized. 7272 Greenville Ave. In addition, the public may compare specific healthcare organizations' results on Core Measures at the The Pathfinder Core Rulebook includes: More than 600 pages of game rules, advice, character options, treasure, and more for players and Game Masters! 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). STK-4 Thrombolytic Therapy10. 3 0 obj https:// We help you select and set up measures that make sense based on your hospitals situation. A modified sampling procedure is required for hospitals performing quarterly sampling for STK. You can download it or email it to yourself to help you remember. Medisolv can help you along the way. If the Length of Stay is greater than 120 days, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. 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. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. endobj STK-4 Thrombolytic Therapy15. 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. A hospital may choose to use a larger sample size than is required. ( STK-6 Discharged on Statin Medication9. 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. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. 2021). The following links provide you with information available on past, present and future versions of the specification manuals, including release notes, measure information forms, data dictionaries, missing and invalid data, population and sampling, data transmission, tools and resources, and appendices. The American Medical Association reserves all rights to approve any license with any Federal agency. endobj This is increasingly important as the health care system moves towards value-based reimbursement models. Claims-Based Measures by Category Claims-Based Patient Safety Measures for 2022 Claims-Based Mortality Measures for 2022 Claims-Based Coordination of Care Measures for 2022 Set the Initial Patient Population Reject Case Flag to equal Yes. >0SPJ*@6W/rq+ERY_X&14>k( The required monthly sample is 60 cases. Pets and Your Health / Healthy Bond for Life, La Iniciativa Nacional de Control de la Hipertensin, Contact your local Get With The Guidelines, Get With The Guidelines Data Request Form. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. U.S. Government Rights Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. CPT is a registered trademark of the American Medical Association. 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. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. ASR-OP-2c Ischemic Stroke; drip and ship4. The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). We can make a difference on your journey to provide consistently excellent care for each and every patient. 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. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation. Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. A hospitals ischemic stroke patient population size is 7 cases during March. National Center 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. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. sI At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). Time from symptom onset to stroke alert is delayed in in-hospital stroke. 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. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). The annual Acute Care Hospital Quality Improvement Program Measures reference guide provides a comparison of measures for five Centers for Medicare & Medicaid Services (CMS) acute care hospital quality improvement programs, including the: Hospital IQR Program Hospital Value-Based Purchasing (VBP) Program Promoting Interoperability Program %%EOF Percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. 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. % 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. The AMA is a third party beneficiary to this Agreement. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. REMINDER: Stroke is now a Core Measure for CMS!!! Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. The two sub-populations must be sampled independently from each other. 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. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. A hospitals hemorrhagic stroke patient population size is 60 cases during March. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. Data Source: American Heart Association Get With The Guidelines stroke database. This Agreement will terminate upon notice if you violate its terms. 0 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. Hospitals now have one place to submit both chart-abstracted and eCQM data. Test your ideas. stream Patient education should include information about the event (e.g., cause, treatment, and risk factors), the role of various medications or strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! 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.
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