Major causes of HF are coronary artery disease, high blood pressure, and diabetes. 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. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. Quarterly sampling for the two combined populations for Joint Commission certification purposes. STK-8 Stroke Education10. 1 0 obj Dude JA, Lohse KR, Cramer SC, Worrall BB; GPAS Collaboration Phenotyping Core. 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. 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). CSTK-09 Arrival Time to Skin Puncture, 8. 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. STK-6 Discharged on Statin Medication9. A hospitals Hemorrhagic sub-population is 100 during the first quarter. 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. 2 0 obj Test your ideas. A hospitals ischemic stroke patient population size is 129 cases during March. CPT is a registered trademark of the American Medical Association. 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). The required quarterly sample size would be 100% of the patient population or 5 cases for the quarter, No sampling; 100% Initial Patient Population required. Saturday: 9 a.m. - 5 p.m. CT 2021). But hospitals see benefits as well. STK-10 Assessed for Rehabilitation. . Numerous published studies demonstrate the program's success in improving patient outcomes. endobj <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> endobj Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. Sign up to get the latest information about your choice of CMS topics. 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. Return to Clinical Data Processing Flow in the Data Processing section. a set of re-specified measures in 2019, which were updated in 2021. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Chart-abstracted measures specificationsScreen Reader Text. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Mcarbo p365 short stroke flat trigger - ywna.wikinger-turnier.de The following table identifies the population . Using the monthly 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 25 cases for the month (20% of 123 equals 24.6 rounded to the next highest whole number equals 25). STK-OP-1b Hemorrhagic Strok3. Official websites use .govA The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. So, Ive attempted to structure it in a way that will be a reference for you. with acute ischemic stroke in the hospital setting will submit this measure. The required sample size for the CSTK-01 measure is a minimum of 42 cases for the month (28 cases from Table 4 plus 14 cases from Table 5 equals 42). Understanding core measures for heart-failure treatment - American Nurse This Agreement will terminate upon notice if you violate its terms. . Clinical Measures Outcomes | Cleveland Clinic Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 28 cases for the month. 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%. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). U.S. Government Rights CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Centers for Medicare and Medicaid Services Measures Inventory Tool Drive performance improvement using our new business intelligence tools. Each measure includes patients from one or more categories. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). 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. The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. 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). The required quarterly sample is 45 cases. Secure .gov websites use HTTPSA Arrhythmia means that the heart's normal beating rhythm is interrupted. National Center Written by American Heart Association editorial staff and reviewed by science and medicine advisers. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. 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. The next measure set we review is abbreviated ASR-IP/OP. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). 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). 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. STK-2 Discharged on Antithrombotic Therapy13. 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, Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. Measure 6a is new and is being pilot tested in 2009. Identifying Best Practices to Improve In-Hospital Stroke Management 2021; 96:e1812-e1822 . Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. 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. Hospital Outpatient Quality Measure Stroke. REMINDER: Stroke is now a Core Measure for CMS!!! CPT is a registered trademark of the American Medical Association. Find the exact resources you need to succeed in your accreditation journey. Eleven (11) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. PDF Quality ID #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy 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. Medisolv can help you along the way. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. Honestly though Stroke Outpatient versus Outpatient Stroke. These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. 10960 Grantchester Way, Suite 520Columbia, MD 21044. 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 In the final section, I review the way this information is submitted to The Joint Commission and CMS. <> >0SPJ*@6W/rq+ERY_X&14>k( Clinical Performance Measures for Stroke Rehabilitation: Performance 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. See our editorial policies and staff. A hospitals hemorrhagic stroke patient population size is 60 cases during March. 4 0 obj Hospital Core Measures Defined - ESO CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. Hospital Inpatient Measures - QualityNet Home Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. decreased providers collection burden and cost. 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. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. 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). 1 0 obj Time from symptom onset to stroke alert is delayed in in-hospital stroke. The Perfect Care Report identifies patients that received perfect care. ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. PDF Stroke Core Stroke Measures - University of Florida %PDF-1.5 PDF Core Measures: The Nurse's Role - r N They also could require other measures. Recommended Core Measures | CMS STK-4 Thrombolytic Therapy15. endobj Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . stream Include the patient in the Initial Patient Population for the appropriate measures. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Unauthorized use prohibited. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. Refine processes and protocols to ensure they are in line with the guidelines. Updated eCQM Specifications and eCQM Materials for 2021 Reporting Now CSTK-02 Modified Rankin Score (mRS at 90 Days)3. You can use the words "AND" and "OR" along . hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. 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. This item requires a Core Return or Core Charge. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Stroke Corner - Education - neuropt.org STK-8 Stroke Education18. PDF California EMS System Core Quality Measures Instruction Manual Stroke Core Measure Data | Fort Sanders Regional Medical Center, a Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. 3 0 obj Share sensitive information only on official, secure websites. Core Measure Data as of 3/2/2022. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Percent of ischemic stroke patients who received antithrombotic therapy by the end of hospital day two. The two sub-populations must be sampled independently from each other. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. 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). Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. 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. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. 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. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ IQR Measures - Centers for Medicare & Medicaid Services Comprehensive Stroke (CSTK) (v2021A1) - Performance Measurement Network Chart Abstracted Measures for Certification. 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. endobj <> Disclaimer of Warranties and Liabilities.