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). An injection of TPA is usually given through a vein in the arm within the first three hours. A hospitals ischemic stroke patient population size is 200 patients during March. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. 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. 0 CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 5. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! Use the month and day portion of admission date and birthdate to yield the most accurate age. 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ 2021). <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> %PDF-1.7 CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. Below are the list of Stroke measures by Certification Program. Find the exact resources you need to succeed in your accreditation journey. %PDF-1.5 endobj 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%. Quarterly sampling for the two combined populations for Joint Commission certification purposes. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB 2021; 96:e1812-e1822 . Measure ID # Measure Short Name OP-23 . ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. Unauthorized use prohibited. The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. So, Ive attempted to structure it in a way that will be a reference for you. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. CSTK-02 Modified Rankin Score (mRS at 90 Days)3. Ready to get started with CMIT 2.0? The required quarterly sample is 45 cases. We help you select and set up measures that make sense based on your hospitals situation. This item requires a Core Return or Core Charge. <> Once a patient is qualified, he/she moves to the second part of the algorithm which tells you which sub-population he/she falls into. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. 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. CPT is a registered trademark of the American Medical Association. 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 STK-8 Stroke Education10. A hospitals hemorrhagic stroke patient population size is 17 cases during March. TARGET: STROKE MEASURE 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]. The following are Stroke eCQMs used by The Joint Commission. Calculate the Length of Stay. Today, the Core Quality Measures Collaborative (CQMC) released four updated core measure sets covering specific clinical areas as part of its mission to provide useful quality metrics as the nation's health care system moves from one that pays based on volume of services to one that pays for value. View them by specific areas by clicking here. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. 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. Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. Arrhythmia means that the heart's normal beating rhythm is interrupted. 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. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. STK-6 Discharged on Statin Medication12. 4 0 obj 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). 7272 Greenville Ave. 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 The Pathfinder Core Rulebook includes: More than 600 pages of game rules, advice, character options, treasure, and more for players and Game Masters! 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. STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. <> The following are Stroke chart abstracted measures used by The Joint Commission. a set of re-specified measures in 2019, which were updated in 2021. Measure Type: OutpatientNumber of Measures Included: There are five process measures (youll see one additional measure listed below that is not reported and one additional measure that is retired starting with July 1, 2021 discharges). 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. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. 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. We help you measure, assess and improve your performance. Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment. A hospital may choose to use a larger sample size than is required. A hospitals Ischemic sub-population is 5 patients during February. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. 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. Learn about the "gold standard" in quality. decreased providers collection burden and cost. n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! A hospitals ischemic stroke patient population size is 7 cases during March. The AMA is a third party beneficiary to this Agreement. Using the quarterly sampling table for the ischemic 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 required monthly sample is 60 cases. %PDF-1.4 % Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. Patient Age, in years, is equal to the Admission Date minus the Birthdate. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 2023 American Heart Association, Inc. All rights reserved. There are five major stroke measure sets. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. Data Source: American Heart Association Get With The Guidelines stroke database. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. In the final section, I review the way this information is submitted to The Joint Commission and CMS. <>>> The two sub-populations must be sampled independently from each other. The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. STK-5 Antithrombotic Therapy By End of Hospital Day Two16. 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. Program details are found in Part 2. ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. 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. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. {8Dm.;JHTBXEXh^^^.Y)oH 6K;ANf!;*#.\1\c"1cKE. 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. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. This is increasingly important as the health care system moves towards value-based reimbursement models. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. The required quarterly sample sizes for each sub-population would be 79 and 5. sI with acute ischemic stroke in the hospital setting will submit this measure. endstream endobj startxref Stroke Core Measure - About Us - Mayo Clinic , . 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. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. 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. STK-10 Assessed for Rehabilitation. Here I have broken it into the inpatient measure set and the outpatient measure set. 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. Using the quarterly sampling table for the Hemorrhagic sub-population, the sample size required is 20% of this sub-population, or 79 cases for the quarter (twenty percent of 392 equals 78.4 rounded up to the next whole number equals 79). Finally, I have listed a few more resources for you. 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. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. 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$a-4>b(L CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. 1-800-242-8721 x[6 >tK(E4.z~bK[K6IL[Ev9$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#. 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. endstream endobj 647 0 obj <>/Metadata 18 0 R/Pages 644 0 R/StructTreeRoot 24 0 R/Type/Catalog/ViewerPreferences<>>> endobj 648 0 obj <>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 1/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 649 0 obj <>stream 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. <> Using the quarterly sampling table for the Ischemic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. A modified sampling procedure is required for hospitals performing quarterly sampling for STK. Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. 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. Saturday: 9 a.m. - 5 p.m. CT Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter. The American Medical Association reserves all rights to approve any license with any Federal agency. 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. OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. By not making a selection you will be agreeing to the use of our cookies. This consensus core set was further discussed by all Collaborative members before being finalized. 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. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. Joint Commission Clinical Measures. Official websites use .govA Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter.

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