The ACM is a pass-fail measure at the individual patient level that asks whether an eligible patient has received all of the appropriate care for the condition for which he or she is being treated. 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. Calculate Patient Age. 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. 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. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. STK-6 Discharged on Statin Medication17. You can download it or email it to yourself to help you remember. We help you select and set up measures that make sense based on your hospitals situation. <>>>
Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. May 2021 Measure ID# Measure Short Name Measure Description STK-1 Venous Thromboembolism (VTE) This measure captures the proportion of ischemic or hemorrhagic Prophylaxis stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. Part 2: A review of the different stroke certifications. A hospitals Ischemic sub-population is 100 during the first quarter. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. Hospital Outpatient Quality Measure Stroke. U.S. Government Rights This Agreement will terminate upon notice if you violate its terms. *Note: Significant changes to this measure set begin July 1, 2021.
CSTK-06 Nimodipine Treatment Administered6. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. 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. Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. 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. lock CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture11. Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. Comprehensive Stroke (CSTK) (v2021A1) - Performance Measurement Network Monthly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 228 during March. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Start STK Initial Patient Population logic sub-routine. 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. In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. A hospitals Ischemic sub-population is 5 patients during February. . February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. This Agreement will terminate upon notice if you violate its terms. Closed on Sundays. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. The required quarterly sample is 45 cases. 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 The required quarterly sample is 45 cases. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. A hospital may choose to use a larger sample size than is required. You can use the words "AND" and "OR" along . Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. The following are Stroke eCQMs used by The Joint Commission. 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 Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. Brainstorm with your team to find ways to improve your hospital's treatment rates. The AMA does not directly or indirectly practice medicine or dispense medical services. Here is a diagram that outlines the submission differences. 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. PDF STROKE - American Heart Association stream
STK-6 Discharged on Statin Medication9. 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. 3= recommended; the outcome measure has good psychometric . This post is a guide to understanding the differences between the five major stroke measure sets. Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. 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. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB A hospitals ischemic stroke patient population size is 200 patients during the second quarter. . A hospitals ischemic stroke patient population size is 200 patients during March. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. All rights reserved. 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). Stroke Core Measure - About Us - Mayo Clinic , . STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. MjMO2n7( LBm6N.Hl#|oKP?lEF@L9ew,w\XpP{]8vxmtV}Or,kU{ `B7{"'Tf(DL[}ZEY 7'XoFo(|{%Jlv,_v}%DPnpoAucQGPy'YVJGXv:E
j5(kts,?BcBKd?R . with acute ischemic stroke in the hospital setting will submit this measure. A hospital may choose to use a larger sample size than is required. In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. Stroke Core Stroke Measures As a Certified Stroke Center the stroke committee would like to provide physicians with updates on how we are performing on the stroke performance and quality measures. 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. Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. }J Hospital Core Measures Defined - ESO 1 0 obj
Medisolv can help you along the way. 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. The required quarterly sample sizes for each sub-population would be 79 and 5. 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. Patient Age, in years, is equal to the Admission Date minus the Birthdate. endstream
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Measure ID # Measure Short Name OP-23 . Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. Initial Population: Inpatient hospitalizations for patients age 18 and older . We keep you on track for your submission deadlines and ensure you dont miss critical dates. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. 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. Using the quarterly 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 quarterly sample size, so 100% of the subpopulation or all 19 cases are sampled. 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. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 84 cases for the quarter. PDF Standardized Performance Measures for Primary Stroke Centers Time from symptom onset to stroke alert is delayed in in-hospital stroke. 2021). ( CSTK-02 Modified Rankin Score (mRS at 90 Days)3. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. Below are the list of Stroke measures by Certification Program. 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. 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. A hospitals Hemorrhagic sub-population is 3 patients during January. A hospitals hemorrhagic stroke patient population size is 295 cases during March. PDF Core Measures: The Nurse's Role - r N For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. I hope this high-level overview was helpful and can be a reference for you. Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. 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. Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. 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. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. 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. This content does not have an Arabic version. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. Its a nightmare trying to keep straight this wide range of acronym-filled information. uz'*\08 DLli_{5:G}M=}nS`M6C'{AREuw%~NM5Ydam\[\_#$
s8S@ AE"4u0qwCmWN N`h,bp``+bv\~B9M 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. Find evidence-based sources on preventing infections in clinical settings. A hospitals hemorrhagic stroke patient population size is 60 cases during March. A hospitals ischemic stroke patient population size is 200 cases during the second quarter. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. Medisolv can help you along the way. Program details are found in Part 2. Monday - Friday: 7 a.m. 7 p.m. CT endobj
Please see link below for more information. CSTK-09 Arrival Time to Skin Puncture, 8. See how our expertise and rigorous standards can help organizations like yours. Stroke (STK) (v2021B) 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 All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). The core measurescan be found at: http://www.qualityforum.org/cqmc/. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. Ongoing monitoring by the Collaborative of the use of these measures will enable modifications of measure sets, as needed and based on lessons learned, including minimizing unintended consequences and selection of new measures as better measures become available. 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. The six measures are: . STK-2 Discharged on Antithrombotic Therapy5. 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. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. Assemble your multidisciplinary team to determine roles and processes for entering patient data. STK-4 Thrombolytic Therapy10. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. This item requires a Core Return or Core Charge. Medisolv Can HelpThis is a big year for Quality. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per the sub-populations for the quarter. 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 CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. Return to Clinical Data Processing Flow in the Data Processing section. Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients An antithrombotic is a medication that prevents blood clots. STK-8 Stroke Education13. "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. Heres how you know. 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. Drive performance improvement using our new business intelligence tools. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. All rights reserved. Anticoagulation Therapy for Atrial Fibrillation/Flutter Neurology. The listed denominator criteria are used to identify the intended patient population. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. PDF Stroke Core Performance Measures HOS-Sanford Medical Center Fargo This means the patient passed every measure they qualified for. Measures for TJC Acute Stroke Ready Center Certification, 1. Remember that changes do not have to be large. In addition, stroke rehabilitation incorporates prevention and treatment of medical and mental health complications such as aspiration pneumonia, soft-tissue contractures, decubitus ulcers, infection, deep vein thrombosis (DVT), malnourishment, and depression. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. A single copy of these materials may be reprinted for noncommercial personal use only. 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.