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 AMA does not directly or indirectly practice medicine or dispense medical services. >ob=AOtVt. website belongs to an official government organization in the United States. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. Assemble your multidisciplinary team to determine roles and processes for entering patient data. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. with acute ischemic stroke in the hospital setting will submit this measure. 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). 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. CSTK-06 Nimodipine Treatment Administered6. Chart-abstracted measures specificationsScreen Reader Text. Studies at this time suggest that antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity. <> Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . STK-1 Venous Thromboembolism (VTE Prophylaxis)4. hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ ASR-IP-3: Discharged on Antithrombotic Therapy4. STK-8 Stroke Education18. STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). The required quarterly sample is 45 cases. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. The AMA is a third party beneficiary to this Agreement. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> ruTv?U J4lUBex(a8{g$CHj ~>-z I&8:+hlvM(XdvY;D|BOl,Yu'D> YR9Gbl6GrJ8'},^V)\i/0 Gg:} >!81I88{'swe )I6v#{$&YymLyn\tl S3r6.o?x@q$_1A=U$H3%QUx . % 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. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB https:// Heres a good reference document in case you get confused. 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. stream ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. }J Patient Age, in years, is equal to the Admission Date minus the Birthdate. 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. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 37 cases are sampled. The following are Stroke chart abstracted measures used by The Joint Commission. We help troubleshoot technical and clinical issues to improve your measures. Start STK Initial Patient Population logic sub-routine. I also included the complete list of measures required for each certification. CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. 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. Using the quarterly sampling table for the Ischemic 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). Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. 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. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. A hospitals ischemic stroke patient population size is 295 cases during March. This content does not have an Arabic version. Heart Attack), Pneumonia, and Surgical Site Infection prevention. 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. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. 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. 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. Time from symptom onset to stroke alert is delayed in in-hospital stroke. 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). We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. CSM Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Arrhythmia means that the heart's normal beating rhythm is interrupted. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. 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. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. CMIT searches all fields in the inventory and is not case-sensitive. Find more information on our content editorial process. 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. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. A hospitals ischemic stroke patient population size is 70 cases during March. 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. 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. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. 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). STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 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 These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. 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. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. PDF Stroke Performance Measures - Centers for Disease Control and Prevention <>>> Measures that include patient and/or caregiver engagement Adult Recommended Core Measures Controlling High Blood Pressure Use of High-Risk Medications in the Elderly Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Use of Imaging Studies for Low Back Pain Centers for Medicare and Medicaid Services Measures Inventory Tool This post is a guide to understanding the differences between the five major stroke measure sets. Commercial health plans are rolling out the core measures as part of their contract cycle. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. 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. Domain-specific outcomes for stroke clinical trials: what the modified Rankin isn't ranking. 3 0 obj This is increasingly important as the health care system moves towards value-based reimbursement models. Anticoagulation Therapy for Atrial Fibrillation/Flutter Neurology. lock A hospitals ischemic stroke patient population size is 200 patients during March. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. A hospitals Ischemic sub-population is 5 patients during the first quarter. Implementing International Standards of Practice in A Low Resource Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. CSTK-09b Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who present directly to your hospital and undergo endovascular treatment, 6. % means youve safely connected to the .gov website. hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji A hospitals hemorrhagic stroke patient population size is 200 cases during the second quarter. 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. We keep you on track for your submission deadlines and ensure you dont miss critical dates. Measure 6a is new and is being pilot tested in 2009. Learn about the priorities that drive us and how we are helping propel health care forward. hbspt.cta._relativeUrls=true;hbspt.cta.load(491484, '41fd9d46-8610-4a5f-a135-c143fe55a31f', {"useNewLoader":"true","region":"na1"}); By JoAnne Marino April 30, 2021 Regulatory Updates: Hospital. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. <>>> *All health/medical information on this website has been reviewed and approved by the American Heart Association, based on scientific research and American Heart Association guidelines. Drive performance improvement using our new business intelligence tools. 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. All rights reserved. A hospitals ischemic stroke patient population size is 129 cases during March. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the month. Research projects are hypothesis-driven studies that are developed into manuscripts suitable for peer-reviewed publication. STK-10 Assessed for Rehabilitation. CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. *7.`"}K3t;qBEN]1F"9V>7[?)] An injection of TPA is usually given through a vein in the arm within the first three hours. 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). n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! The following table identifies the population . ASR-OP-2c Ischemic Stroke; drip and ship4. 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. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Sometimes it works best to start small and build on success. Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. STK-OP-1b Hemorrhagic Strok3. In the final section, I review the way this information is submitted to The Joint Commission and CMS. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. A hospitals Hemorrhagic sub-population is 100 during the first quarter. Visit: . Understanding Stroke Measure Sets - f.hubspotusercontent30.net Comprehensive Stroke (CSTK) (v2021A1) Home Comprehensive Stroke (CSTK) Comprehensive Stroke (CSTK) On this page: Comprehensive Stroke (CSTK) Initial Patient Population Monthly Sampling Sample Size Examples Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**4. 10960 Grantchester Way, Suite 520Columbia, MD 21044. 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . 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. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. Clinical Measures Outcomes | Cleveland Clinic Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. So, Ive attempted to structure it in a way that will be a reference for you. PDF Hospital OQR Quality Measures and Timelines for CY 2021 Payment The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! Monday - Friday: 7 a.m. 7 p.m. CT CSTK-02 Modified Rankin Score (mRS at 90 Days)3. 2022 Hospital IQR Requirements - Medisolv Create your baseline by entering 30 records into the Patient Management Tool. Part 2: A review of the different stroke certifications. Patients admitted to the hospital for inpatient acute care are included in the CSTK 1-Ischemic Stroke Without Procedure subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. TJC is adding three additional measures beginning with July 1, 2021 discharges.Certification Requirement: The Joint Commissions Primary Stroke Certification, Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible **ADDED as of 7/1/2021**, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, Measure Type: OutpatientNumber of Measures Included: 1 process measureAccreditation Requirement: CMS Outpatient Quality Reporting program. STK-6 Discharged on Statin Medication12. Especially if you use an EHR vendor right now, youll notice a huge difference. U.S. Government Rights Monthly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 228 during March. Using the monthly sampling table for the Ischemic sub-population, the sample size is less than the minimum required monthly sample size, so 100% of this sub-population is sampled. "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. ASR-OP-2b Hemorrhagic Stroke3. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. If the Patient Age is less than 18 years, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. Data collection for STK-OP-1 will replace ASR-OP-2. CPT is a registered trademark of the American Medical Association. 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 nations health care system moves from one that pays based on volume of services to one that pays for value. January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. Use the month and day portion of admission date and birthdate to yield the most accurate age. The final clinical diagnosis is used to identify the measure population. To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. Joint Commission Clinical Measures. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Using the monthly sampling table for the Hemorrhagic 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). Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. Heres how you know. Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. The coalition was convened in 2015 by Americas Health Insurance Providers (AHIP) and the Centers for Medicare & Medicaid Services (CMS) and is housed at the National Quality Forum (NQF). 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. 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.
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