Especially if you use an EHR vendor right now, youll notice a huge difference. A hospitals hemorrhagic stroke patient population size is 295 cases during March. 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. STK-10 Assessed for Rehabilitation, Measures for TJC Comprehensive Stroke Center Certification, 1. 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. Comprehensive Core Stroke Measures were developed for the management of both ischemic and hemorrhagic stroke patients in hospitals equipped with clinical expertise, infrastructure, and specialized neurointerventional and imaging services needed to provide a higher level of stroke care. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. 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. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Using the monthly sampling table for the Hemorrhagic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. 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. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this Agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. *** AHRQ is the measure steward for the survey instrument in the Adult Core Set (NQF #0006) and NCQA is the developer of the survey administration protocol. A hospitals Ischemic sub-population is 316 during January. 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. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. To submit a research proposal for the Get With The Guidelines- Stroke program, email a completed Get With The Guidelines Data Request Form (download) to [emailprotected]. Using the monthly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 11 cases are sampled. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. CSTK-09 Arrival Time to Skin Puncture, 1. Measures for TJC Acute Stroke Ready Center Certification, 1. Using the quarterly sampling table for the Hemorrhagic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. View them by specific areas by clicking here. This item requires a Core Return or Core Charge. This began in Fiscal Year (FY) 2014. A hospitals ischemic stroke patient population size is 7 cases during March. 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 stroke subpopulation, the sample size required is 28 cases for the month. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. 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. See how our expertise and rigorous standards can help organizations like yours. Program details are found in Part 2. They are responsible for making the necessary updates to the measure and for informing NQF (National Quality Forum) about any changes that are made to the measure on an annual basis. These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. Stroke Core Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 . Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. % Researchers also have the opportunity to conduct investigator-led research projects using data from the Get With The Guidelines- Stroke program. Arrhythmia means that the heart's normal beating rhythm is interrupted. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. 4 0 obj ASR-IP-3: Discharged on Antithrombotic Therapy4. Remember that changes do not have to be large. 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. Here I have broken it into the inpatient measure set and the outpatient measure set. <> If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation. Return to Clinical Data Processing Flow in the Data Processing section. Find more information on our content editorial process. n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! 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. We keep you on track for your submission deadlines and ensure you dont miss critical dates. %PDF-1.5 STK-10 Assessed for Rehabilitation. A hospital may choose to use a larger sample size than is required. The American Medical Association reserves all rights to approve any license with any Federal agency. 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. Test your ideas. So, Ive attempted to structure it in a way that will be a reference for you. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). STK-4 Thrombolytic Therapy15. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. CMS will go through a public notice and comment rule-making for implementation of these core sets and looks forward to public input on the measures included in these core measure sets. 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. Understanding Stroke Measure Sets - f.hubspotusercontent30.net Twenty (20) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. 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). 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 . National Center January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> STK-OP-1a Overall Rate (Not Reported2. . CSTK-05 Hemorrhagic Transformation, 1. Find more information on our content editorial process. An antithrombotic is a medication that prevents blood clots. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. 4 0 obj STK-4 Thrombolytic Therapy7. 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. https:// 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. 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Reports, http://www.qualityforum.org/CQMC_Core_Sets.aspx. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. 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. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this Agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. Using the quarterly sampling table for the hemorrhagic 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). Refine processes and protocols to ensure they are in line with the guidelines. 2 0 obj 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. Heres how you know. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). Return to Clinical Data Processing Flow in the Data Processing section. 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 All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. But hospitals see benefits as well. Official websites use .govA Visit: . decreased providers collection burden and cost. REMINDER: Stroke is now a Core Measure for CMS!!! CSM 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. %%EOF In addition, the public may compare specific healthcare organizations' results on Core Measures at the 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). 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 What is wrong with these people making it so complicated for us? hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Calculate the Length of Stay. 3= recommended; the outcome measure has good psychometric . You can download it or email it to yourself to help you remember. 3 0 obj A hospitals hemorrhagic stroke patient population size is 17 cases during March. Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. Share sensitive information only on official, secure websites. In this post we are either referencing CMS or The Joint Commission as the Measure Stewards. 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. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. <>>> *Note: Significant changes to this measure set begin July 1, 2021. Patient Age, in years, is equal to the Admission Date minus the Birthdate. endobj ASR-OP-2b Hemorrhagic Stroke3. Each measure includes patients from one or more categories. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. STK-8 Stroke Education18. 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. Calculate Patient Age. STK-2 Discharged on Antithrombotic Therapy5. Its a nightmare trying to keep straight this wide range of acronym-filled information. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. JoAnne has a background in Quality Management and has been working with hospitals on their Core Measures compliance with CMS and The Joint Commission since 2008. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. If the Principal Diagnosis code falls on Table 8.1 it will be placed in the Ischemic Stroke, or sub-pop 1 and if it has a Principal Diagnosis code that falls on Table 8.2, then it will be placed in the Hemorrhagic Stroke or sub-pop-2. 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. }J Part 2: A review of the different stroke certifications. Percent of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well. 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. Ready to get started with CMIT 2.0? ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). The listed denominator criteria are used to identify the intended patient population. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5 @/K6jPw*sfoqW}"3v}qCmqytT_.NnwT*_kL?hokU^dU2h=>tLi Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. CSTK-09a Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who are transferred from another hospital and undergo endovascular treatment2. Here is a diagram that outlines the submission differences. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. The guiding principles used by the Collaborative in developing the core measure sets are that they be meaningful to patients, consumers, and physicians, while reducing variability in measure selection, collection burden, and cost. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. 1-800-242-8721 CMS is already using measures from the each of the core sets. 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. 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. Especially if you use an EHR vendor right now, youll notice a huge difference. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. 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. uz'*\08 DLli_{5:G}M=}nS`M6C'{AREuw%~NM5Ydam\[\_#$ s8S@ AE"4u0qwCmWN N`h,bp``+bv\~B9M CSTK-09b Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who present directly to your hospital and undergo endovascular treatment, 6. STK-2 Discharged on Antithrombotic Therapy8. The required sample size for the CSTK-01 measure is a minimum of 42 cases for the month (28 cases from Table 4 plus 14 cases from Table 5 equals 42). Once a patient is qualified, he/she moves to the second part of the algorithm which tells you which sub-population he/she falls into. Clinical practice guidelines for the prevention of VTE recommend the use of preventive therapies in at-risk patients. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. x[6 >tK(E4.z~bK[K6IL[Ev9$g8oon_G|&"JLEE DFowJEM/7^G7Zt]kv\}{\](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#. The numerator options included in this 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.
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