CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. 4 0 obj The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. 3 0 obj 3 0 obj STK-1 Venous Thromboembolism (VTE Prophylaxis)7. or Calculate Patient Age. Share sensitive information only on official, secure websites. Mayo Clinic does not endorse any of the third party products and services advertised. For the purposes of this blog, since we are focusing specifically on stroke measures, there is only one stroke measure that is used for Accreditation purposes by both CMS and TJC: OP-23. a set of re-specified measures in 2019, which were updated in 2021. Chart-abstracted measures specificationsScreen Reader Text. Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. 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. Patients admitted to the hospital for inpatient acute care are included in the CSTK 3-Hemorrhagic Stroke subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.2, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. 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. Set the Initial Patient Population Reject Case Flag to equal Yes. endobj Measure ID # Measure Short Name OP-23 . 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. Test your ideas. Q2 (April 1-June 30); Q3 (July 1-September 30); Q4 (October 1-December 31); Q1 . <> 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. Ready to get started with CMIT 2.0? Source: Medisolv Perfect Care Report (eff. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. Monday - Friday: 7 a.m. 7 p.m. CT Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. TARGET: STROKE MEASURE Door to IV rt-PA in 60 minutes (Historic-Quality): Percent of ischemic stroke patients receiving IV t-PA at your hospital who are treated within 60 minutes after triage (ED arrival). Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. The following are Stroke chart abstracted measures used by The Joint Commission. <> 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. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received A hospitals ischemic stroke patient population size is 200 patients during March. Contact Us, Hours STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. Brainstorm with your team to find ways to improve your hospital's treatment rates. STK-6 Discharged on Statin Medication17. Calculate the Length of Stay. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. Return to Clinical Data Processing Flow in the Data Processing section. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 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 goal is to quickly get rid of any blood clot(s) to restore function to the area that is impacted by a stroke, such as the brain. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. 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 six measures are: . STK-5 Antithrombotic Therapy By End of Hospital Day Two8. Understanding Stroke Measure Sets - f.hubspotusercontent30.net Saturday: 9 a.m. - 5 p.m. CT A hospitals Ischemic sub-population is 316 during January. https:// 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 . 1-800-AHA-USA-1 STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. A single copy of these materials may be reprinted for noncommercial personal use only. Process all cases that have successfully reached the point in the Clinical Data Processing Flow which calls this Initial Patient Population Algorithm. %%EOF Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)7. STK-1 Venous Thromboembolism (VTE Prophylaxis)12. 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. 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. ASR-OP-2b Hemorrhagic Stroke3. The AMA does not directly or indirectly practice medicine or dispense medical services. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 20% of this subpopulation or 26 cases for the month (20% of 129 equals 25.8 rounded to the next highest whole number equals 26). A hospitals ischemic stroke patient population size is 495 cases during the second quarter. }J Using the monthly sampling table for the Ischemic sub-population, the sample size required is 20% of this sub-population, or 46 cases for the quarter (twenty percent of 228 equals 45.6 rounded up to the next whole number equals 46). We keep you on track for your submission deadlines and ensure you dont miss critical dates. The AMA is a third party beneficiary to this Agreement. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Dallas, TX 75231, Customer Service This means the patient passed every measure they qualified for. CSM special February 2021 Motor planning after stroke CSM special January 2021 January 2021 Stroke SIG and CSM 2 January 2021 Stroke SIG and CSM January 2021, Locomotor Podcast - Intensity and stepping. CSTK-09 Arrival Time to Skin Puncture, 8. 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. Unauthorized use prohibited. Official websites use .govA Measures for TJC Acute Stroke Ready Center Certification, 1. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. Find more information on our content editorial process. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Designed to be meaningful to patients, consumers, and physicians, the alignment of these core measure sets will aid in: CMS believes that by reducing burden on providers and focusing quality improvement on key areas across payers, quality of care can be improved for patients more effectively and efficiently. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 17 cases are sampled. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. Sixty (60) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. 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. 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. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. A hospitals hemorrhagic stroke patient population size is 295 cases during March. A hospitals Ischemic sub-population is 5 patients during the first quarter. Dude JA, Lohse KR, Cramer SC, Worrall BB; GPAS Collaboration Phenotyping Core. See how our expertise and rigorous standards can help organizations like yours. 2021; 96:e1812-e1822 . Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment. Find more information on our content editorial process. To search the historic measure inventory, enter one or more terms in the search box and hit enter or click the search button. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Core measures are based on the most common condition's hospitals see, such as acute myocardial infarction (AMI), heart failure (HF), pneumonia, surgical care, children's asthma care, venous thromboembolism (VTE), stroke, and more. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. 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-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). A modified sampling procedure is required for hospitals performing quarterly sampling for STK. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. Please see link below for more information. You can decide how often to receive updates. See our editorial policies and staff. %PDF-1.5 ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. A hospitals ischemic stroke patient population size is 200 cases during the second quarter. 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. Core Measure Data as of 3/2/2022. There are no Stroke eCQMs applicable or available for Certification purposes. *7.`"}K3t;qBEN]1F"9V>7[?)] 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 Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. 1 0 obj STK-10 Assessed for Rehabilitation. 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. A hospital may choose to use a larger sample size than is required. But hospitals see benefits as well. CMIT searches all fields in the inventory and is not case-sensitive. 2021). Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. So, Ive attempted to structure it in a way that will be a reference for you. 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. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. Remember that changes do not have to be large. CSM 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. The AMA is a third party beneficiary to this Agreement. A hospitals ischemic stroke patient population size is 129 cases during March. The final clinical diagnosis is used to identify the measure population. The AMA does not directly or indirectly practice medicine or dispense medical services. Initial Population: Inpatient hospitalizations for patients age 18 and older . CSTK-09 Arrival Time to Skin Puncture, 1. We help you measure, assess and improve your performance. 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. 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). x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. 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. To address this problem, the Centers for Medicare & Medicaid Services (CMS), commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations, and consumers worked together through the Core Quality Measures Collaborative to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible. CSTK-02 Modified Rankin Score (mRS at 90 Days)3. % Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. This began in Fiscal Year (FY) 2014. Quarterly sampling for the two combined populations for Joint Commission certification purposes. <> Set the Initial Patient Population Reject Case Flag to equal Yes. The following are the list of required chart-abstracted stroke measures for each certification program. A hospitals Hemorrhagic sub-population is 3 patients during January. n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! Measure 6a is new and is being pilot tested in 2009. 2021; 97: . Using the notice and public comment rule-making process, CMS also intends to implement new core measures across applicable Medicare quality programs as appropriate, while eliminating redundant measures that are not part of the core set. A hospitals hemorrhagic stroke patient population size is 129 cases during March. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. % STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**4. Using the quarterly sampling table for the Hemorrhagic sub-population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. CSTK-09b Time (in minutes) from hospital arrival to skin puncture in patients with acute ischemic stroke who present directly to your hospital and undergo endovascular treatment, 6. A hospitals ischemic stroke patient population size is 392 cases during the second quarter. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. CPT is provided as is without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Studies at this time suggest that antithrombotic therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce stroke mortality and morbidity. By not making a selection you will be agreeing to the use of our cookies. Commercial health plans are rolling out the core measures as part of their contract cycle. R,A`=N T$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 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. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. All rights reserved. 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. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 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. An antithrombotic is a medication that prevents blood clots. The Pathfinder Core Rulebook includes: More than 600 pages of game rules, advice, character options, treasure, and more for players and Game Masters! Use the month and day portion of admission date and birthdate to yield the most accurate age. 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. 4 0 obj You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT.

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