ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. 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. CPT only copyright 2019 American Medical Association. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . 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. Heres how you know. Chart-abstracted measures specificationsScreen Reader Text. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. 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. The next measure set we review is abbreviated ASR-IP/OP. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. See how our expertise and rigorous standards can help organizations like yours. Centers for Medicare and Medicaid Services Measures Inventory Tool 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. All rights reserved. 1-800-AHA-USA-1 Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. These core measure sets are a major step forward for alignment of quality measures between public and private payers and provides a framework upon which future efforts can be based. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Stroke Performance Measure 1: VTE Prophylaxis (ischemic and hemorrhagic stroke patients who received 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. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. Sometimes it works best to start small and build on success. 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$Ae[BvzWR?y'1XV%^m#. The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). CSM special February 2021 Motor planning after stroke CSM special January 2021 January 2021 Stroke SIG and CSM 2 January 2021 Stroke SIG and CSM January 2021, Locomotor Podcast - Intensity and stepping. Dallas, TX 75231, Customer Service U.S. Government Rights There are no Stroke eCQMs applicable or available for Certification purposes. A hospitals Ischemic sub-population is 100 during the first quarter. Measures for TJC Acute Stroke Ready Center Certification, 1. To address this problem, the Centers for Medicare & Medicaid Services (CMS), commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations, and consumers worked together through the Core Quality Measures Collaborative to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible. ruTv?U J4lUBex(a8{g$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 . Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients 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. Learn how working with the Joint Commission benefits your organization and community. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Measure Type: InpatientNumber of Measures Included: 3 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Measure Type: OutpatientNumber of Measures Included: 2 process measuresCertification Requirement: The Joint Commissions Disease-Specific Care Certification, Door to Transfer to Another Hospital**RETIRED Effective July 1, 2021**, Note: All Joint Commission certified acute stroke ready hospitals, as well as those seeking initial certification, will be required to collect the STK-OP-1 Door to Transfer to Another Hospital measure for discharges on and after July 1, 2021. 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. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. Set the Initial Patient Population Reject Case Flag to equal Yes. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population. Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). The CMS Measure Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to promote healthcare quality and quality improvement. %%EOF January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. A hospital may choose to use a larger sample size than is required. IQR Measures - Centers for Medicare & Medicaid Services It is important to always refer to the latest edition. Regulatory/AccreditationExamples would include the Center for Medicare & Medicaid Services (CMS) required core measures (e.g., fibrinolytic therapy received within 30 minutes of emergency department (ED) arrival, aspirin at arrival) and documentation of Joint Commission standard achievement. /'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 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. Stroke Corner - Education - neuropt.org Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. endobj All rights reserved. There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, physicians and other clinicians, and policymakers. 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. 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. CPT only copyright 2019 American Medical Association. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Core Rulebook (disambiguation) This is a disambiguation page; that is, one that points to other pages that might otherwise have the same name.Pathfinder 2E.Expand your capabilities by selecting general feats that improve your statistics or give you. 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). A hospitals Ischemic sub-population is 316 during January. The following are Stroke eCQMs used by The Joint Commission. Stroke is a leading cause of serious, long-term disability in the United States. Each measure includes patients from one or more categories. lock Heart Attack), Pneumonia, and Surgical Site Infection prevention. endobj A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. The six measures are: . STK-OP-1a Overall Rate (Not Reported2. 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. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. Q2 (April 1-June 30); Q3 (July 1-September 30); Q4 (October 1-December 31); Q1 . You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. In the final section, I review the way this information is submitted to The Joint Commission and CMS. 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. lock But hospitals see benefits as well. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. In the specifications manual, Version 2021B, it is in Section 7: Joint Commission National Quality Measures Data Processing, Joint Commission Stroke Measures table: https://manual.jointcommission.org/releases/TJC2021B/TransmissionChapterTJC.html. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. Eleven (11) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). STK-2 Discharged on Antithrombotic Therapy13. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. *** 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. Return to Clinical Data Processing Flow in the Data Processing section. Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. Unauthorized use prohibited. This Agreement will terminate upon notice if you violate its terms. Since the program's start in 2003, over 2,000hospitals have entered more than 5million patient records into the Get With The Guidelines- Stroke database. The required quarterly sample is 45 cases. Commercial health plans are rolling out the core measures as part of their contract cycle. The required quarterly sample is 45 cases. One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. A hospitals ischemic stroke patient population size is 200 patients during the second quarter. Hospitals report on these measures quarterly or monthly, and compliance can affect TJC accreditation and CMS . ( This means the patient passed every measure they qualified for. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. STK-6 Discharged on Statin Medication12. 690 0 obj <>stream Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. An antithrombotic agent is a drug that reduces the formation of blood clots. The median number of Adult Core Set measures reported by states is 22.5 measures for FFY 2019, up from 20 measures reported for FFY 2018 and 17 measures for FFY 2017. 671 0 obj <>/Filter/FlateDecode/ID[<8968A4F338E55446928FCF4A155C4BC8>]/Index[646 45]/Info 645 0 R/Length 114/Prev 86415/Root 647 0 R/Size 691/Type/XRef/W[1 2 1]>>stream 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. What is wrong with these people making it so complicated for us? CQMC will release four additional updated core measure sets and two new core measure sets over the coming months. Percent of ischemic stroke patients who received antithrombotic therapy by the end of hospital day two. 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. 2023 Medisolv, Inc. All Rights Reserved. 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. Contact Us, Hours Stroke patients are at increased risk of developing venous thromboembolism (deep vein blood clots). Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. 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). A hospitals ischemic stroke patient population size is 70 cases during March. 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . 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. 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. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! The Differences Between The 5 Major Stroke Measure Sets - Medisolv Download Get With The Guidelines- Stroke fact sheets and forms here. 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. A hospitals Ischemic sub-population is 5 patients during February. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. Updated eCQM Specifications and eCQM Materials for 2021 Reporting Now CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. Set expectations for your organization's performance that are reasonable, achievable and survey-able. The required monthly sample is 60 cases. 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 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. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. 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. Medisolv can help you along the way. %PDF-1.4 % 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). You can decide how often to receive updates. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. 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. We keep you on track for your submission deadlines and ensure you dont miss critical dates. 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. Anticoagulation therapy is a course of drug therapy in which medications are administered to a patient to slow the rate at which the patient's blood clots. ) Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. This began in Fiscal Year (FY) 2014. hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! Part 1: A review of the different stroke measure sets. In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. 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. Development of Stroke Performance Measures | Stroke %PDF-1.5 To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). The Differences Between The 5 Major Stroke Measure Sets, Thrombolytic Therapy: Inpatient Admission, Antithrombotic Therapy By End of Hospital Day 2, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible, Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship), CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only, CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), 1. The required quarterly sample is 60 cases. CSTK-09 Arrival Time to Skin Puncture, 1. % STK-OP-1g Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible**ADDED as of 7/1/2021**8. Here I have broken it into the inpatient measure set and the outpatient measure set. PDF Standardized Performance Measures for Primary Stroke Centers STK-8 Stroke Education10.
