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 7272 Greenville Ave. STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) **RETIRED 7/1/2021**4. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. There are no Stroke eCQMs applicable or available for Certification purposes. STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. Dallas, TX 75231, Customer Service Please see link below for more information. 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. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. Of FSRMC patients treated with tPA, a clot-dissolver, or who underwent a procedure to retrieve a blood clot, 2.4% experienced complications, compared to the national average complication rate of 6.8%. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. CPT is a registered trademark of the American Medical Association. The required quarterly sample size for the CSTK-01 measure is a minimum of 84 cases (42 cases from Table 1 plus 42 cases from Table 2 equals 84). CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 42 cases for the quarter. The required quarterly sample is 45 cases. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! You receive one consultant that you can call anytime with questions or concerns. Find the exact resources you need to succeed in your accreditation journey. Set the Initial Patient Population Reject Case Flag to equal Yes. Find more information on our content editorial process. 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 A hospitals ischemic stroke patient population size is 295 cases during March. 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. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. Measures for TJC Acute Stroke Ready Center Certification, 1. 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. Unauthorized use prohibited. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. The following are the list of required chart-abstracted stroke measures for each certification program. Youll see them abbreviated like this: Measure Type: InpatientNumber of Measures Included: 10Certification Requirement: The Joint Commissions Comprehensive Stroke Certification. Medisolv Can HelpThis is a big year for Quality. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. Saturday: 9 a.m. - 5 p.m. CT <> A hospitals ischemic stroke patient population size is 392 cases during the second quarter. A hospitals hemorrhagic stroke patient population size is 295 cases during March. A single copy of these materials may be reprinted for noncommercial personal use only. 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 treatment, 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, Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH ), 2. We help troubleshoot technical and clinical issues to improve your measures. endobj Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ *{o7@FNhR/ 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. Find more information on our content editorial process. endobj Calculate the Length of Stay. Quarterly sampling for the two combined populations for Joint Commission certification purposes. stream 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. February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. Find evidence-based sources on preventing infections in clinical settings. Patient Age, in years, is equal to the Admission Date minus the Birthdate. Quarterly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 392 during the first quarter. 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. STK-8 Stroke Education10. Calculate Patient Age. lock *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. 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. This means the patient passed every measure they qualified for. hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ 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. 3= recommended; the outcome measure has good psychometric . Understanding Stroke Measure Sets - f.hubspotusercontent30.net Major causes of HF are coronary artery disease, high blood pressure, and diabetes. STK-2 Discharged on Antithrombotic Therapy13. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. STK-1 Venous Thromboembolism (VTE Prophylaxis)12. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. 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. 4 0 obj The American Medical Association reserves all rights to approve any license with any Federal agency. Submission of aggregate data is still required. STK-6 Discharged on Statin Medication9. A hospitals Ischemic sub-population is 316 during January. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. <>>> Percent of ischemic stroke patients with atrial fibrillation or atrial flutter who are prescribed anticoagulation therapy at hospital discharge. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. These updated core sets are a result of months of consensus-based review and deliberation among the groups 75+ multi-stakeholder member organizations, evaluating hundreds of existing quality measures against the CQMCs rigorous criteria. 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. 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. It is difficult to have actionable and useful information because physicians and other clinicians must currently report multiple quality measures to different entities. The Duke Health system tracks and measures the care we provide to our patients based on these quality measures. 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]. The six measures are: . means youve safely connected to the .gov website. 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 129 cases during March. The AMA does not directly or indirectly practice medicine or dispense medical services. A hospital may choose to use a larger sample size than is required. 4 0 obj CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. endstream endobj startxref Return to Clinical Data Processing Flow in the Data Processing section. 2021; 97: . Return to Clinical Data Processing Flow in the Data Processing section. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. ) Program details are found in Part 2. STK-OP-1b Hemorrhagic Strok3. 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). 2018 - 2021. It is important to always refer to the latest edition. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. 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. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. 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. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 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). 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). website belongs to an official government organization in the United States. STK-8 Stroke Education18. Return to Clinical Data Processing Flow in the Data Processing section. % TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. %%EOF Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter.

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