Hospital Outpatient Quality Measure Stroke. 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. ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. Percent of ischemic stroke patients who received antithrombotic therapy by the end of hospital day two. Set the Initial Patient Population Reject Case Flag to equal Yes. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. <> Measures for TJC Acute Stroke Ready Center Certification, 1. Mayo Clinic does not endorse any of the third party products and services advertised. Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. Hospitals now have one place to submit both chart-abstracted and eCQM data. 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 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. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. STK-4 Thrombolytic Therapy15. You can decide how often to receive updates. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. The psychometric properties of the measures are reviewed using a modified EDGE (Evidence Database to Guide Effectiveness) template (a format recommended by the APTA EDGE task force). The required quarterly sample sizes for each sub-population would be 79 and 5. All rights reserved. 0 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. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. Find more information on our content editorial process. Time from symptom onset to stroke alert is delayed in in-hospital stroke. Nonvalvular atrial fibrillation is a common arrhythmia and an important risk factor for stroke. Heres a good reference document in case you get confused. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. The Centers for Medicare & Medicaid Services (CMS) has posted the electronic clinical quality measure ( eCQM) specifications for the 2021 reporting period for Eligible Hospitals and Critical Access Hospitals, and the 2021 performance period for Eligible Professionals and Eligible Clinicians. Part 2: A review of the different stroke certifications. . Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. 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). Set the Initial Patient Population Reject Case Flag to equal Yes. A hospitals hemorrhagic stroke patient population size is 17 cases during March. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. 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: 2012 . Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. 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. TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. The following table identifies the population . They also could require other measures. endobj decreased providers collection burden and cost. Core Measure Data as of 3/2/2022. Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. We can make a difference on your journey to provide consistently excellent care for each and every patient. 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. 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%. A single copy of these materials may be reprinted for noncommercial personal use only. ) CSTK-09 Arrival Time to Skin Puncture, 8. Q2 (April 1-June 30); Q3 (July 1-September 30); Q4 (October 1-December 31); Q1 . A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. I also included the complete list of measures required for each certification. ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. 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 Heres how you know. Part 1: A review of the different stroke measure sets. Learn how working with the Joint Commission benefits your organization and community. National Center Initial Population: Inpatient hospitalizations for patients age 18 and older . Find the exact resources you need to succeed in your accreditation journey. stream These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. *Note: There are additional measures needed to fulfill this certification. 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. This began in Fiscal Year (FY) 2014. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. Watch the "Introduction to CMIT 2.0" video to learn more about the latest features! Using the monthly 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 25 cases for the month (20% of 123 equals 24.6 rounded to the next highest whole number equals 25). A hospitals Hemorrhagic sub-population is 3 patients during January. Source: Medisolv Perfect Care Report (eff. Eleven (11) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. 1-800-AHA-USA-1 <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Using the monthy sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 14 cases for the month. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. CSTK-05 Hemorrhagic Transformation, 1. Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. Dallas, TX 75231, Customer Service 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. 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). Early rehabilitation interventions initiated following stroke can enhance the recovery process and minimize functional disability. ASR-OP-2c Ischemic Stroke; drip and ship4. 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. These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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. STK-2 Discharged on Antithrombotic Therapy5. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. *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. January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. 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. 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. 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. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. 10960 Grantchester Way, Suite 520Columbia, MD 21044. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) 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. Request Appointment Quality and Mayo Clinic Arizona Florida Minnesota Event reporting Quality measures Quality rankings Stroke Core Measure Loading chart. Disclaimer of Warranties and Liabilities. Test your ideas. 2 0 obj 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). endobj The reduction of LDL cholesterol, through lifestyle modification and drug therapy when appropriate, is recommended for the prevention of recurrent ischemic stroke, heart attack, and other major vascular events. 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). The following are Stroke eCQMs used by The Joint Commission. CSTK-05b:Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 2. The administration of anticoagulation therapy is an effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients. The most common signs and symptoms of HF are shortness of breath on exertion; orthopnea; weight gain with edema in the feet, legs, or lower back; fatigue; and weakness. STK-2 Discharged on Antithrombotic Therapy13. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. 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. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. The listed denominator criteria are used to identify the intended patient population. 3 0 obj Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. endobj 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. stream 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. 4 0 obj Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. 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. 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.
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