stroke core measures 2021

A hospitals hemorrhagic stroke patient population size is 295 cases during March. 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). . These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Part 1: A review of the different stroke measure sets. CMIT searches all fields in the inventory and is not case-sensitive. 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. endobj x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) STK-6 Discharged on Statin Medication17. The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. 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. Learn more about the communities and organizations we serve. This Agreement will terminate upon notice if you violate its terms. Heres how you know. This Agreement will terminate upon notice if you violate its terms. Find more information on our content editorial process. }J 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). For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form(PDF). Saturday: 9 a.m. - 5 p.m. CT Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. with acute ischemic stroke in the hospital setting will submit this measure. 3 0 obj %PDF-1.4 % 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. Download Get With The Guidelines- Stroke fact sheets and forms here. CMS is already using measures from the each of the core sets. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. 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#. Learn how working with the Joint Commission benefits your organization and community. 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. 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. endobj Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only3. A hospitals ischemic stroke patient population size is 70 cases during March. The final clinical diagnosis is used to identify the measure population. 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). 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. All rights reserved. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. 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%. Measure Set Stroke Measure ID # STR-1 Measure Name Prehospital Screening for Suspected Stroke Patients Written by American Heart Association editorial staff and reviewed by science and medicine advisers. 2 0 obj Learn about the priorities that drive us and how we are helping propel health care forward. CSTK-03 Severity Measurement Performed for SAH and ICH Patients (Overall Rate)3. Find more information on our content editorial process. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. 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. stroke patients receiving IV t-PA at your hospital who are treated within 45 minutes after triage (ED arrival). 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. The required quarterly sample is 45 cases. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. 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. Start STK Initial Patient Population logic sub-routine. <> A hospital may choose to use a larger sample size than is required. TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. %PDF-1.5 Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. The listed denominator criteria are used to identify the intended patient population. Sometimes it works best to start small and build on success. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. Program details are found in Part 2. Commercial health plans are rolling out the core measures as part of their contract cycle. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> STK-2 Discharged on Antithrombotic Therapy13. By not making a selection you will be agreeing to the use of our cookies. STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. REMINDER: Stroke is now a Core Measure for CMS!!! 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. The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. Measure 6a is new and is being pilot tested in 2009. CSTK-05b: Hemorrhagic Transformation Patients Treated with Intra-Arterial (IA) Thrombolytic (t-PA) Therapy or Mechanical Endovascular Reperfusion Therapy, 4. Below are the list of Stroke measures by Certification Program. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. %PDF-1.7 Electronic Clinical Quality Measures (eCQMs) for Accreditation, Chart Abstracted Measures for Accreditation, Electronic Clinical Quality Measures (eCQMs) for Certification. 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. 2023 Medisolv, Inc. All Rights Reserved. Core Measure Data as of 3/2/2022. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. Disclaimer of Warranties and Liabilities. It is important to always refer to the latest edition. 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). 690 0 obj <>stream Monday - Friday: 7 a.m. 7 p.m. CT Stroke Core Stroke Measures As a Certified Stroke Center the stroke committee would like to provide physicians with updates on how we are performing on the stroke performance and quality measures. 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 sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. The AMA is a third party beneficiary to this Agreement. m/P]H(ZVk[/ "+TPy9|9J1C0.ZOK_i@"$B'r~-("tNZmO}cv!eB You can download it or email it to yourself to help you remember. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. website belongs to an official government organization in the United States. This consensus core set was further discussed by all Collaborative members before being finalized.

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