Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. 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. 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). . Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. 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. These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. 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). There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size required is 84 cases for the quarter. U.S. Government Rights REMINDER: Stroke is now a Core Measure for CMS!!! Hospital Outpatient Quality Measure Stroke. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. STK-8 Stroke Education13. STK-6 Discharged on Statin Medication9. STK-1 Venous Thromboembolism (VTE Prophylaxis)12. Forty states reported at least half (16) of the Adult Core Set measures for FFY 2019. A hospitals ischemic stroke patient population size is 200 cases during the second quarter. 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]. STK-5 Antithrombotic Therapy By End of Hospital Day Two16. Calculate Patient Age. JoAnne has a background in Quality Management and has been working with hospitals on their Core Measures compliance with CMS and The Joint Commission since 2008. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. 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. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. They also could require other measures. 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. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. Understanding core measures for heart-failure treatment - American Nurse PDF Quality ID #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy The American Medical Association reserves all rights to approve any license with any Federal agency. Especially if you use an EHR vendor right now, youll notice a huge difference. We help you measure, assess and improve your performance. % <>/Metadata 285 0 R/ViewerPreferences 286 0 R>> The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. 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 . The American Medical Association reserves all rights to approve any license with any Federal agency. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. The final clinical diagnosis is used to identify the measure population. See our editorial policies and staff. PDF Stroke Core Stroke Measures - University of Florida Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. x[o ?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. endobj %PDF-1.4 % Set the Initial Patient Population Reject Case Flag to equal Yes. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. Neurology. A hospitals ischemic stroke patient population size is 200 patients during March. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). 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. 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. An official website of the United States government I also included the complete list of measures required for each certification. The AMA does not directly or indirectly practice medicine or dispense medical services. In addition, the public may compare specific healthcare organizations' results on Core Measures at the It is important to always refer to the latest edition. Initial Population: Inpatient hospitalizations for patients age 18 and older . endobj Monthly sampling for the Ischemic sub-population: A hospitals Ischemic sub-population is 228 during March. Unauthorized use prohibited. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. 2023 American Heart Association, Inc. All rights reserved. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. IQR Measures - Centers for Medicare & Medicaid Services Percent of ischemic stroke patients who received antithrombotic therapy by the end of hospital day two. You receive one consultant that you can call anytime with questions or concerns. Disclaimer of Warranties and Liabilities. 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. STK-OP-1f Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO7. Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. CSTK-10b Functional Status Prior to Stroke-Dependent: IV Alteplase Only, 3. This is increasingly important as the health care system moves towards value-based reimbursement models. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). Learn about the priorities that drive us and how we are helping propel health care forward. 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 nation's health care system moves from one that pays based on volume of services to one that pays for value. A hospitals Ischemic sub-population is 5 patients during February. 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. CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. We help troubleshoot technical and clinical issues to improve your measures. 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 Percent of ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. The Measure Steward refers to the organization that is responsible for providing the required measure information for the measure maintenance process that occurs approximately every three years. CSTK-03 Severity Measurement Performed for SAH and ICH Patients (Overall Rate)3. 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). In the final section, I review the way this information is submitted to The Joint Commission and CMS. 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. Section 3. Measuring Emergency Department Performance Create your baseline by entering 30 records into the Patient Management Tool. Finally, I have listed a few more resources for you. 3 0 obj STK-4 Thrombolytic Therapy10. <> 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . Please see link below for more information. Here I have broken it into the inpatient measure set and the outpatient measure set. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. Measures for TJC Acute Stroke Ready Center Certification, 1. A hospitals hemorrhagic stroke patient population size is 67 cases during the second quarter. 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. Heres a good reference document in case you get confused. . Return to Clinical Data Processing Flow in the Data Processing section. Commercial health plans are rolling out the core measures as part of their contract cycle. A hospitals Hemorrhagic sub-population is 316 during February. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. Here is a diagram that outlines the submission differences. stream A hospitals Ischemic sub-population is 100 during the first quarter. The six measures are: . Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. lock The two Measure Stewards (CMS and TJC) require hospitals to submit their chart-abstracted data in two different ways. Numerous published studies demonstrate the program's success in improving patient outcomes. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. Percent of ischemic or hemorrhagic stroke patients, or their caregivers, who were given educational materials during the hospital stay addressing. 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 treatment2. The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. One-hundred and twenty-three (123) 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. hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! 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. Centers for Medicare and Medicaid Services Measures Inventory Tool You can download it or email it to yourself to help you remember. PDF Stroke Core Performance Measures HOS-Sanford Medical Center Fargo PDF Standardized Performance Measures for Primary Stroke Centers We develop and implement measures for accountability and quality improvement. February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. CQMC will release four additional updated core measure sets and two new core measure sets over the coming months. n01Qf i# ]gmJIYan{"I,$ }T/~yN)NeiAog@ckRLkd,'? $BJ8W(d`W $0s2[AS}4cpLtaDZhTb E,Jy;;S N/! Stroke - Diagnosis and treatment - Mayo Clinic STK-8 Stroke Education18. ** The Adult Core Set includes the NCQA version of the measure, whichis adapted from the CMS measure (NQF #1879). 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. %%EOF We keep you on track for your submission deadlines and ensure you dont miss critical dates. ASR-IP-3: Discharged on Antithrombotic Therapy4. 3 0 obj Stroke Core Measure Data | Fort Sanders Regional Medical Center, a ) 2 0 obj An IV injection of recombinant tissue plasminogen activator (TPA) also called alteplase (Activase) or tenecteplase (TNKase) is the gold standard treatment for ischemic stroke. PDF CMCS Informational Bulletin - Medicaid.gov Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. A hospitals hemorrhagic stroke patient population size is 295 cases during March. Each certification may require your hospital to submit one or more of the five measure sets we reviewed above. Download Get With The Guidelines- Stroke fact sheets and forms here. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. 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. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. decreased providers collection burden and cost. 0 Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. The required quarterly sample is 45 cases. Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment. Through the use of a multi-stakeholder process, the Collaborative promotes alignment and harmonization of measure use and collection across payers in both the public and private sectors. The following table identifies the population . The Ischemic sub-population has 392 patients per quarter, which requires a 20% sample size, or 79 cases (twenty percent of 392 equals 78.4 rounded to the next highest whole number equals 79). If the ICD-10-CM Principal Diagnosis Code is on Table 8.1, the patient is in the first Ischemic Stroke sub-population and is eligible to be sampled for the first STK sub-population. <>>> 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. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. 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. Get With The Guidelines- Stroke supports hospitals in many ways, including: Data submission and feedback reporting are performed using the American Heart Association's Get With The Guidelines Registry (IRP)(link opens in new window). STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. <> Dude JA, Lohse KR, Cramer SC, Worrall BB; GPAS Collaboration Phenotyping Core. Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. 2021; 96:e1812-e1822 . 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 .