stroke core measures 2021

Contact Us, Hours 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 following are Stroke chart abstracted measures used by The Joint Commission. <> %PDF-1.5 One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. The Core Quality Measures Project currently includes 6 of 11 National EMS Quality Measures. 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. The Hemorrhagic sub-population is less than the minimum required quarterly sample size, so 100% of this sub-population is sampled. STK-5 Antithrombotic Therapy By End of Hospital Day Two8. Oh, also, I included a ton of resources and links throughout this article and a specific list of resources at the end. We aim to determine feasibility of implementing stroke core measures and training through blended learning modules in resource poor countries to improve stroke outcomes. Eleven (11) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. STK-OP-1h Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible**ADDED as of 7/1/2021**9. ASR-IP-2: Antithrombotic Therapy Administered By End of Hospital Day 23. <> Initial Population: Inpatient hospitalizations for patients age 18 and older . <>>> CSTK-05 Hemorrhagic Transformation, 1. 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 STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. endobj A hospitals ischemic stroke patient population size is 295 cases during March. Commercial health plans are rolling out the core measures as part of their contract cycle. STK-2 Discharged on Antithrombotic Therapy5. This section includes the measure type (inpatient vs outpatient), the number of measures in the set, which certification the measure set is a part of, a list of the measures in the set and the associated algorithm. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. endobj Get more information about cookies and how you can refuse them by clicking on the learn more button below. This section reviews The Joint Commission certifications and clarifies the CMS accreditation requirement. The required quarterly sample size would be 100% of the patient population or 5 cases for the quarter, No sampling; 100% Initial Patient Population required. Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). endobj *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. ASR-OP-2c Ischemic Stroke; drip and ship4. Secure .gov websites use HTTPSA means youve safely connected to the .gov website. A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. CSTK-06 Nimodipine Treatment Administered6. Major causes of HF are coronary artery disease, high blood pressure, and diabetes. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. 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. You can download it or email it to yourself to help you remember. Finally, I have listed a few more resources for you. Chart-abstracted measures specificationsScreen Reader Text. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Approximately 2-4% of patients with stroke have their event while hospitalized for another condition, with almost one half resulting from a vascular procedure. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. There are no Stroke eCQMs applicable or available for Certification purposes. A hospitals Ischemic sub-population is 5 patients during the first quarter. In light of these points, a blueprint is proposed for using domain-specific outcome measures in stroke recovery trials. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. Chart Abstracted Measures for Certification. 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#. hWn8,CIDE ;its8MZAt,9!%_e'Kaxs8>f9! STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. 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]. 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. Using the quarterly sampling table for the hemorrhagic 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). Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42 cases for the quarter. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Learn how working with the Joint Commission benefits your organization and community. 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 measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). 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. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. Sign up to get the latest information about your choice of CMS topics. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy4. The six measures are: . A hospitals ischemic stroke patient population size is 7 cases during March. endobj 4 0 obj 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. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. Medisolv can help you along the way. 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. Closed on Sundays. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. I also included the complete list of measures required for each certification. Patient Age, in years, is equal to the Admission Date minus the Birthdate. All rights reserved. Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. An antithrombotic agent is a drug that reduces the formation of blood clots. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, Rate of Rapid Effective Reperfusion From Hospital Arrival. 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. 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. *{o7@FNhR/ We help troubleshoot technical and clinical issues to improve your measures. Sometimes it works best to start small and build on success. Learn more about the communities and organizations we serve. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% of the Initial Patient Population is required, Patient level data must be processed in order to submit your aggregate data. If you search for multiple terms, CMIT will return all deliverables containing at least one of the terms. 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. Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. Refine processes and protocols to ensure they are in line with the guidelines. Repeat steps 8 and 9 until your team is happy with your treatment rates and your hospital is eligible for. In this post we are either referencing CMS or The Joint Commission as the Measure Stewards. CSTK-03 Severity Measurement Performed for SAH and ICH Patients (Overall Rate)3. Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. lock 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. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). Get With The Guidelines- Stroke has been funded in the past through support from Janssen Pharmaceuticals, Boeringher-Ingelheim, and Merck. 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 Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). 3 0 obj 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. 2021; 97: . 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). This post is a guide to understanding the differences between the five major stroke measure sets. The required quarterly sample is 60 cases. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. The AMA is a third party beneficiary to this Agreement. The final clinical diagnosis is used to identify the measure population. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 19 cases are sampled. 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. A hospitals ischemic stroke patient population size is 495 cases during the second quarter. Measure ID # Measure Short Name OP-23 . A hospital may choose to use a larger sample size than is required. Please see http://www.qualityforum.org/CQMC_Core_Sets.aspx for more information. Core Measure Data as of 3/2/2022. 4 0 obj 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). 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, Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. Time from symptom onset to stroke alert is delayed in in-hospital stroke. <> The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. 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). 3 0 obj CSTK-02 Modified Rankin Score (mRS at 90 Days)3. 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. 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. 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. Here is a diagram that outlines the submission differences. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 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%. 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. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 228 during March. 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. STK-8 Stroke Education13. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. 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. Brainstorm with your team to find ways to improve your hospital's treatment rates. This may be achieved by administering the t-PA drug intravenously to eligible patients within three hours of stroke onset. STK-6 Discharged on Statin Medication9. The AMA is a third party beneficiary to this Agreement. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. Part 2: A review of the different stroke certifications. The two sub-populations must be sampled independently from each other. Part 1: A review of the different stroke measure sets. 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. with acute ischemic stroke in the hospital setting will submit this measure. Calculate the Length of Stay. Saturday: 9 a.m. - 5 p.m. CT 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. CPT only copyright 2019 American Medical Association. Stroke Core Measures Stroke 'core measures' are critical steps in a patient's hospital stay that have been established based on outcomes. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the month. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5 @/K6jPw*sfoqW}"3v}qCmqytT_.NnwT*_kL?hokU^dU2h=>tLi %PDF-1.7 This Agreement will terminate upon notice if you violate its terms. This item requires a Core Return or Core Charge. You can decide how often to receive updates. Measure 6a is new and is being pilot tested in 2009. The core measurescan be found at: http://www.qualityforum.org/cqmc/. Data Source: American Heart Association Get With The Guidelines stroke database. Each measure includes patients from one or more categories. 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. 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. 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 . 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. This content does not have an Arabic version. *Note: There are additional measures needed to fulfill this certification. endstream endobj startxref 646 0 obj <> endobj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> website belongs to an official government organization in the United States. In addition, the public may compare specific healthcare organizations' results on Core Measures at the %PDF-1.4 % 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. 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 hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter. TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. 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). CMS is already using measures from the each of the core sets. 2 0 obj Assemble your multidisciplinary team to determine roles and processes for entering patient data. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. A hospital may choose to use a larger sample size than is required. *Note: Significant changes to this measure set begin July 1, 2021. 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. Fifty (50) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. STK-10 Assessed for Rehabilitation. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. We keep you on track for your submission deadlines and ensure you dont miss critical dates. Return to Clinical Data Processing Flow in the Data Processing section. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. January 1, 2021: Actual Primary Completion Date : June 30, 2021: Estimated Study Completion Date : December 31, 2021: Groups and Cohorts. 3= recommended; the outcome measure has good psychometric . 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. The American Medical Association reserves all rights to approve any license with any Federal agency. Ready to get started with CMIT 2.0? This is increasingly important as the health care system moves towards value-based reimbursement models. 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 QualityResearch@heart.org. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50 cases for the month. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Its a nightmare trying to keep straight this wide range of acronym-filled information. Set the Initial Patient Population Reject Case Flag to equal No. All rights reserved. So, Ive attempted to structure it in a way that will be a reference for you. REMINDER: Stroke is now a Core Measure for CMS!!! 7.gbu>/u?3>kW?^n-'\\o.T(A2Y/-.>+ A hospitals Hemorrhagic sub-population is 3 patients during January. 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. Much like we saw how cases fall into their respective sub-populations with CSTK, cases for STK use the same criteria when determining which sub-population a case will qualify for. 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). These measures include aggressive use of medications, such as antithrombotics, anticoagulation therapy, deep vein thrombosis prophylaxis, cholesterol-reducing drugs and smoking cessation, all aimed at reducing death and disability and improving the lives of stroke patients.