A hospitals ischemic stroke patient population size is 495 cases during the second quarter. %PDF-1.4 % website belongs to an official government organization in the United States. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. All rights reserved. Early rehabilitation interventions initiated following stroke can enhance the recovery process and minimize functional disability. STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. Return to Clinical Data Processing Flow in the Data Processing section. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. endstream endobj startxref You receive one consultant that you can call anytime with questions or concerns. 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 . Initial Population: Inpatient hospitalizations for patients age 18 and older . All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 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. This means the patient passed every measure they qualified for. 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. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> All rights reserved. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. 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. All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. 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. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. PDF 2021 Core Set of Adult Health Care Quality Measures for - Medicaid Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. R,A`=N T$gZq,AW@0H#`.K#AJk_~}~Dc7?o=0T,qp{"+&y8N^-9yG-W +~ZY(DA[xvc2EGJv;P.Q12`3'o0f}ahq+ci;")i EmNW`0}d\K?QD-ki'e1ACa%i^\|.I$a-4>b(L . The primary source is the Disease-Specific Care Certification Manual, ASRH addendum. U.S. Government Rights STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . 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). Neurology. If the Length of Stay is greater than 120 days, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. 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. Stroke | The Joint Commission STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. Percent of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well. Data collection for STK-OP-1 will replace ASR-OP-2. Identifying Best Practices to Improve In-Hospital Stroke Management One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. Return to Clinical Data Processing Flow in the Data Processing section. The following sample size tables for each option automatically build in the number of cases needed to obtain the required sample sizes. The core measurescan be found at: http://www.qualityforum.org/cqmc/. 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. Understanding Stroke Measure Sets - f.hubspotusercontent30.net A hospitals Hemorrhagic sub-population is 316 during February. 1 0 obj 3= recommended; the outcome measure has good psychometric . The listed denominator criteria are used to identify the intended patient population. 4 0 obj endobj STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. %PDF-1.5 The following are Stroke eCQMs used by The Joint Commission. lock 4= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. The following links provide you with information available on past, present and future versions of the specification manuals, including release notes, measure information forms, data dictionaries, missing and invalid data, population and sampling, data transmission, tools and resources, and appendices. ASR-OP-1 Thrombolytic Therapy (Drip and Ship)5. Source: Medisolv Perfect Care Report (eff. with acute ischemic stroke in the hospital setting will submit this measure. Its a nightmare trying to keep straight this wide range of acronym-filled information. CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome), 1. Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. Updated eCQM Specifications and eCQM Materials for 2021 Reporting Now 7272 Greenville Ave. 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. 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. Click on the link(s) below to access measure specific resources: The Joint Commission is a registered trademark of the Joint Commission enterprise. This content does not have an Arabic version. 0 hbbd``b` SY ~H0[@D1HI-Hp @o$xA }:.PHplp%H^'n&F&QT'340 Ji The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. 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%. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. CSM endobj The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the sub-populations for the quarter. The numerator options included in this Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). CSTK-06 Nimodipine Treatment Administered6. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. STK-1 Venous Thromboembolism (VTE Prophylaxis)7. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. STK-2 Discharged on Antithrombotic Therapy8. Centers for Medicare and Medicaid Services Measures Inventory Tool Core Measures are evidence-based standards of care established by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). Especially if you use an EHR vendor right now, youll notice a huge difference. The six measures are: . You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. In addition, the public may compare specific healthcare organizations' results on Core Measures at the

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