These core measure sets are a major step forward for alignment of quality measures between public and private payers and provides a framework upon which future efforts can be based. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. <>>> Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. 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. Calculate the Length of Stay. 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. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. *** AHRQ is the measure steward for the survey instrument in the Adult Core Set (NQF #0006) and NCQA is the developer of the survey administration protocol. In addition, stroke rehabilitation incorporates prevention and treatment of medical and mental health complications such as aspiration pneumonia, soft-tissue contractures, decubitus ulcers, infection, deep vein thrombosis (DVT), malnourishment, and depression. 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. The CMS Measure Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to promote healthcare quality and quality improvement. A hospitals Hemorrhagic sub-population is 3 patients during the first quarter. Using the monthly sampling table for the Ischemic 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). You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Patient Age, in years, is equal to the Admission Date minus the Birthdate. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75 cases for the quarter. <> This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. 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. Disclaimer of Warranties and Liabilities. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs. 3 0 obj You can use the words "AND" and "OR" along . ASR OP-2 Door to Transfer to Another Hospital **RETIRED Effective July 1, 2021**, 1. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. Set the Initial Patient Population Reject Case Flag to equal Yes. STK-OP-1a Overall Rate (Not Reported2. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5 @/K6jPw*sfoqW}"3v}qCmqytT_.NnwT*_kL?hokU^dU2h=>tLi CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. The American Medical Association does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. 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 . Return to Clinical Data Processing Flow in the Data Processing section. What is wrong with these people making it so complicated for us? CSTK-09 Arrival Time to Skin Puncture, 8. Find evidence-based sources on preventing infections in clinical settings. Especially if you use an EHR vendor right now, youll notice a huge difference. 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. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. 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). endobj If the Patient Age is less than 18 years, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. 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. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. Quarterly sampling for the two combined populations for Joint Commission certification purposes. The AMA does not directly or indirectly practice medicine or dispense medical services. 3 0 obj Visit: . 0 The measure development and maintenance process is guided by expertise and advice provided by the Stroke Measure Maintenance Technical Advisory Panel (TAP). Learn about the "gold standard" in quality. 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. CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. >0SPJ*@6W/rq+ERY_X&14>k( ( The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. 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. A hospitals Hemorrhagic sub-population is 100 during the first quarter. STK-8 Stroke Education13. *7.`"}K3t;qBEN]1F"9V>7[?)] Using the quarterly 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 45 cases for the quarter (20% of 223 equals 44.6 rounded to the next highest whole number equals 45). Each measure includes patients from one or more categories. 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. 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). Additionally, the Collaborative developed a framework of aims and principles that informed the selection of core measure sets. A hospitals ischemic stroke patient population size is 200 patients during the second quarter. Understanding Stroke Measure Sets - f.hubspotusercontent30.net OP Stroke General Data Element List General Data Element Name Collected For: Arrival Time CPT only copyright 2019 American Medical Association. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. The required quarterly sample sizes for each sub-population would be 79 and 5. STK-2 Discharged on Antithrombotic Therapy5. TARGET: STROKE MEASURE CSTK-05 Hemorrhagic Transformation, 1. 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). These updated core sets are a result of months of consensus-based review and deliberation among the groups 75+ multi-stakeholder member organizations, evaluating hundreds of existing quality measures against the CQMCs rigorous criteria. A hospitals Ischemic sub-population is 100 during the first quarter. Core measures are based on the most common condition's hospitals see, such as acute myocardial infarction (AMI), heart failure (HF), pneumonia, surgical care, children's asthma care, venous thromboembolism (VTE), stroke, and more. Calculate Patient Age. A hospitals Ischemic sub-population is 5 patients during the first quarter. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. 4 0 obj Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 17 cases are sampled.