PDF California EMS System Core Quality Measures Instruction Manual . A single copy of these materials may be reprinted for noncommercial personal use only. 2023 American Heart Association, Inc. All rights reserved. x[o ?;8o b+cIC[jN_:u!s@>:H?O>/?w`}?gheqMU Especially if you use an EHR vendor right now, youll notice a huge difference. STK-1 Venous Thromboembolism (VTE Prophylaxis)4. CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival10. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population. *{o7@FNhR/ CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only, 2. Information in this course pertains to 01/1/13 - 12/31/13, version 4.2 of the Specifications Manual. Clinical Measures Outcomes | Cleveland Clinic stream The next measure set we review is abbreviated ASR-IP/OP. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. Stroke Core Measure - About Us - Mayo Clinic , . In addition, the public may compare specific healthcare organizations' results on Core Measures at the Hospital Inpatient Measures - QualityNet Home Hospital Core Measures Defined - ESO Stroke Corner - Education - neuropt.org Comprehensive Stroke (CSTK) (v2021A1) - Performance Measurement Network ruTv?U J4lUBex(a8{g$CHj ~>-z I&8:+hlvM(XdvY;D|BOl,Yu'D> YR9Gbl6GrJ8'},^V)\i/0 Gg:} >!81I88{'swe )I6v#{$&YymLyn\tl S3r6.o?x@q$_1A=U$H3%QUx . CPT is a registered trademark of the American Medical Association. endobj Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. 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. Using the monthly 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. 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 . A hospital may choose to use a larger sample size than is required. 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). Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . By improving stroke care, our Get With The Guidelines- Stroke program benefits patients as well as hospitals. Clinical Performance Measures for Stroke Rehabilitation: Performance 4 0 obj You can decide how often to receive updates. 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. Finally, I have listed a few more resources for you. <> CSTK-05 Hemorrhagic Transformation, 1. The required monthly sample is 60 cases. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. 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. Sixty (60) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. CSTK-05 Hemorrhagic Transformation, 1. Claims-Based Measures by Category Claims-Based Patient Safety Measures for 2022 Claims-Based Mortality Measures for 2022 Claims-Based Coordination of Care Measures for 2022 Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. Measure 6a is new and is being pilot tested in 2009. The required sample size for the CSTK-01 measure is a minimum of 42 cases for the month (28 cases from Table 4 plus 14 cases from Table 5 equals 42). STK-OP-1i Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO**ADDED as of 7/1/2021**, 3. Source: Medisolv Perfect Care Report (eff. This is a big year for Quality. 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 STK-10 Assessed for Rehabilitation, Measures for TJC Thrombectomy Capable Stroke Center Certification, 1. One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during March. 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. Specifications for these measures are available below: There are no Stroke chart abstracted measures applicable or available for Accreditation purposes. 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. Specifications Manual for Joint Commission National Quality Measures (v2021A1), Comprehensive Stroke (CSTK) Initial Patient Population, First Pass of a Mechanical Reperfusion Device, Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation, Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation, IV Alteplase Prior to IA or Mechanical Reperfusion Therapy, Initial Blood Glucose Value at Hospital Arrival, Initial Blood Pressure at Hospital Arrival, Initial Platelet Count at Hospital Arrival, NIHSS Score Documented Closest to IA Alteplase or MER Initiation, NIHSS Score Documented Closest to IV Alteplase Initiation, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Date, Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade Time, Reason for Not Administering Nimodipine Treatment, Reason for Not Administering a Procoagulant Reversal Agent, 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, National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients), Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH ), Hemorrhagic Transformation (Overall Rate), Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade), Modified Rankin Score (mRS at 90 Days: Favorable Outcome), Rate of Rapid Effective Reperfusion From Hospital Arrival, Rate of Rapid Effective Reperfusion From Skin Puncture, 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. <>>> The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. This Agreement will terminate upon notice if you violate its terms. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function. PDF CMCS Informational Bulletin - Medicaid.gov Get more information about cookies and how you can refuse them by clicking on the learn more button below. Do not process cases that have been rejected before this point in the Clinical Data Processing Flow. Stroke is a leading cause of serious, long-term disability in the United States. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. with acute ischemic stroke in the hospital setting will submit this measure. A hospitals Hemorrhagic sub-population is 316 during February. The two Measure Stewards (CMS and TJC) require hospitals to submit their chart-abstracted data in two different ways. 3 0 obj U.S. Government Rights Arrhythmia means that the heart's normal beating rhythm is interrupted. So, Ive attempted to structure it in a way that will be a reference for you. I also included the complete list of measures required for each certification. At the beginning of 2020, The Joint Commission switched over to the Direct Data Submission Platform (DDSP). We keep you on track for your submission deadlines and ensure you dont miss critical dates. CMS is already using measures from the each of the core sets. 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. Stroke | UofL Health STK-5 Antithrombotic Therapy By End of Hospital Day Two8. CMS and TJC update Core Measures and retire some Core Measures on an ongoing basis. CSM A hospitals Hemorrhagic sub-population is 100 during the first quarter. lock 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. STK-OP-1 Door to Transfer to Another Hospital, 1. Saturday: 9 a.m. - 5 p.m. CT In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care. Learn more about the communities and organizations we serve. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC).