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A hospitals Hemorrhagic sub-population is 3 patients during January. <>>> CSM Saturday: 9 a.m. - 5 p.m. CT STK-1 Venous Thromboembolism (VTE Prophylaxis)7. Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. You can download it or email it to yourself to help you remember. <>>> February 2021 intimacy and sex after stroke February 2021 Post-stroke outcome, falls and fatigue February 2021 improving stroke care. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to Length of Stay Calculation. 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. 4 0 obj In regard to stroke, The Joint Commission has four different types of certification programs that go along with these stroke measure sets. Disclaimer of Warranties and Liabilities. ASR-OP-2d Ischemic Stroke; no IV alteplase prior to transfer, Measures for TJC Primary Stroke Center Certification, 1. 2023 Medisolv, Inc. All Rights Reserved. Written by American Heart Association editorial staff and reviewed by science and medicine advisers. Neurology. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the month. Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. {8Dm.;JHTBXEXh^^^.Y)oH 6K;ANf!;*#.\1\c"1cKE. Based on this review and discussion the workgroups identified a consensus core set for the selected clinical areas. Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 150 cases for the quarter. STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible5. Download Get With The Guidelines- Stroke fact sheets and forms here. CSTK-09 Arrival Time to Skin Puncture, 1. STK-8 Stroke Education18. All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. A hospitals ischemic stroke patient population size is 7 cases during March. <> 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). hbspt.cta._relativeUrls=true;hbspt.cta.load(491484, '41fd9d46-8610-4a5f-a135-c143fe55a31f', {"useNewLoader":"true","region":"na1"}); By JoAnne Marino April 30, 2021 Regulatory Updates: Hospital. website belongs to an official government organization in the United States. Dude JA, Lohse KR, Cramer SC, Worrall BB; GPAS Collaboration Phenotyping Core. A hospitals Hemorrhagic sub-population is 316 during February. The AMA does not directly or indirectly practice medicine or dispense medical services. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. Unauthorized use prohibited. They also could require other measures. In addition, 36 states reported more Adult Core Set measures for FFY 2019 than for FFY 2018. The six measures are: . A hospitals ischemic stroke patient population size is 495 cases during the second quarter. *7.`"}K3t;qBEN]1F"9V>7[?)] 2021 94.5% (307/325) 2020 91.7% (275/300) STK-2 2022 100.0% (117/117) . We help troubleshoot technical and clinical issues to improve your measures. 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. 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. Use the month and day portion of admission date and birthdate to yield the most accurate age. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter for the measure set cannot sample. Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes: A hospitals Hemorrhagic sub-population is 392 during the first quarter. %%EOF Improve Maternal Outcomes at Your Health Care Facility, Accreditation Standards & Resource Center, Ambulatory Health Care: 2023 National Patient Safety Goals, Assisted Living Community: 2023 National Patient Safety Goals, Behavioral Health Care and Human Services: 2023 National Patient Safety Goals, Critical Access Hospital: 2023 National Patient Safety Goals, Home Care: 2023 National Patient Safety Goals, Hospital: 2023 National Patient Safety Goals, Laboratory Services: 2023 National Patient Safety Goals, Nursing Care Center: 2023 National Patient Safety Goals, Office-Based Surgery: 2023 National Patient Safety Goals, The Term Licensed Independent Practitioner Eliminated, Updates to the Patient Blood Management Certification Program Requirements, New Assisted Living Community Accreditation Memory Care Certification Option, Health Care Equity Standard Elevated to National Patient Safety Goal, New and Revised Emergency Management Standards, New Health Care Equity Certification Program, Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care, Updates to the Assisted Living Community Accreditation Requirements, Updates to the Comprehensive Cardiac Center Certification Program, Health Care Workforce Safety and Well-Being, Report a Patient Safety Concern or Complaint, The Joint Commission Stands for Racial Justice and Equity, The Joint Commission Journal on Quality and Patient Safety, John M. Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Measures for Acute Stroke Ready Center Certification, Measures for Primary Stroke Center Certification, Measures for Thrombectomy Capable Stroke Center Certification, Measures for Comprehensive Stroke Center Certification, eSTK-2 Discharged on Antithrombotic Therapy, eSTK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, eSTK-5 Antithrombotic Therapy by End of Hospital Day Two, ASR-IP-1 Thrombolytic Therapy: Inpatient Admission, ASR-IP-2 Antithrombotic Therapy By End of Hospital Day 2, ASR-IP-3 Discharged on Antithrombotic Therapy, ASR-OP-1 Thrombolytic Therapy: Drip and Ship, CSTK-01 National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients, CSTK-02 Modified Rankin Score (mRS) at 90 Days, CSTK-03 Severity Measurement Performed for SAH and ICH Patients, CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH), CSTK-06 Nimodipine Treatment Administered, CSTK-08 Thrombolysis in Cerebral Infarction (TICI) Post-Treatment Reperfusion Grade, CSTK-10 Modified Rankin Score (mRS) at 90 Days: Favorable Outcome, CSTK-11 Rate of Rapid Effective Reperfusion From Hospital Arrival, CSTK-12 Rate of Rapid Effective Reperfusion From Skin Puncture, STK-1 Venous Thromboembolism (VTE) Prophylaxis, STK-2 Discharged on Antithrombotic Therapy, STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-5 Antithrombotic Therapy By End of Hospital Day Two, STK-OP-1 Door to Transfer to Another Hospital, STK-VOL-1 Eligible Ischemic Stroke Patients Who Receive Mechanical Endovascular Reperfusion Therapy. Return to Clinical Data Processing Flow in the Data Processing section. 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. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. ASR OP-2 Door to Transfer to Another Hospital **RETIRED Effective July 1, 2021**, 1. hb``` eaX`3P@7pi%It' s9MZxTPN )4 3Hr102)iq }p!>8O:nI-BFo4NB4@4@c _ R/ Length of Stay, in days, is equal to the Discharge Date minus the Admission Date. 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. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 3 0 obj 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. In this post we are either referencing CMS or The Joint Commission as the Measure Stewards. CSTK-01 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)2. %PDF-1.5 This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter6. There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, physicians and other clinicians, and policymakers. A hospitals Ischemic sub-population is 5 patients during the first quarter. CMIT searches all fields in the inventory and is not case-sensitive. CSTK-10c Functional Status Prior to Stroke-Independent: MER Therapy, 4. .gov STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter9. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Comprehensive Stroke (CSTK) (v2021A1) Home Comprehensive Stroke (CSTK) Comprehensive Stroke (CSTK) On this page: Comprehensive Stroke (CSTK) Initial Patient Population Monthly Sampling Sample Size Examples Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible6. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. STK-OP-1a Overall Rate (Not Reported2. Stroke is a leading cause of serious, long-term disability in the United States. Hospital OQR Quality Measures and Timelines for the CY 2021 Payment Determination . >0SPJ*@6W/rq+ERY_X&14>k( The following are Stroke eCQMs used by The Joint Commission. Stroke (STK) (v2021B) Home Stroke (STK) Release Notes: Measure Information Form Version 2021B Stroke (STK) On this page: Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements Related Materials Initial Patient Population Algorithm Stroke (STK) Initial Patient Population Algorithm Narrative Its a nightmare trying to keep straight this wide range of acronym-filled information. Submission of aggregate data is still required. Chart Abstracted Measures for Certification. The Centers for Medicare & Medicaid Services (CMS) has posted the electronic clinical quality measure ( eCQM) specifications for the 2021 reporting period for Eligible Hospitals and Critical Access Hospitals, and the 2021 performance period for Eligible Professionals and Eligible Clinicians. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. For an overview of data housed in the Stroke Patient Management Tool, please refer to the Stroke Case Record Form (PDF). x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) LqV)%0w#lP.s9XsG58gX'5L S AP*=;%)e0J9_T-NXC4*~bTdsSFnde#;nOOyOqsi]qQV/Fb3KtK. stream Due to exclusions, hospitals selecting sample cases MUST submit AT LEAST the minimum required sample size. Finally, I have listed a few more resources for you. promotion of measurement that is evidence-based and generates valuable information for quality improvement, reduction in the variability in measure selection, and. A hospitals Ischemic sub-population is 316 during January. 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. *Note: There are additional measures needed to fulfill this certification. endobj The following table identifies the population . Calculate the Length of Stay. Learn how working with the Joint Commission benefits your organization and community. Quarterly sampling for the two combined populations for Joint Commission certification purposes. Especially if you use an EHR vendor right now, youll notice a huge difference.