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TJC V2019a PDF

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Version 2019A

Table of Contents
Acknowledgment and Conditions of Use
Introduction
Using the Specifications Manual for Joint Commission National Quality Measures

National Quality Measure Sets

Section 1: Measure Information Forms

Hospital Based Inpatient Psychiatric Services (HBIPS)

HBIPS-1
HBIPS-2
HBIPS-3
HBIPS-5
Perinatal Care (PC)
PC-01
PC-02
PC-03
PC-04
PC-05
PC-06

Certification Measure Sets

Section 2: Measure Information Forms

Acute Stroke Ready Inpatient (ASR-IP)

ASR-IP-1
ASR-IP-2
ASR-IP-3
Acute Stroke Ready Outpatient (ASR-OP)
ASR-OP-1
ASR-OP-2
Advanced Certification Heart Failure (ACHF)
ACHF-01
ACHF-02
ACHF-03
ACHF-04

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ACHF-05
ACHF-06
Advanced Certification Heart Failure Outpatient (ACHFOP)
ACHFOP-01
ACHFOP-02
ACHFOP-03
ACHFOP-04
ACHFOP-05
ACHFOP-06
ACHFOP-07
Comprehensive Stroke (CSTK)
CSTK-01
CSTK-02
CSTK-03
CSTK-04
CSTK-05
CSTK-06
CSTK-07
CSTK-08
CSTK-09
CSTK-10
CSTK-11
CSTK-12
Palliative Care (PAL)
PAL-01
PAL-02
PAL-03
PAL-04
PAL-05
Stroke (STK)
STK-1
STK-10
STK-2
STK-3
STK-4
STK-5
STK-6
STK-8
Stroke Outpatient (STK-OP)
STK-OP-1
Total Hip and Total Knee Replacement Inpatient (THKR-IP)
THKR-IP-1
THKR-IP-2
THKR-IP-3
THKR-IP-4
Total Hip and Total Knee Replacement Outpatient (THKR-OP)

Section 3: Introduction to the Data Dictionary

Introduction to the Data Dictionary

Alphabetical List of Data Elements

Section 4: Missing and Invalid Data

Missing and Invalid Data

Section 5: Population and Sampling Specifications

Population and Sampling Specifications

Section 6: Reserved for future use

Section 7: Joint Commission National Quality Measures Data Transmission

Joint Commission National Quality Measures Data Transmission

Transmission Data Elements
Transmission Data Processing Flow: Clinical
Transmission Data Processing Flow: Population and Sampling

Appendices

A. ICD-10-CM Code Tables

C. Medication Tables
D. Glossary of General Terms
E. Overview of Measure Information Form and Flowchart Formats
G. Resources
H. Miscellaneous Tables

Release Notes

Release Notes for Manual v2019A - February 4, 2019

Show previous release notes...

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Acknowledgement
No royalty or use fee is required for copying or reprinting this manual, but the following are required as a
condition of usage: 1) disclosure that the Speciﬁcations Manual is periodically updated, and that the version
being copied or reprinted may not be up-to-date when used unless the copier or printer has verified the
version to be up-to-date and affirms that, and 2) users participating in Joint Commission accreditation,
including ORYX® vendors, are required to update their software and associated documentation based on the
published manual production timelines.

Example Acknowledgement: The Speciﬁcations Manual for Joint Commission National Quality Measures
[Version XX, Month, Year] is periodically updated by The Joint Commission. Users of the Speciﬁcations
Manual for Joint Commission National Quality Measures must update their software and associated
documentation based on the published manual production timelines.

CPT® Notice
The five character CPT® codes included in the Speciﬁcations Manual for Joint Commission National Quality
Measures are obtained from Current Procedural Terminology (CPT®), copyright 2019 by the American
Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character
identifying codes and modifiers for reporting medical services and procedures.

The responsibility for the content of the Specifications Manual for Joint Commission National Quality Measures
is with Joint Commission and no endorsement by the AMA is intended or should be implied. The AMA
disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or
interpretation of information contained in the Specifications Manual for Joint Commission National Quality
Measures. 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. The AMA does not
directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data
contained or not contained herein. Any use of CPT outside of the Specifications Manual for Joint Commission
National Quality Measures should refer to the most current Current Procedural Terminology which contains
the complete and most current listing of CPT codes and descriptive terms.

CPT is a registered trademark of the American Medical Association.

The Joint Commission Quality Initiative

In 1987, The Joint Commission announced its Agenda for Change, which outlined a series of major steps
designed to modernize the accreditation process. A key component of the Agenda for Change was the
eventual introduction of standardized core performance measures into the accreditation process. As the
vision to integrate performance measurement into accreditation became more focused, the name ORYX®
was chosen for the entire initiative. ORYX® is The Joint Commission's performance measurement and
improvement initiative, which integrates outcomes and other performance measure data into the
accreditation process.

The ORYX® initiative became operational in March of 1999, when performance measurement systems began
transmitting data to The Joint Commission on behalf of accredited hospitals. ORYX® measurement
requirements are intended to support Joint Commission accredited organizations in their quality
improvement efforts.

The initial phase of the ORYX® initiative provided healthcare organizations a great degree of flexibility in
terms of the measures that could be reported. Over time, the ORYX® measures have evolved into
standardized valid, reliable, and evidence-based quality measures

The initial CMS/Joint Commission alignment efforts addressed chart-abstracted measures and
subsequently both organizations have worked on aligning as closely as possible the electronic clinical
quality measures (eCQMs).

Related Joint Commission Activities

Accreditation Process

In January 2000, Joint Commission surveyors began using organization-specific ORYX® Pre-Survey Reports,
effectively commencing the use of performance measure data in the survey process.

In 2004, the survey process was substantially modified to be more data-driven and patient-centered thus
enhancing its value, relevance, and credibility. Many of the key components of the survey process utilize data
derived from the national hospital inpatient quality measures. The survey process now has a greater focus
on evaluating actual care processes because patients are traced through the care, treatment and/or services
they receive. In addition, surveyors conduct “systems tracers” to analyze key operational systems that
directly impact the quality and safety of patient care.

In June 2010 The Joint Commission categorized its process core performance measures into accountability
and non-accountability measures. This approach placed more emphasis on an organization's performance
on accountability measures — quality measures that meet four criteria designed to identify measures that
produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement:

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Research: Strong scientific evidence demonstrates that performing the evidence-based care process
improves health outcomes (either directly or by reducing risk of adverse outcomes).
Proximity: Performing the care process is closely connected to the patient outcome; there are
relatively few clinical processes that occur after the one that is measured and before the improved
outcome occurs.
Accuracy: The measure accurately assesses whether or not the care process has actually been
provided. That is, the measure should be capable of indicating whether the process has been
delivered with sufficient effectiveness to make improved outcomes likely.
Adverse Effects: Implementing the measure has little or no chance of inducing unintended adverse
consequences.

Data Analysis

The Joint Commission has developed a target measure range approach (target analysis) as a basis to
evaluate Joint Commission accredited organizations' rating for the performance measures.

The use of target analysis in addition to a control chart is a key feature of the Joint Commission's analytic
methods in the ORYX® initiative. The two analyses are alike in that an organization's actual (or observed)
performance level is evaluated against a comparative norm, but are fundamentally different as to how such a
norm is established. In control chart analysis, the norm is determined from an organization's own historic
data so that one may assess the organization's internal process stability. In target analysis, the norm is
obtained based on multiple organizations' performance data to evaluate an organization's relative
performance level. Therefore, the two analyses evaluate an organization's performance in two distinct
perspectives and, as a result, can provide a more comprehensive framework to assess an organization's
overall performance level.

ORYX® Performance Measure Report

The ORYX® Performance Measure Report, available quarterly, is designed to support and help guide Joint
Commission-accredited hospitals in their performance assessment and improvement activities through the
use of summary dashboards and comprehensive measure details depicting the organization’s performance
on each measure for which The Joint Commission receives data from the organization. Joint Commission
surveyors receive an identical copy of the report prior to an onsite survey. Surveyors use the report as a
guide to understanding how the organization uses and responds to performance measure data.

Certification Process

The Joint Commission uses two methodologies for performance measurement for disease-specific care
programs. Each certified program collects either standardized or nonstandardized measures, as directed by
The Joint Commission. During the certification review the program will demonstrate that it has established a
data history that supports quality improvement. Selected standardized measure sets have been incorporated
in this specification manual to centralize the measures used for Joint Commission programs into one

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manual. For more information on the certification process refer to The Joint Commission website and the
specific certification program of interest.

Quality Check™

Quality Check is a directory of the more than 20,000 Joint Commission–accredited and certified health care
organizations and programs throughout the United States. The Joint Commission Quality Report
differentiates health care organizations based on accreditation decision categories and other related
information. While the accreditation decision reflects the process for assessing an organization’s
commitment to achieving continuous improvement in key areas of safety and quality, the Quality Report also
reflects information about a hospital’s performance on National Patient Safety Goals, National Quality
Improvement Goals for those hospitals reporting ORYX® chart abstracted performance measure data
through a vendor, as well as certain special recognitions and achievements. Quality Check displays hospital
performance on the National Quality Improvement Goal using individual measures which are updated
quarterly, for the most recent rolling four quarters (12 months) of chart-abstracted data. Hospital
performance at the individual measure level is displayed. The display includes that hospital’s observed rate
of performance on each reported chart-abstracted measure through the use of various comparative symbols
(plus, minus, check, or star), a display of the hospital’s performance against a target range of performance
established using data received from all hospitals reporting on each measure, and a comparison of the
hospital’s performance on each measure both on a nationwide and statewide level.

Quality Check™ can be accessed at http://www.qualitycheck.org to search for healthcare organizations by

name, type, and/or location. Interactive links to information are designed to help individuals better
understand how to use and interpret the information presented.

Annual Report

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety has been released
annually since 2008. This comprehensive report summarizes the performance of all Joint Commission-
accredited hospitals on ORYX® accountability measures.

Pioneers in Quality

Pioneers in Quality™ is a Joint Commission program started in 2016 to assist hospitals on their journey
toward electronic clinical quality measure (eCQM) adoption and reporting. Hospitals collect eCQM
information through electronic health records (EHRs) and transmit the data to The Joint Commission (as
part of its ORYX® performance measurement requirements) and to the Centers for Medicare & Medicaid
Services (CMS). The Pioneers in Quality™ program provides resources to aid hospitals in the transition from
chart-abstracted measures to eCQMs. Key components of the Pioneers in Quality™ program include regular
educational webinars focused on eCQM adoption, Expert-to-Expert series webinars, a comprehensive eCQM
resource portal and recognition for eCQM pioneers in America’s Hospitals: Improving Quality and Safety – The
Joint Commission’s Annual Report.

The Joint Commission began accepting direct data submission of electronic clinical quality measure (eCQM)
data from hospitals with the submission of calendar year (CY) 2017 eCQM data. The Direct Data Submission
Platform enables an ORYX eCQM process that simplifies operations and reduces the burden for our
accredited hospitals while ensuring regulatory compliance and security.

Related National Activities

National Quality Forum

The NQF has approved a set of national voluntary consensus standards for measuring the quality of hospital
care. These measures will permit consumers, providers, purchasers, and quality improvement professionals
to evaluate and compare the quality of care in general acute care hospitals across the nation using a
standard set of measures.

CMS Hospital Inpatient Quality Reporting Program

The Hospital Inpatient Quality Reporting Program was originally mandated by Section 501(b) of the Medicare
Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. This section of the MMA authorized
CMS to pay hospitals that successfully report designated quality measures a higher annual update to their
payment rates. Initially, the MMA provided for a 0.4 percentage point reduction in the annual market basket
(the measure of inflation in costs of goods and services used by hospitals in treating Medicare patients)
update for hospitals that did not successfully report. The Deficit Reduction Act of 2005 increased that
reduction to 2.0 percentage points. This was modified by the American Recovery and Reinvestment Act of
2009 and the Affordable Care Act of 2010, which provided that beginning in fiscal year (FY) 2015, the
reduction would be by one-quarter of such applicable annual payment rate update if all Hospital Inpatient
Quality Reporting Program requirements are not met. Under the Hospital Inpatient Quality Reporting
Program, CMS collects quality data from hospitals paid under the Inpatient Prospective Payment System,
with the goal of driving quality improvement through measurement and transparency by publicly displaying
data to help consumers make more informed decisions about their health care. It is also intended to
encourage hospitals and clinicians to improve the quality and cost of inpatient care provided to all patients.
The data collected through the program are available to consumers and providers on the Hospital Compare
website at: https://www.medicare.gov/hospitalcompare/search.html. Data for selected measures are also
used for paying a portion of hospitals based on the quality and efficiency of care, including the Hospital
Value-Based Purchasing Program, Hospital-Acquired Condition Reduction Program, and Hospital
Readmissions Reduction Program.

Hospital Value-Based Purchasing Program

Congress authorized the Inpatient Hospital VBP in Section 3001(a) of the Affordable Care Act. The program
uses the hospital quality data reporting infrastructure that was developed for the Hospital Inpatient Quality

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Reporting (IQR) Program. The Hospital Value-Based Purchasing (VBP) program is part of CMS’s ongoing
effort to structure Medicare’s payment system to reward providers for the quality of care they provide. This
program adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS), based on
the quality of care they deliver not just the quantity of services they provide. How hospitals perform on
quality and resource use measures is linked to the IPPS. The IPPS makes up the largest share of Medicare
spending, affecting payment for inpatient stays in approximately 3,000 hospitals across the country. The
Hospital VBP Program is funded by reducing participating hospitals’ base operating Medicare severity
diagnosis-related group (MS-DRG) payments by 2%. Any leftover funds are redistributed to hospitals based
on their Total Performance Scores (TPS). What hospitals earn depends on the range and distribution of all
eligible/participating hospitals’ TPS scores for a FY. It’s possible for a hospital to earn back a value-based
incentive payment percentage that is less than, equal to, or more than the applicable reduction for that FY.
The Hospital VBP Program is designed to promote better clinical outcomes for hospital patients, as well as
improve their experience of care during hospital stays. Specifically, Hospital VBP seeks to encourage
hospitals to improve the quality and safety of care that Medicare beneficiaries and all patients receive during
acute-care inpatient stays by:

Eliminating or reducing the occurrence of adverse events (healthcare errors resulting in patient harm).
Adopting evidence-based care standards and protocols that result in the best outcomes for the most
patients.
Re-engineering hospital processes that improve patients’ experience of care.
Increasing the transparency of care for consumers.
Recognizing hospitals that are involved in the provision of high-quality care at a lower cost to
Medicare.

Electronic Clinical Quality Measures (eCQMs) Overview

Effective CY 2016, hospitals are required to electronically report clinical quality measures as a portion of the
Hospital Inpatient Quality Reporting (IQR) and the Medicare EHR Incentive Programs. These quality
measures were developed specifically to allow an electronic health record (EHR) system certified to the
Office of the National Coordinator (ONC) standards to capture, export, calculate, and report the measure
data. The CQMs required for reporting are electronically specified, using industry standards for the measure
logic (Health Quality Measures Format [HQMF]) and the data transmission (Quality Reporting Document
Architecture [QRDA]: Category I – patient-level data). As the industry updates these standards, CMS and ONC
expect to reflect those updates in their respective requirements. Hospitals that successfully submit eCQM
data to meet Hospital IQR Program requirements will also fulfill the Medicare EHR Incentive Program
requirement for electronic reporting of CQMs with one submission. Eligible hospitals (EHs) are required to
report eCQMs to the Hospital IQR Program. EHs and Critical Access Hospitals (CAHs) are required to
electronically report to the Medicare EHR Incentive Program.

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Using The Specifications Manual for Joint
Commission National Quality Measures
This portion of The Speciﬁcations Manual provides a brief overview of the information contained within each
section of the manual. It is intended for use as a quick reference to assist in the implementation of the Joint
Commission national quality measures. The sections of this manual are interrelated and are most useful
when considered together.

Measures listed in this manual are Chart-Abstracted Measures. Chart abstraction is the review of medical
record documentation from the current episode of care for the purposes of data collection and submission.

In addition, some of the measures in this manual have been retooled as eMeasures and are eligible for
voluntary electronic submission for ORYX performance measure reporting requirements or the Hospital
Inpatient Quality Reporting (IQR) program). For information about the requirements and technical
specifications of the Quality Reporting Document Architecture (QRDA) specifications and data submission,
see the resources located on QualityNet, [Hospitals-Inpatient], Electronically Specified Clinical Quality
Measures (eCQM) Reporting. The Joint Commission ORYX performance measure reporting requirements are
available on the Joint Commission website under the Measurement tab and on Performance Measurement
System Extranet track site (PET) under Manuals and Guides, eCQM Documentation.

Selected standardized measure sets used in the Joint Commission Certification programs have been
incorporated in this specification manual. This is being done to centralize the measures used for Joint
Commission programs into one manual. Note: the Stroke (STK) measures data for certification can be
submitted through an ORYX vendor, however the Advanced Certification Heart Failure (ACHF) measures data
cannot be submitted through an ORYX vendor and may only be submitted through the Certification Measure
Information Process (CMIP).

This manual contains references to CMS and QIO programs that, while not applicable to the Joint
Commission, have been retained to remain consistent with the CMS and Joint Commission aligned
Speciﬁcations Manual for National Hospital Inpatient Quality Measures.

Section 1 and 2: Measurement Information

The measure set sections contain specific measure information forms for each measure. This is followed by
a data element list for the measures, including the general data elements, algorithm output data elements,
and the specific measure data elements. Next is a document that describes the initial patient population and
sample size requirements for each measure set. Also included are subsections for each specific measure.
These contain a Measure Information Form (MIF) and the Performance Measure Algorithm.

The algorithms and data elements needed to calculate each of the Joint Commission national quality
measures are identified in the MIF. Each algorithm provides the logical steps, data element evaluation,
arithmetic calculations, and data manipulation steps that are required to calculate a given measure.

Section 3: Data Dictionary

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The Data Dictionary describes the patient-level and facility-level data elements required to capture and
calculate individual measurements. It specifies those data elements that must be collected for each patient
that falls into the selected measure population and the data elements needed for a specific measure.

Section 4: Missing and Invalid Data

This section addresses the Joint Commission's approach to missing and invalid data. Missing data refers to
data elements that have no values present for one or more episodes of care and invalid data refers to data
element values that fall outside the range of the allowable values. Information and examples are provided on
how the “Unable to Determine” (UTD) value is utilized within the measure algorithm and on submission into
the Joint Commission's Data Warehouse. This section also describes the general and measure specific data
elements that are required for submission and how missing and/or invalid data will be handled.

Section 5: Population and Sampling Methods

Sampling is an available option for all Joint Commission national quality measures if certain requirements
are met. This section provides guidance on defining the hospital's Initial Patient Population and information
and examples on the order of data flow, sample size requirements, sampling approaches and the
transmission of Initial Patient Population and sample data elements to the Joint Commission's Data
Warehouse. Specific measure set sample size requirements tables are located in the Measure Information
section.

Section 6: Reserved for future use

Joint Commission National Quality Measure Verification Process: This section has been moved to the ORYX
Technical Implementation Guide and is available to ORYX Vendors via the Joint Commission's extranet site for
measurement systems (PET).

Section 7: Joint Commission National Quality Measures Data Transmission

This section of the manual is provided to highlight the unique data transmission specifications for Joint
Commission national quality measure data. This section is divided into four parts: Joint Commission
National Quality Measure Data Transmission, Guidelines for Submission of Data, Transmission Data Element
List, and Transmission Data Processing Flow.

The Joint Commission Data Transmission section provides information related to the transmission of Joint
Commission national quality measure data to the Joint Commission's Data Warehouse. The Guidelines for
Submission of Data includes an overview of the data required to be submitted to the Joint Commission's
Data Warehouse, as well as the Hospital Clinical Data XML file layout and the Hospital Initial Patient
Population Data XML file Layout.

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The Transmission Data Element List describes the data elements that are either used to identify the hospital
and measure set associated to the transmitted data or are calculated by the vendor using the hospital's
patient-level data and measure results. These data elements are not used in the Initial Patient Population
Algorithms or Measure Algorithms. The Transmission Data Processing Flows contains information regarding
the order in which the Joint Commission's Data Warehouse evaluates the Joint Commission national quality
measures and the population and sampling data.

Appendix A: Code Tables

For many of the measures, eligibility for inclusion or exclusion in the Initial Patient Population of interest is
defined by the presence of certain ICD-10-CM diagnosis and ICD-10-PCS procedure codes within the patient-
level record. Appendix A contains the ICD-10 code tables that define these indicator populations for all
measures within each measure set. There is a description of the code as defined in a coding manual and a
shortened description that may be used in a data abstraction tool. The Measure Information Section also
refers to the codes or tables provided in this section. ICD-10 codes are modified by the National Center for
Health Statistics (NCHS) and the Centers for Medicare & Medicaid Services (CMS). The code tables in this
Appendix are evaluated semiannually and modified based on these changes. Potential changes become
effective beginning with either April 1st or October 1st discharges. Updates will be provided as indicated.

Appendix C: Medication Tables

Some of the Joint Commission national quality measures address the use of certain medications. This
Appendix contains tables with the specific names of medications that may be associated with medication
categories (e.g., trade names). For example, Haloperidol may also be documented as Haldol. These tables
are provided to facilitate appropriate data collection of applicable medications. These tables are not meant
to be an inclusive list of all available therapeutic agents; rather they represent current information available
at the time of publication. Approved medication tables will be updated regularly. Discrepancies must be
reported. See the Resource Section of this manual for contact information.

Appendix D: Glossary of General Terms

Appendix E: Overview of Measure Information Form and Flowchart Formats

Each measure has an associated Measure Information Form and Flowchart (calculation algorithm). This
Appendix explains each of the terms used on the Measure Information Form and provides a brief
introduction to flowcharting, including an explanation of flowchart symbols.

Appendix G: Resources

This section lists resources that are available to assist with the Joint Commission measures.

The tables in this Appendix contain clinical information to supplement the data element dictionary and
provide additional details for data abstraction. They are referenced under the data dictionary under the Notes
for Abstraction or the Guidelines for Abstraction.

Appendix P: Preview Section

The preview section is intended to provide an overview of future updates. The information provided in this
section is not to be programmed or submitted. Placement in this appendix does not assume that the
information listed will be implemented in a future manual.

Set Measures

Set Measure Short Name

Measure ID

HBIPS-1 Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient
Strengths completed

HBIPS-2 Hours of physical restraint use

HBIPS-3 Hours of seclusion use

HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification

General Data Elements

Element Name Collected For

Admission Date All Records,

Birthdate All Records,

CMS Certification Number Transmission, Hospital Clinical Data File,

Optional for All Records,

Discharge Date All Records, Not collected for HBIPS-2 and

HBIPS-3

Health Care Organization Identifier All Records, Patient Population Data File,
Hospital Clinical Data File,

Hispanic Ethnicity All Records,

ICD-10-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records

ICD-10-PCS Other Procedure Dates All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File, Used in
calculation of the Joint Commission's
aggregate data and in the transmission of
the Hospital Clinical Data file.

Payment Source All Records, Optional for HBIPS-2 and

HBIPS-3

Psychiatric Care Setting All Records, HBIPS

Race All Records,

Sex All Records,

Vendor Tracking Identifier All Records, Transmission, Hospital Clinical

Data File,

Algorithm Output Data Elements

Element Name Collected For

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File

Measurement Value Calculation, Transmission, Hospital Clinical

Data File

Measure Set Specific Data Elements

Element Name Collected For

Appropriate Justification for Multiple Antipsychotic Medications HBIPS-5

Discharge Disposition HBIPS-5

Event Date HBIPS-2, HBIPS-3

Event Type HBIPS-2, HBIPS-3

Minutes of Physical Restraint HBIPS-2

Minutes of Seclusion HBIPS-3

Number of Antipsychotic Medications Prescribed at Discharge HBIPS-5

Patient Status at Discharge HBIPS-5

Patient Strengths HBIPS-1

Psychiatric Inpatient Days - Medicare Only HBIPS-2, HBIPS-3

Psychiatric Inpatient Days-Non-Medicare Only HBIPS-2, HBIPS-3

Psychological Trauma History HBIPS-1

Substance Use HBIPS-1

Total Leave Days - Medicare Only HBIPS-2, HBIPS-3

Total Leave Days-Non-Medicare Only HBIPS-2, HBIPS-3

Violence Risk to Others HBIPS-1

Violence Risk to Self HBIPS-1

Related Materials

Document Name

Acknowledgement

Appendix A - Code Tables

Appendix C - Medication Tables

Appendix D - Glossary of Terms

Appendix E - Overview of Measure Information Form and Flowchart Formats

Appendix G - Resources

Appendix H - Miscellaneous Tables

Cover Page for the Joint Commission Manual

Data Dictionary

Introduction to the Manual

Missing and Invalid Data

Sampling

Table of Contents

Transmission Alpha Data Dictionary

Transmission Data Processing Flow: Clinical

Transmission Data Processing Flow: Population and Sampling

Transmission of Data

Using the The Joint Commission's National Measure Specifications Manual

Hospital-Based Inpatient Psychiatric Services (HBIPS) Measure Set Initial Patient

Population

The HBIPS measure set is unique in that there are two distinct Initial Patient Populations within the measure
set, one for the discharge measures (HBIPS-1, HBIPS-5) and the other for event measures (HBIPS-2 and
HBIPS-3).

Initial Patient Population for Discharge Measures (HBIPS-1, HBIPS-5)

The general population of the HBIPS discharge measures can be identified by using four data elements that
are common to the discharge performance measures in the HBIPS set:

ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes

Discharge Date
Birthdate
Psychiatric Care Setting

The HBIPS Discharge Topic Population is defined as patients discharged from the Psychiatric Care Setting
with an ICD-10-CM Principal or Other Diagnosis Code for Mental Disorders as defined in Appendix A, Table
10.01 and a Patient Age at Discharge (Discharge Date -— Birthdate) >= 1 year.

There are four distinct strata within the HBIPS Discharge Topic Population; each is identified by a specific
age range. The patients in each stratum are counted in the HBIPS Initial Patient Population for discharge
measures of multiple measures.

Discharge Measures Age Strata Initial Patient Population definition

HBIPS-1a and 5a (overall Age greater than and equal to 1 The count of all patients in strata 1, 2, 3,
measures) year and 4

HBIPS-1b and 5b Age 1 year through 12 years The count of all patients in stratum 1

HBIPS-1c and 5c Age 13 years through 17 years The count of all patients in stratum 2

HBIPS-1d and 5d Age 18 years through 64 years The count of all patients in stratum 3

HBIPS-1e and 5e Age greater than and equal to 65 The count of all patients in stratum 4
years

Patients discharged from the hospital with an ICD-10-CM Principal or Other Diagnosis Code for Mental
Disorders as defined in Appendix A, Table 10.01 are included in one of the HBIPS Strata Initial Populations
for discharge measures and are eligible to be sampled if they have:

Discharge Stratum 1 — Age 1 year through 12 years stratum — A Patient Age at Discharge (Discharge Date -—
Birthdate) >= 1 year and < 13 years

Discharge Stratum 2 - Age 13 years through 17 years stratum — A Patient Age at Discharge (Discharge Date -
— Birthdate) >= 13 years and < 18 years

Discharge Stratum 3 - Age 18 years through 64 years stratum — A Patient Age at Discharge (Discharge Date -
— Birthdate) >= 18 years and < 65 years

Discharge Stratum 4 - Age greater than and equal to 65 years stratum — A Patient Age at Discharge
(Discharge Date -— Birthdate) >= 65 years

Initial Patient Population for Event Measures (HBIPS-2 and HBIPS-3)

The population of the HBIPS event measures can be identified by using two data elements that are common
to the event performance measures in the HBIPS set:

Event Date
Psychiatric Care Setting

The HBIPS Event Topic Population (common to all HBIPS event measures) is defined as patients with an
event (Event Date exists) while they are in the hospital with a Patient Age at Time of Event (Event Date -—
Birthdate) >= 1 year and the patient was in a Psychiatric Care Setting (='Y') when the event occurred. There
are four distinct strata or sub-populations within the HBIPS Event Topic Population, each identified by a
specific age range. The patients in each stratum are counted in the HBIPS Initial Patient Population for event
measures of multiple measures.

Event Measures Age Strata Initial Patient Population definition

HBIPS-2a and 3a (overall Age greater than and equal to 1 The count of all patients in strata 1, 2, 3,
measures) year and 4

HBIPS-2b and 3b Age 1 year through 12 years The count of all patients in stratum 1

HBIPS-2c and 3c Age 13 years through 17 years The count of all patients in stratum 2

HBIPS-2d and 3d Age 18 years through 64 years The count of all patients in stratum 3

HBIPS-2e and 3e Age greater than and equal to 65 The count of all patients in stratum 4
years

Patients for which an event occurs (Event Date exists) while in a Psychiatric Care Setting (='Y') in the hospital
are included in one of the Strata Initial Populations for the event measures. There is no sampling for the
HBIPS event measures. All patients in the Initial Population for HBIPS event measures are automatically
sampled.

Event Stratum 1 — Age 1 year through 12 years stratum — A Patient Age at Time of Event (Event Date -—
Birthdate) >= 1 year and < 13 years

Event Stratum 2 - Age 13 years through 17 years stratum — A Patient Age at Time of Event (Event Date —-
Birthdate) >= 13 years and < 18 years

Event Stratum 3 - Age 18 years through 64 years stratum — A Patient Age at Time of Event (Event Date -—
Birthdate) >= 18 years and < 65 years

Event Stratum 4 - Age greater than and equal to 65 years stratum — A Patient Age at Time of Event (Event
Date —- Birthdate) >= 65 years

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Sample Size Requirements

Note For Joint Commission purposes, the HBIPS measure set is not included in the aligned Global Sampling
methodology. All patients meeting the definition of the HBIPS Initial Patient Populations are eligible to be
sampled, abstracted, and transmitted to the Joint Commission's Data Warehouse.

Sample Size Requirements for HBIPS Discharge Measures (HBIPS-1, HBIPS-5)

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures
consistently produce statistically valid and useful data. Because the sample for a measure set will rarely be
equal to the effective sample due to exclusions and contraindications, hospitals selecting sample cases
MUST submit AT LEAST the minimum required sample size.

The following sample size tables for each option automatically build in the number of cases needed to
obtain the required sample sizes. For information concerning how to perform sampling, refer to the
Population and Sampling Specifications section in this manual.

Quarterly Sampling

For hospitals selecting sample cases for the HBIPS discharge measures, a modified sampling procedure is
required. Hospitals selecting sample cases for this set must ensure that each individual stratum's population
and effective quarterly sample size meets the following conditions:

Select within each of the four individual measure strata. The effective quarterly sample size within a
stratum is at least 44 cases per quarter. Cases are placed into the appropriate stratum based upon
the patient's age.
The required quarterly sample size is at least 20% of the stratum population for the quarter.

Quarterly Sample Size

Based on Initial Patient Population for the HBIPS Discharge (HBIPS-DSC) Measures

Hospital's Measures

Average Quarterly Minimum Required

Stratum Initial Patient Stratum Sample Size
Population Size “n”
“N”

Average Quarterly Minimum Required

Stratum Initial Patient Stratum Sample Size
Population Size “n”
“N”

> 877 176

221 —- 877 20% of the Initial Patient Population

44 -— 220 44

< 44 No sampling; 100% of the Initial Patient Population is required

Monthly Sampling

For hospitals selecting sample cases for HBIPS discharge measures, a modified sampling procedure is
required. Hospitals selecting sample cases for this set must ensure that each individual strata population
and effective monthly sample size meets the following conditions:

Select within each of the four individual measure strata. The effective monthly sample size within a
stratum is at least 15 cases per month. Cases are placed into the appropriate stratum based upon the
patient's age.
The required monthly sample size is at least 20% of the stratum population for the month.

Monthly Sample Size

Based on Initial Patient Population for the HBIPS Discharge (HBIPS-DSC) Measures

Hospital's Measures

Average Monthly Minimum Required

Stratum Initial Patient Stratum Sample Size
Population Size “n”
“N”

> 295 60

76 —- 295 20% of the Initial Patient Population

15 —- 75 15

< 15 No sampling; 100% of the Initial Patient Population is required

Sample Size Examples

All sampled strata in HBIPS should be used in the calculation of all HBIPS discharge measures. All of the
HBIPS discharge measures' specific exclusion criteria are used to filter out cases that do not belong in the
measure denominator. Using HBIPS-1b as an example, include cases covering all sampled strata, although
the measure-specific exclusion criteria would only allow cases with an age of 1 year through 12 years to be
included in the denominator.

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Quarterly sampling:
When applicable, larger hospitals must also abide by the required quarterly sample sizes for the four
individual measure strata a minimum of 44 or 20% of population required sample cases per stratum
when Initial Patient Population size is 44 or greater.
The HBIPS Initial Patient Population sizes for a hospital are 5, 100, 221, and 876 patients for
each stratum respectively per quarter. The required quarterly sample sizes would be 5, 44, 45,
and 176.
The 1st stratum is less than the minimum required quarterly sample size, so 100% of
this stratum is sampled.
The 2nd stratum has 100 patients per quarter, which falls in the average quarterly
population size of 44 to 220 patients, so 44 cases are sampled.
The 3rd stratum has 221 patients per quarter, which requires a 20% sample size, of 45
cases (twenty percent of 221 equals 44.2 rounded to the next highest whole number =
45).
The 4th stratum has 876 patients per quarter, which is more than the maximum
condition, so a minimum of 176 cases are required to be sampled.

Monthly sampling:
When applicable, larger hospitals must also abide by the required monthly sample sizes for the four
individual measure strata a minimum of 15 required sample cases per stratum when Initial Patient
Population size is 15 or greater.
The HBIPS Initial Patient Population sizes for a hospital are 5, 45, 294 and 400 patients
respectively in July. The required monthly sample sizes would be 5, 15, 59, and 60.
The 1st stratum is less than the minimum required monthly sample size, so 100% of this
stratum is sampled.
The 2nd stratum has 45 patients per month, which falls in the average monthly
population size of 15 to 75 patients, so 15 cases are sampled.
The 3rd stratum has 294 patients per month, which requires a 20% sample size, of 59
cases (twenty percent of 294 equals 58.8 rounded to the next highest whole number =
59).
The 4th stratum has 400 patients per month, which is more than the maximum
condition, so a minimum of 60 cases are required to be sampled.

Sampling Requirements for HBIPS Event Measures (HBIPS-2 and HBIPS-3)

The measures in HBIPS-EVT (HBIPS-2 and HBIPS-3) are not eligible for sampling and will use the entire Initial
Patient Population for reporting.

Measure Information Form

Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measure ID: HBIPS-1

Set Measure ID Performance Measure Name

HBIPS-1a Admission Screening- Overall Rate

HBIPS-1b Admission Screening- Children (1 through 12 years)

HBIPS-1c Admission Screening- Adolescent (13 through 17 years)

HBIPS-1d Admission Screening- Adult (18 through 64 years)

HBIPS-1e Admission Screening- Older Adult (≥65 years)

Performance Measure Name: Admission Screening for Violence Risk, Substance Use, Psychological Trauma
History and Patient Strengths completed

Description: Patients admitted to a hospital-based inpatient psychiatric setting who are screened within the
first three days of admission for all of the following: risk of violence to self or others, substance use,
psychological trauma history and patient strengths.

Rationale: Substantial evidence exists that there is a high prevalence of co-occurring substance use
disorders as well as history of trauma among persons admitted to acute psychiatric settings. Professional
literature suggests that these factors are under-identified yet integral to current psychiatric status and
should be assessed in order to develop appropriate treatment (Ziedonis, 2004; NASMHPD, 2005). Similarly,
persons admitted to inpatient settings require a careful assessment of risk for violence and the use of
seclusion and restraint. Careful assessment of risk is critical to safety and treatment. Effective,
individualized treatment relies on assessments that explicitly recognize patients' strengths. These strengths
may be characteristics of the individuals themselves, supports provided by families and others, or
contributions made by the individuals' community or cultural environment (Rapp, 1998). In the same way,
inpatient environments require assessment for factors that lead to conflict or less than optimal outcomes.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Psychiatric inpatients with admission screening within the first three days of
admission for all of the following: risk of violence to self or others; substance use; psychological trauma
history; and patient strengths

Included Populations: Not applicable

Data Elements:

Patient Strengths
Psychological Trauma History
Substance Use
Violence Risk to Others
Violence Risk to Self

Denominator Statement: Psychiatric inpatient discharges

Included Populations:

Patients with ICD-10-CM Principal or Other Diagnosis Codes for Mental Disorders as defined in
Appendix A, Table 10.01

Excluded Populations:

Patients for whom there is an inability to complete admission screening for Violence Risk,
Substance Use, Psychological Trauma History and Patient Strengths within the first three days of
admission
Patients with a Length of Stay ≤ 3 days or ≥ 365 days

Data Elements:

Admission Date
Birthdate
Discharge Date
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
Psychiatric Care Setting

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include
administrative/billing data and medical records.

Data Accuracy: Hospitals may wish to implement periodic audits to monitor and ensure data accuracy.

Measure Analysis Suggestions: The data elements for each of the five initial assessment elements provide
an opportunity to assess each component individually. However, completion of all five initial assessment
categories is required for this measure.

Sampling: Yes. For additional information see the Sampling Section.

Selected References:

American Psychiatric Association (2016). Practice Guidelines for the Psychiatric Evaluation of Adults.
Third edition. Arlington (VA): American Psychiatric Association.
Lyons JS, Uziel-Miller ND, Reyes F, Sokol PT (2000). Strengths of children and adolescents in
residential settings: Prevalence and associations with psychopathology and discharge placement.
Journal of the American Academy of Child & Adolescent Psychiatry, Vol 39(2): 176-181.
NASMHPD. (2005) Position Statement on Services and Supports to Trauma Survivors. Alexandria, VA:
NASMHPD.
Rapp CA (1998). The strengths model: Case management with people suffering from severe and
persistent mental illness. London: Oxford University Press.
Ruiz P (2004). Addressing Culture, Race, & Ethnicity in Psychiatric Practice. Psychiatric Annals, Vol
34(7): 527-532.
Ziedonis DM (2004). Integrated treatment of co-occurring mental illness and addiction: Clinical
intervention, program, and system perspectives. CNS Spectrums 9(12): 892,894-904,925.

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measure ID: HBIPS-2

Set Measure ID Performance Measure Name

HBIPS-2a Physical Restraint- Overall Rate

HBIPS-2b Physical Restraint- Children (1 through 12 years)

HBIPS-2c Physical Restraint- Adolescent (13 through 17 years)

HBIPS-2d Physical Restraint- Adult (18 through 64 years)

HBIPS-2e Physical Restraint- Older Adult (≥ 65 years)

Performance Measure Name: Hours of physical restraint use

Description: The total number of hours that all patients admitted to a hospital-based inpatient psychiatric
setting were maintained in physical restraint.

Rationale: Mental health providers that value and respect an individual's autonomy, independence and safety
seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of
seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when
restraint and seclusion are used; such use is rigorously monitored and analyzed to prevent future use.
Providers also seek to prevent violence or aggression from occurring in their treatment environments by
focusing their attention on prevention activities that have a growing evidence base (Donat, 2003).

Type Of Measure: Process

Improvement Noted As: Decrease in the rate

Numerator Statement: The total number of hours that all psychiatric inpatients were maintained in physical
restraint

Numerator Basis: The numerator evaluates the number of hours of physical restraint; however, the algorithm
calculates the number of minutes to ensure a more accurate calculation of the measure. Convert the
minutes to hours when analyzing and reporting this measure.

Included Populations:

Patients for whom at least one physical restraint event is reported during the month

Excluded Populations: None

Event Date
Event Type
Minutes of Physical Restraint

Denominator Statement: Number of psychiatric inpatient days

Denominator Basis: per 1,000 hours

Included Populations:

All psychiatric inpatient days

Excluded Populations:

Total leave days

Data Elements:

Admission Date
Birthdate
Psychiatric Care Setting
Psychiatric Inpatient Days - Medicare Only
Psychiatric Inpatient Days-Non-Medicare Only
Total Leave Days - Medicare Only
Total Leave Days-Non-Medicare Only

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include
administrative/billing data and medical records.

Data Accuracy: Hospitals may wish to implement periodic audits to monitor and ensure data accuracy.

Measure Analysis Suggestions: In order to further examine the issue of restraint use within a facility it may
be useful to study the incidence of physical restraint use by collecting additional information about the
clinical justification for use.

Sampling: No.

Data Reported As: Aggregate rate generated from count data reported as a ratio .

Selected References:

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Donat, D. (August, 2003). An analysis of successful efforts to reduce the use of seclusion and
restraint at a public psychiatric hospital. Psychiatric Services. 54(8): 1119-1123.
Fisher, W. A. (2003). Elements of successful restraint and seclusion reduction programs and their
application in a large, urban, state psychiatric hospital. Journal of Psychiatric Practice, 9(1), 7-15.
Huckshorn, K.A. (2004/September). Reducing seclusion and restraint use in mental health settings:
Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services. 42(9). Pp.
22-31.
Mohr, W. K., & Anderson, J. A. (2001). Faulty assumptions associated with the use of restraints with
children. Journal of Child and Adolescent Psychiatric Nursing, 14(3), 141- 151.
Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services, 56 (9), 1104-1142.
Success Stories and Ideas for Reducing Restraint/Seclusion. (2003). A compendium of strategies
created by the American Psychiatric Association (APA), the American Psychiatric Nurses Association
(APNA), the National Association of Psychiatric Health Systems (NAPHS), and the American Hospital
Association Section for Psychiatric and Substance Abuse Services (AHA). Retrieved from the Internet
on February 10, 2010 at http://www.naphs.org

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measure ID: HBIPS-3

Set Measure ID Performance Measure Name

HBIPS-3a Seclusion- Overall Rate

HBIPS-3b Seclusion- Children (1 through 12 years)

HBIPS-3c Seclusion- Adolescent (13 through 17 years)

HBIPS-3d Seclusion- Adult (18 through 64 years)

HBIPS-3e Seclusion- Older Adult (≥ 65 years)

Performance Measure Name: Hours of seclusion use

Description: The total number of hours that all patients admitted to a hospital-based inpatient psychiatric
setting were held in seclusion.

Rationale: Mental health providers that value and respect an individual's autonomy, independence and safety
seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003). The use of
seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when
restraint or seclusion are used; such use is rigorously monitored and analyzed to prevent future use.
Providers also seek to prevent violence or aggression from occurring in their treatment environments by
focusing their attention on prevention activities that have a growing evidence base (Donat, 2003).

Type Of Measure: Process

Improvement Noted As: Decrease in the rate

Numerator Statement: The total number of hours that all psychiatric inpatients were held in seclusion

Numerator Basis: The numerator evaluates the number of hours of seclusion; however, the algorithm
calculates the number of minutes to ensure a more accurate calculation of the measure. Convert the
minutes to hours when analyzing and reporting this measure.

Included Populations:

Patients for whom at least one seclusion event is reported during the month

Excluded Populations: None

Event Date
Event Type
Minutes of Seclusion

Denominator Statement: Number of psychiatric inpatient days

Denominator Basis: per 1,000 hours

Included Populations:

All psychiatric inpatient days

Excluded Populations:

Total leave days

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include
administrative/billing data and medical records.

Data Accuracy: Hospitals may wish to implement periodic audits to monitor and ensure data accuracy.

Measure Analysis Suggestions: In order to further examine the issue of seclusion use within your facility it
may be useful to study the incidence of seclusion use by collecting additional information about the clinical
justification for use.

Sampling: No.

Data Reported As: Aggregate rate generated from count data reported as a ratio .

Selected References:

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Donat, D. (August, 2003). An analysis of successful efforts to reduce the use of seclusion and
restraint at a public psychiatric hospital. Psychiatric Services. 54(8): 1119-1123.
Fisher, W. A. (2003). Elements of successful restraint and seclusion reduction programs and their
application in a large, urban, state psychiatric hospital. Journal of Psychiatric Practice, 9(1), 7-15.
Huckshorn, K.A. (2004/September). Reducing seclusion and restraint use in mental health settings:
Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services. 42(9). Pp.
22-31.
Mohr, W. K., & Anderson, J. A. (2001). Faulty assumptions associated with the use of restraints with
children. Journal of Child and Adolescent Psychiatric Nursing, 14(3), 141- 151.
Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services, 56 (9), 1104-1142.
Success Stories and Ideas for Reducing Restraint/Seclusion. (2003). A compendium of strategies
created by the American Psychiatric Association (APA), the American Psychiatric Nurses Association
(APNA), the National Association of Psychiatric Health Systems (NAPHS), and the American Hospital
Association Section for Psychiatric and Substance Abuse Services (AHA). Retrieved from the Internet
on February 10, 2010 at http://www.naphs.org

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Measure Information Form
Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)

Set Measure ID: HBIPS-5

Set Measure Performance Measure Name

HBIPS-5a Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Overall Rate

HBIPS-5b Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Children (1

through 12 years)

HBIPS-5c Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adolescent (13
through 17 years)

HBIPS-5d Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adult (18 through
64 years)

HBIPS-5e Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Older Adult (≥ 65
years)

Performance Measure Name: Patients discharged on multiple antipsychotic medications with appropriate
justification

Description: Patients discharged from a hospital-based inpatient psychiatric setting on two or more
antipsychotic medications with appropriate justification

Rationale: Research studies have found that 4-35% of outpatients and 30-50% of inpatients treated with an
antipsychotic medication concurrently received 2 or more antipsychotics (Covell, Jackson, Evans, & Essock,
2002; Ganguly, Kotzan, Miller, Kennedy, & Martin, 2004; Gilmer, Dolder, Folsom, Mastin, & Jeste, 2007;
Kreyenbuhl, Valenstein, McCarthy, Ganocyz, & Blow, 2006; Stahl & Grady, 2004). One study reported 4.6% of
patients concurrently received 3 or more antipsychotics (Jaffe & Levine, 2003). These findings are seen
across diverse sectors: state mental health authorities, the Veterans Health System and Medicaid-financed
care. Antipsychotic polypharmacy can lead to greater side effects, often without improving clinical outcomes
(Ananth, Parameswaran, & Gunatilake, 2004; Stahl & Grady, 2004). As a result, a range of stakeholders have
called for efforts to reduce unnecessary use of multiple antipsychotics (Centorrino, Gören, Hennen,
Salvatore, Kelleher, & Baldessarini, 2004; Gilmer, Dolder, Folsom, Mastin, & Jeste, 2007; National Association
of State Mental Health Program Directors, 2001; University HealthSystem Consortium, 2006). Practice
guidelines recommend the use of a second antipsychotic only after multiple trials of a single antipsychotic
have proven inadequate (American Psychiatric Association [APA] Practice Guidelines, 2004). Randomized
controlled trials (RCTs) provide some evidence to support augmentation with a second antipsychotic in
treatment resistant patients. Most of these studies were limited to augmentation of clozapine with another
second-generation antipsychotic (Tranulis, Skalli, Lalonde, & Nicole, 2008). Among patients without a
documented history of previous treatment failures of antipsychotic monotherapy, multiple RCTs and other
controlled trials failed to show a benefit of antipsychotic polypharmacy over monotherapy (Ananth,
Parameswaran, & Gunatilake, 2004; Centorrino, Gören, Hennen, Salvatore, Kelleher, & Baldessarini, 2004;
Potkin, Thyrum, Alva, Bera, Yeh, & Arvanitis, 2002; Shim et al., 2007; Stahl,& Grady, 2004). Clinical

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circumstances, such as shorter inpatient stays, may require hospitals to discharge a patient on multiple
antipsychotics with an aftercare plan to transition to monotherapy. In such cases, effective communication
between the inpatient and aftercare clinician is an essential element of care.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Psychiatric inpatients discharged on two or more routinely scheduled antipsychotic
medications with appropriate justification

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Appropriate Justiﬁcation for Multiple Antipsychotic Medications

Denominator Statement: Psychiatric inpatient discharges

Included Populations:

Patients with ICD-10-CM Principal or Other Diagnosis Codes for Mental Disorders as defined in
Appendix A, Table 10.01 discharged on two or more routinely scheduled antipsychotic
medications (refer to Appendix C, Table 10.0- Antipsychotic Medications).

Excluded Populations:

Patients who expired

Patients with an unplanned departure resulting in discharge due to elopement
Patients with an unplanned departure resulting in discharge due to failing to return from leave
Patients with a length of stay ≤ 3 days

Data Elements:

Admission Date
Birthdate
Discharge Date
Discharge Disposition
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
Number of Antipsychotic Medications Prescribed at Discharge
Patient Status at Discharge
Psychiatric Care Setting

Data Collection Approach: Retrospective data sources for required data elements include
administrative/billing data and medical records.

Data Accuracy: Hospitals may wish to implement periodic audits to monitor and ensure data accuracy.

Measure Analysis Suggestions: For quality improvement purposes, the measurement system may want to
create reports to identify patients discharged on two or more antipsychotic medications without appropriate
supporting documentation. This would allow healthcare organizations to target education efforts.

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American Psychiatric Association (APA). (2004). Steering Committee on Practice Guidelines. Practice
guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 161(2
Suppl):1-56
Ananth, J., Parameswaran, S., & Gunatilake, S. (2004). Antipsychotic polypharmacy comparing
monotherapy with polypharmacy and augmentation. Curr Med Chem. 11(3):313-327 Curr Pharm Des.
10(18):2231-2238.
Centorrino, F., Gören, J.L., Hennen, J., Salvatore, P., Kelleher, J.P., & Baldessarini, R.J. (2004) Multiple
versus single antipsychotic agents for hospitalized psychiatric patients: a case control study of risk
versus benefit. Am J Psychiatry. 161 (4):700-706.
Covell, N.H., Jackson, C.T., Evans, A.C., & Essock, S.M. (2002). Antipsychotic prescribing practices in
Connecticut's public mental health system: rates of changing medication prescribing styles. Schiz
Bull. 28(1):17-29,
Ganguly, R., Kotzan, J.A., Miller, L.S., Kennedy, K., & Martin, B.C. (2004). Prevalence, trends, and factors
associated with antipsychotic polypharmacy among Medicaid-eligible schizophrenia patients, 1998-
2000. J Clin Psychiatry. 65(10):1377-88.
Gilmer, T.P., Dolder, C.R., Folsom, D.P., Mastin, W., & Jeste, D.V. (2007), Antipsychotic polypharmacy
trends among Medicaid beneficiaries with schizophrenia in San Diego County, 1999 - 2004. Psychiatric
Serv. 59(7):1007-1010.
Jaffe, A.B. & Levine, J. (2003). Antipsychotic medication co-prescribing in a large state hospital
system. Pharmacoepidemiol Drug Saf.12:41-48.
Kreyenbuhl, J., Valenstein, M., McCarthy, J.F., Ganocyz, D., & Blow, F.C. (2006). Long-term combination
antipsychotic treatment in VA patients with schizophrenia. Schiz Res.84:90-99.
National Association of State Mental Health Program Directors (NASMHPD). (2001).Technical report
on psychiatric polypharmacy. Alexandria, VA.
Potkin, S.G., Thyrum, P.T., Alva, G., Bera, R., Yeh, C., & Arvanitis, L.A. (2002). The safety and
pharmacokinetics of quetiapine when coadministered with haloperidol, risperidone or thioridazine. J
Clin Psychopharmacol. 22:121-130.
Shim, J.C., Shin, J.G., Kelly, D.L., Jung, D.U., Seo, Y.S., Liu, K.H., et al. (2007). Adjunctive treatment with
a dopamine partial agonist aripiprazole, for treatment of antipsychotic-induced hyperprolactinemia: A

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placebo controlled trial. Am J Psych.164:1404-1410.
Stahl, S.M. & Grady, M.M. (2004). A critical review of atypical antipsychotic utilization: comparing
monotherapy with polypharmacy augmentation. Curr Med Chem.11:313-327.
Tranulis, C., Skalli, L., Lalonde, P., & Nicole, L. (2008). Benefits and risks of antipsychotic polypharmacy.
An evidence based review of the literature. Drug Saf.31(1):7-20
University HealthSystem Consortium. (2006). Mental health performance measures field brief.
Oakbrook, IL.

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Perinatal Care (PC)

Set Measures

Set Measure ID Measure Short Name

PC-01 Elective Delivery

PC-02 Cesarean Birth

PC-03 Antenatal Steroids

PC-04 Health Care-Associated Bloodstream Infections in Newborns

PC-05 Exclusive Breast Milk Feeding

PC-06 Unexpected Complications in Term Newborns

General Data Elements

Element Name Collected For

Admission Date All Records,

Birthdate All Records,

Discharge Date All Records, Not collected for HBIPS-2 and

HBIPS-3

Health Care Organization Identifier All Records, Patient Population Data File,
Hospital Clinical Data File,

Hispanic Ethnicity All Records,

ICD-10-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records

ICD-10-PCS Other Procedure Dates All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File, Used in
calculation of the Joint Commission's
aggregate data and in the transmission of
the Hospital Clinical Data file.

Payment Source All Records, Optional for HBIPS-2 and

HBIPS-3

Race All Records,

Sex All Records,

Algorithm Output Data Elements

Element Name Collected For

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File

Measurement Value Calculation, Transmission, Hospital Clinical

Data File

Measure Set Specific Data Elements

Element Name Collected For

Admission to NICU PC-05

Antenatal Steroids Initiated PC-03

Birth Weight PC-04, PC-06

Bloodstream Infection Confirmed PC-04

Bloodstream Infection Present on Admission PC-04

Discharge Disposition PC-04, PC-05, PC-06

Exclusive Breast Milk Feeding PC-05

Gestational Age PC-01, PC-02, PC-03

History of Stillbirth PC-01

Labor PC-01

Previous Live Births PC-02

Prior Uterine Surgery PC-01

Reason for Not Initiating Antenatal Steroids PC-03

Term Newborn PC-05, PC-06

Related Materials

Document Name

Acknowledgement

Appendix A - Code Tables

Appendix C - Medication Tables

Appendix D - Glossary of Terms

Appendix E - Overview of Measure Information Form and Flowchart Formats

Appendix G - Resources

Appendix H - Miscellaneous Tables

Cover Page for the Joint Commission Manual

Data Dictionary

Introduction to the Manual

Missing and Invalid Data

Sampling

Table of Contents

Transmission Alpha Data Dictionary

Transmission Data Processing Flow: Clinical

Transmission Data Processing Flow: Population and Sampling

Transmission of Data

Using the The Joint Commission's National Measure Specifications Manual

The PC measure set is unique in that there are two distinct Initial Patient Populations within the measure set,
mothers and newborns.

Mothers
The population of the PC-Mother measures (PC-01, 02, and 03) are identified using 4 data elements:

Admission Date
Birthdate
Discharge Date
ICD-10-PCS Principal or Other Procedure Code

Patients admitted to the hospital for inpatient acute care are included in the PC Mother Initial sampling
group if they have: ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 11.01.1, a
Patient Age (Admission Date — Birthdate) >= 8 years and < 65 and a Length of Stay (Discharge Date -
Admission Date) ≤ 120 days.

Note: Hospitals are NOT required to sample their data. If sampling offers minimal benefit (e.g., a hospital has
80 cases for the quarter and must select a sample of 76 cases), or if the hospital has access to a data
source which makes medical record review unnecessary (e.g., using vital records, delivery logs or clinical
information systems as a data source for some of the maternal measures in the perinatal measure set), the
hospital may choose to use all cases.

Newborns
The population of the PC-Newborn measures (PC-04, 05 and PC-06) are identified using 6 data elements:

Admission Date
Birthdate
Discharge Date
ICD-10-CM Principal or Other Diagnosis Code
ICD-10-PCS Principal or Other Procedure Code
Birth Weight

Within the PC-Newborn population, there are three subpopulations, i.e Newborns with Blood Stream Infection
or BSI, Newborns with Breast Feeding, and Newborns with Unexpected Complications, each identified by
Patient Age at admission and a specific group of diagnosis and procedure codes or lack thereof. The
patients in each subpopulation are processed independently through each initial patient population flow.
Patients may fall in any one or two or three subpopulations depending on the presence or absence of the
diagnosis codes or procedure codes and other data elements defined by the respective initial patient
subpopulations.

Measures Initial Patient Population definition

PC-04 The count of all patients in PC-Newborns with BSI

PC-05 The count of all patients in PC-Newborns with Breast Feeding

PC-06 The count of all patients in PC-Newborns with Unexpected Complications

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Patients admitted to the hospital for inpatient acute care are included in one of the PC Newborn
subpopulations if they have:

Newborns with BSI - Patients with a Newborn Patient Age at admission (Admission Date — Birthdate) ≤ 2 days
AND satisfy conditions #1 through #3.

1. NO ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 11.10.2,

2. ONE of the following:
an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Tables 11.12, 11.13, 11.14 Or Birth
Weight >= 500g and <= 1499g
an ICD-10-CM Other Diagnosis Code as defined in Appendix A, Tables 11.15, 11.16, Or Birth
Weight >=1500g with ANY OF THE FOLLOWING:
an ICD-10-PCS-Principal or Other Procedure Code as defined in Appendix A, Tables 11.18 or
11.19
Discharge Disposition of 6 (expired) or a Missing Discharge Disposition
NO ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 11.10.3
Birth Weight Missing or Unable To Determine (UTD).
3. NO ICD-10-CM Other Diagnosis Code as defined in Appendix A, Table 11.20 Or Birth Weight < 500g

There is NO sampling for this measure.

Newborns with Breast Feeding - Patient Age at admission (Admission Date — Birthdate) ≤ 2 days, Length of
Stay (Discharge Date - Admission Date) ≤ 120 days, an ICD-10-CM Principal Diagnosis Code as defined in
Appendix A, Table 11.20.1, NO ICD-10-CM Other Diagnosis Codes as defined in Appendix A, Table 11.21, NO
ICD-10-PCS-Principal or Other Procedure Code as defined in Appendix A, Table 11.22 are included in this
subpopulation and are eligible to be sampled.

Newborns with Unexpected Complications - Patient Age at admission (Admission Date — Birthdate) =0 days,
an ICD-10-CM Principal or other Diagnosis Code as defined in Appendix A, Table 11.20.1, and No ICD-10-CM
Other Diagnosis Codes as defined in Appendix A, Table 11.12, 11.13, 11.14, 11.15, 11.16, 11.20 are included
in this subpopulation.

There is NO sampling for this measure.

Note: Hospitals are encouraged to utilize a data source that reduces unnecessary medical record review e.g.,
using vital records, delivery logs or clinical information systems as a data source.

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Sample Size Requirements
Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may
choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less
than the minimum number of cases per quarter/month for the sampling group cannot sample that sampling
group. Hospitals that have five or fewer discharges for the three combined PC sampling groups (both
Medicare and non-Medicare combined) in a quarter are not required to submit PC patient level data to the
Joint Commission's Data Warehouse.

A hospital may choose to use vital records to identify the PC-Mother Initial Patient Population as given in the
Population section earlier. If a hospital uses this method to identify the initial patient population, then the
hospital is encouraged to submit all the records of the initial population rather than using sampling to
identify the cases for submission. Submitting all the initial patient population provides a more precise
estimate of the performance rate for the measures.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures
consistently produce statistically valid and useful data. Due to exclusions and contraindications, hospitals
selecting sample cases MUST submit AT LEAST the minimum required sample size.

Quarterly Sampling
A modified sampling procedure is required for hospitals performing quarterly sampling for PC. Hospitals
selecting sample cases must ensure that each individual sampling group Initial Patient Population and
sample size meet the following conditions:

Select within the two individual measure sampling groups (mothers and babies).
Select independently from each of the Newborn subpopulation.

Hospitals selecting sample cases for the PC-Mothers must ensure that the Initial Patient Population and
sample size for this PC sampling group meets the following conditions:

Quarterly Sample Size

Based on Initial Patient Population for Mothers

Hospital's Measure

Average Quarterly Minimum Required

Initial Patient Sampling Group Sample Size
Sample Group Size “n”
“N”

>= 1501 301

376 — 1500 20% of the Initial Patient Population size

Average Quarterly Minimum Required

Initial Patient Sampling Group Sample Size
Sample Group Size “n”
“N”

75 — 375 75

< 75 No sampling; 100% of the Initial Patient Population required

Within the PC-Newborn population, there are three subpopulations each identified by Patient Age at
admission and a specific group of diagnosis and procedure codes or lack thereof:

The Newborns with BSI population and PC-Newborns with Unexpected Complications population are
not eligible for sampling. Report the entire Newborns with BSI Initial Patient Population group, and the
entire PC-Newborns with Unexpected Complications Initial Patient Population group for reporting.
Hospitals sampling for the PC-Newborns with Breast Feeding must ensure the sample size
calculations should be based on the newborns with breast feed subpopulation count ONLY. Hospitals
selecting cases for the PC-Newborns with Breastfeeding must ensure that the patient population size
for this subpopulation meets the following conditions:

Quarterly Sample Size

Based on Initial Patient Population for PC-Newborns with Breastfeeding

Hospital's Measure

Average Quarterly Minimum Required

Initial Patient Sample Size
Sample Group Size “n”
“N”

>= 541 109

136 — 540 20% of the Initial Patient Population size

27 — 135 27

< 27 No sampling; 100% of Initial Patient Population required

Monthly Sampling
Hospitals selecting sample cases for the Mothers must ensure that the Initial Patient Population and sample
size for this sampling group meets the following conditions:

Monthly Sample Size

Based on Initial Patient Population for Mothers

Average Monthly Minimum Required Sampling Group

Initial Patient Sample Size
Sample Group Size “n”
“N”

>= 501 101

126 — 500 20% of the Initial Patient Population

25 — 125 25

< 25 No sampling; 100% Initial Patient Population required

Within the PC-Newborn population, there are three sampling groups each identified by Patient Age at
admission and a specific group of diagnosis codes, or lack there of:

Monthly Sample Size

Based on Initial Patient Population for Newborns with Breast Feeding

Hospital's Measure

Average Monthly Minimum Required Sampling Group

Initial Patient Sample Size
Sample Group Size “n”
“N”

>= 181 37

46 — 180 20% of the Initial Patient Population

9 — 45 9

<9 No sampling; 100% Initial Patient Population required

Sample Size Examples

Note: PC-Mothers: All sampling groups in PC-Mother population should be used in the calculation of all PC-
Mother measures. All of the PC measures' specific exclusion criteria are used to filter out cases that do not
belong in the measure denominator.
PC-Newborns: Cases falling within each newborns subpopulation should be run through the respective
Newborn measures only. Cases falling in the Newborns with BSI subpopulation ONLY will flow through the

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PC-04 measure, cases falling in the Newborns with Breast Feeding subpopulation ONLY will flow through the
PC-05 measure only and cases falling in the Newborns with Unexpected Complications subpopulation ONLY
will flow through the PC-06 measure. Cases may fall in all three subpopulations and in such scenarios will be
processed through all three measures. It should be noted that cases should be processed independently
through each of newborn initial subpopulation flows to obtain cases for sampling and abstraction.

Quarterly Sampling
Mother Population

A hospital's Mother Population size is 2300 cases during the second quarter. Using the quarterly
sampling table for the Mother population, the sample size required is 301 cases for the quarter.
A hospital's Mother Population size is 1500 cases during the second quarter. Using the quarterly
sampling table for the Mother population, the sample size required is 20% of this sub-population or
300 cases for the quarter.
A hospital's Mother Population size is 300 cases during the second quarter. Using the quarterly
sampling table for the Mother population, the sample size required 75 cases for the quarter.
A hospital's Mother Population size is 72 cases during the second quarter. Using the quarterly
sampling table for the Mother population, the sample size is less than the minimum required quarterly
sample size, so 100% of this sub-population or all 72 cases are sampled.

Newborns with Breast Feeding

A hospital's Newborns with Breast Feeding Population size is 600 cases during the second quarter.
Using the quarterly sampling table for the Newborns with Breast Feeding population, the sample size
required is 109 cases.
A hospital's Newborns with Breast Feeding Population size is 350 cases during the second quarter.
Using the quarterly sampling table for the Newborns with Breast Feeding population, the sample size
required is 20% of this sub-population or 70 cases for the quarter .
A hospital's Newborns with Breast Feeding Population size is 99 cases during the second quarter.
Using the quarterly sampling table for the Newborns with Breast Feeding population, the sample size
required 27 cases for the quarter.
A hospital's Newborns with Breast Feeding Population size is 25 cases during the second quarter.
Using the quarterly sampling table for the Newborns with Breast Feeding population, the sample size
is less than the minimum required quarterly sample size, so 100% of this sub-population or all 25
cases are sampled.

Newborns with BSI and Unexpected Complications

Monthly Sampling
Mother Population

A hospital's Mother Population size is 510 cases during March. Using the monthly sampling table for
the Mother population, the sample size required is 101 cases for the month.

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A hospital's Mother Population size is 400 cases during March. Using the monthly sampling table for
the Mother population, the sample size required is 20% of this sub-population or 80 cases for the
month.
A hospital's Mother Population size is 125 cases during March. Using the monthly sampling table for
the Mother population, the sample size required is 25 cases for the month.
A hospital's Mother Population size is 20 cases during March. Using the quarterly sampling table for
the Mothers population, the sample size is less than the minimum required quarterly sample size, so
100% of this sub-population or all 20 cases are sampled.

Newborns with Breast Feeding

A hospital's Newborns with Breast Feeding Population size is 200 cases for the month of March.
Using the monthly sampling table for the Newborns with Breast Feeding population, the sample size
required is 37 cases.
A hospital's Newborns with Breast Feeding Population size is 100 cases for the month of March.
Using the monthly sampling table for the Newborns with Breast Feeding population, the sample size
required is 20% of this sub-population or 20 cases for the month.
A hospital's Newborns with Breast Feeding Population size is 30 cases for the month of March. Using
the monthly sampling table for the Newborns with Breast Feeding population, the sample size
required 9 cases for the month.
A hospital's Newborns with Breast Feeding Population size is 8 cases during the second quarter.
Using the monthly sampling table for the Newborns with Breast Feeding population, the sample size
is less than the minimum required monthly sample size, so 100% of this sub-population or all 8 cases
are sampled.

Newborns with BSI and Unexpected Complications

Measure Information Form

Measure Set: Perinatal Care (PC)

Set Measure ID: PC-01

Performance Measure Name: Elective Delivery

Description: Patients with elective vaginal deliveries or elective cesarean births at >= 37 and < 39 weeks of
gestation completed

Rationale: For almost 3 decades, the American College of Obstetricians and Gynecologists (ACOG) and the
American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks
gestation prior to ELECTIVE delivery, either vaginal or operative (ACOG, 1996). A survey conducted in 2007 of
almost 20,000 births in HCA hospitals throughout the U.S. carried out in conjunction with the March of
Dimes at the request of ACOG revealed that almost 1/3 of all babies delivered in the United States are
electively delivered with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines.
Most of these are for convenience, and result in significant short term neonatal morbidity (neonatal intensive
care unit admission rates of 13- 21%) (Clark et al., 2009).

According to Glantz (2005), compared to spontaneous labor, elective inductions result in more cesarean
births and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes
that elective induction doubles the cesarean delivery rate. Repeat elective cesarean births before 39 weeks
gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and
hypoglycemia for the newborns (Tita et al., 2009).

Type Of Measure: Process

Improvement Noted As: Decrease in the rate

Numerator Statement: Patients with elective deliveries

Included Populations: ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for one or
more of the following:

Medical induction of labor as defined in Appendix A, Table 11.05 while not in Labor prior to the
procedure
Cesarean birth as defined in Appendix A, Table 11.06 and all of the following:
not in Labor
no history of a Prior Uterine Surgery

Excluded Populations: None

Data Elements:

Denominator Statement: Patients delivering newborns with >= 37 and < 39 weeks of gestation completed

Included Populations:

ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for delivery as defined in
Appendix A, Table 11.01.1

ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for planned cesarean birth
in labor as defined in Appendix A, Table 11.06.1

Excluded Populations:

ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions possibly
justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07
History of prior stillbirth
Less than 8 years of age
Greater than or equal to 65 years of age
Length of stay > 120 days
Gestational Age < 37 or >= 39 weeks or UTD

Data Elements:

Admission Date
Birthdate
Discharge Date
Gestational Age
History of Stillbirth
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: In order to identify areas for improvement, hospitals may want to review
results based on specific ICD-10 codes or patient populations. Data could be analyzed further to determine
specific patterns or trends to help reduce elective deliveries.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American Academy of Family Physicians. (2000). Tips from Other Journals: Elective induction doubles
cesarean delivery rate, 61, 4.Retrieved December 29, 2008 at:
http://www.aafp.org/afp/20000215/tips/39.html.
American College of Obstetricians and Gynecologists. (November 1996). ACOG Educational Bulletin.
Clark, S., Miller, D., Belfort, M., Dildy, G., Frye, D., & Meyers, J. (2009). Neonatal and maternal outcomes
associated with elective delivery. [Electronic Version]. Am J Obstet Gynecol. 200:156.e1-156.e4.
Glantz, J. (Apr.2005). Elective induction vs. spontaneous labor associations and outcomes. [Electronic
Version]. J Reprod Med. 50(4):235-40.
Tita, A., Landon, M., Spong, C., Lai, Y., Leveno, K., Varner, M, et al. (2009). Timing of elective repeat
cesarean delivery at term and neonatal outcomes. [Electronic Version]. NEJM. 360:2, 111-120.

Original Performance Measure Source / Developer:

Hospital Corporation of America-Women's and Children's Clinical Services

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Perinatal Care (PC)

Set Measure ID: PC-02

Performance Measure Name: Cesarean Birth

Description: Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth

Rationale: The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital,
state and national cesarean birth (CB) rates. Some hospitals now have CB rates over 50%. Hospitals with CB
rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al.,
2004). There are no data that higher rates improve any outcomes, yet the CB rates continue to rise. This
measure seeks to focus attention on the most variable portion of the CB epidemic, the term labor CB in
nulliparous women. This population segment accounts for the large majority of the variable portion of the CB
rate, and is the area most affected by subjectivity.

As compared to other CB measures, what is different about NTSV CB rate (Low-risk Primary CB in first births)
is that there are clear cut quality improvement activities that can be done to address the differences. Main et
al. (2006) found that over 60% of the variation among hospitals can be attributed to first birth labor induction
rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was
not ready the outcomes were poorer. Alfirevic et al. (2004) also showed that labor and delivery guidelines can
make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient
characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital
(Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003). The dramatic variation in NTSV rates seen in
all populations studied is striking according to Menacker (2006). Hospitals within a state (Coonrod et al.,
2008; California Office of Statewide Hospital Planning and Development [OSHPD], 2007) and physicians
within a hospital (Main, 1999) have rates with a 3-5 fold variation.

Type Of Measure: Outcome

Improvement Noted As: Decrease in the rate

Numerator Statement: Patients with cesarean births

Included Populations: ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for
cesarean birth as defined in Appendix A, Table 11.06

Excluded Populations: None

Data Elements:

ICD-10-PCS Other Procedure Codes

Denominator Statement: Nulliparous patients delivered of a live term singleton newborn in vertex
presentation

Included Populations:

ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for delivery as defined in
Appendix A, Table 11.01.1
Nulliparous patients with ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for
outcome of delivery as defined in Appendix A, Table 11.08 and with a delivery of a newborn with
37 weeks or more of gestation completed

Excluded Populations:

ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for multiple gestations and
other presentations as defined in Appendix A, Table 11.09
Less than 8 years of age
Greater than or equal to 65 years of age
Length of Stay >120 days
Gestational Age < 37 weeks or UTD

Data Elements:

Admission Date
Birthdate
Discharge Date
Gestational Age
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
Previous Live Births

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: In order to identify areas for improvement, hospitals may want to review
results based on specific ICD-10 codes or patient populations. Data could then be analyzed further
determine specific patterns or trends to help reduce cesarean births.

Sampling: Yes. For additional information see the Sampling Section.

Selected References:

Agency for Healthcare Research and Quality. (2002). AHRQ Quality Indicators Guide to Inpatient Quality
Indicators: Quality of Care in Hospitals Volume, Mortality, and Utilization. Revision 4 (December 22, 2004).
AHRQ Pub. No. 02-RO204.
Alfirevic, Z., Edwards, G., & Platt, M.J. (2004). The impact of delivery suite guidelines on intrapartum
care in “standard primigravida.” Eur J Obstet Gynecol Reprod Biol.115:28-31.
American College of Obstetricians and Gynecologists. (2000). Task Force on Cesarean Delivery Rates.
Evaluation of Cesarean Delivery. (Developed under the direction of the Task Force on Cesarean Delivery
Rates, Roger K. Freeman, MD, Chair, Arnold W. Cohen, MD, Richard Depp III, MD, Fredric D. Frigoletto Jr,
MD, Gary D.V. Hankins, MD, Ellice Lieberman, MD, DrPH, M. Kathryn Menard, MD, David A. Nagey, MD,
Carol W. Saffold, MD, Lisa Sams, RNC, MSN and ACOG Staff: Stanley Zinberg, MD, MS, Debra A.
Hawks, MPH, and Elizabeth Steele).
Bailit, J.L., Garrett, J.M., Miller, W.C., McMahon, M.J., & Cefalo, R.C. (2002). Hospital primary cesarean
delivery rates and the risk of poor neonatal outcomes. Am J Obstet Gynecol. 187(3):721-7.
Bailit, J. & Garrett, J. (2003). Comparison of risk-adjustment methodologies. Am J Obstet
Gynecol.102:45-51.
Bailit, J.L., Love, T.E., & Dawson, N.V. (2006). Quality of obstetric care and risk-adjusted primary
cesarean delivery rates. Am J Obstet Gynecol.194:402.
Bailit, J.L. (2007). Measuring the quality of inpatient obstetrical care. Ob Gyn Sur. 62:207-213.
Berkowitz, G.S., Fiarman, G.S., Mojica, M.A., et al. (1989). Effect of physician characteristics on the
cesarean birth rate. Am J Obstet Gynecol. 161:146-9.
California Office of Statewide Hospital Planning and Development. (2017). Hospital Volume and
Utilization Indicators for California, Retrieved from the Internet on February 22, 2018 at:
https://www.oshpd.ca.gov/HID/AHRQ-Volume-Utilization.html
Cleary, R., Beard, R.W., Chapple, J., Coles, J., Griffin, M., & Joffe, M. (1996). The standard primipara as a
basis for inter-unit comparisons of maternity care. Br J Obstet Gynecol. 103:223-9.
Coonrod, D.V., Drachman, D., Hobson, P., & Manriquez, M. (2008). Nulliparous term singleton vertex
cesarean delivery rates: institutional and individual level predictors. Am J Obstet Gynecol. 694-696.
DiGiuseppe, D.L., Aron, D.C., Payne, S.M., Snow, R.J., Dieker, L., & Rosenthal, G.E. (2001). Risk adjusting
cesarean delivery rates: a comparison of hospital profiles based on medical record and birth
certificate data. Health Serv Res.36:959-77.
Gould, J., Danielson, B., Korst, L., Phibbs, R., Chance, K.,& Main, E.K., et al. (2004). Cesarean delivery
rate and neonatal morbidity in a low-risk population. Am J Obstet Gynecol, 104:11-19.
Goyert, G.L., Bottoms, F.S., Treadwell, M.C., et al. (1989). The physician factor in cesarean birth rates. N
Engl J Med.320:706-9.
Le Ray, C., Carayol, M., Zeitlin, J., Berat, G., & Goffinet, F. (2006). Level of perinatal care of the maternity
unit and rate of cesarean in low-risk nulliparas. Am J Obstet Gynecol. 107:1269-77.
Luthy, D.A., Malmgren, J.A., Zingheim, R.W., & Leininger, C.J. (2003). Physician contribution to a
cesarean delivery risk model. Am J Obstet Gynecol.188:1579-85.
Main, E.K. (1999). Reducing cesarean birth rates with data-driven quality improvement activities.
Peds. 103: 374-383.
Main E.K., Bloomfield, L., & Hunt, G. (2004). Development of a large-scale obstetric quality-
improvement program that focused on the nulliparous patient at term. Am J Obstet Gynecol.190:1747-

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58.
Main, E.K., Moore, D., Farrell, B., Schimmel, L.D., Altman, R.J., Abrahams, C., et al., (2006). Is there a
useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth
rate as a tool for obstetric quality improvement. Am J Obstet Gynecol. 194:1644-51.
Menacker, F. (2005).Trends in cesarean rates for first births and repeat cesarean rates for low-risk
women: United States, 1990-2003. Nat Vital Stat Rep. 54(4): 1-5.
Romano, P.S., Yasmeen, S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M. (2005). Coding of perineal
lacerations and other complications of obstetric care in hospital discharge data. Am J Obstet
Gynecol.106:717-25.
U.S. Department of Health and Human Services. (2000). Healthy People 2010: Understanding and
Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office. Measure 16-9.
Yasmeen, S., Romano, P.S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M. (2006). Accuracy of obstetric
diagnoses and procedures in hospital discharge data. Am J Obstet Gynecol. 194:992-1001.

Original Performance Measure Source / Developer:

California Maternal Quality Care Collaborative

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Perinatal Care (PC)

Set Measure ID: PC-03

Performance Measure Name: Antenatal Steroids

Description: Patients at risk of preterm delivery at >=24 and <34 weeks gestation receiving antenatal steroids
prior to delivering preterm newborns

Rationale: The National Institutes of Health 1994 recommendation is to give a full course of corticosteroids
to all pregnant women between 24 weeks and 34 weeks of gestation who are at risk of preterm delivery.
Repeated corticosteroid courses should not be used routinely, because clinical trials show decreased brain
size, decreased birth weight, and adrenal insufficiency in newborns exposed to repeated doses. Treatment
should consist of two doses of 12 mg of betamethasone given intramuscularly 24 hours apart or four doses
of 6 mg dexamethasone given intramuscularly every 12 hours.

A single course of corticosteroids should be given at 24 0/7 to 33 6/7 weeks gestation (NIH, 2000). A
Cochrane meta-analysis reinforces the beneficial effect of this therapy regardless of membrane status and
further concludes for all preterm deliveries the single course of corticosteroids should be routinely
administered (Roberts & Dalziel, 2006).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients with antenatal steroids initiated prior to delivering preterm newborns

Included Populations: Antenatal steroids initiated (refer to Appendix C, Table 11.0, antenatal steroid
medications)

Excluded Populations: None

Data Elements:

Antenatal Steroids Initiated

Denominator Statement: Patients delivering live preterm newborns with >=24 and <34 weeks gestation
completed

Included Populations:

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ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for delivery as defined in
Appendix A, Table 11.01.1

Excluded Populations:

Less than 8 years of age

Greater than or equal to 65 years of age
Length of Stay >120 days
Documented Reason for Not Initiating Antenatal Steroids
ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for fetal demise as defined
in Appendix A, Table 11.09.1
Gestational Age < 24 or >= 34 weeks or UTD

Data Elements:

Admission Date
Birthdate
Discharge Date
Gestational Age
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
Reason for Not Initiating Antenatal Steroids

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records. Data are collected as weeks and days of gestation, but the vendor converts to total
days of gestation for data transmission and measure calculation.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: In order to identify areas for improvement in antenatal steroid administration
rates, hospitals may wish to review documentation for reasons. Education efforts can be targeted based on
the specific reasons identified.

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American College of Obstetricians and Gynecologists. (ACOG). (2013). Practice Bulletin: Clinical
Management Guidelines for Obstetrician-Gynecologists for Premature rupture of membranes.
Lockwood, C.J., ed. & Lemons, J.A., ed. (2007). Guidelines for Perinatal Care, Sixth Edition, American
Academy of Pediatrics and the American College of Obstetricians and Gynecologists, ISBN 978-1-58110-

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270-3; ISBN 978-1-932328-36-3, pp. 178-181.
NIH Consensus Development Conference Statement: The Effect of Corticosteroids for Fetal Maturation
on Perinatal Outcomes. February 28-March 2, 1994.
NIH Consensus Statement: Antenatal corticosteroids revisited: repeat courses.2000. 17(2)1-18.
Roberts, D. & Dalziel, S.R. (2010) Antenatal corticosteroids for accelerating fetal lung maturation for
women at risk of preterm birth (Review). The Cochrane Collaboration. Issue 9.

Original Performance Measure Source / Developer:

Providence St Vincent's Hospital/Council of Women and Infant's Specialty Hospitals

Measure Information Form

Measure Set: Perinatal Care (PC)

Set Measure ID: PC-04

Performance Measure Name: Health Care-Associated Bloodstream Infections in Newborns

Description: Staphylococcal and gram negative septicemias or bacteremias in high-risk newborns

Rationale: Health care-associated bacteremia is significant problem for infants admitted into neonatal
intensive care units (NICUs) and other hospital units. This is especially true for very low birth weight infants
who are at high risk for these infections due to their immature immune systems and need for invasive
monitoring and supportive care (Adams-Chapman & Stoll, 2002; Bloom et al., 2003; Clark et al., 2004a; Clark
et al., 2004b; Gaynes et al., 1996; Payne et al., 2004; Sohn et al., 2001; Stoll et al., 2002). Reported health
care-associated infection rates range from 6% to 33%, but the rate varies widely among different centers
(Adams-Chapman & Stoll, 2002; Bloom et al.,2003; Clark et al.,2004b ; Sohn et al.,2001; Stoll et al.,2002).
Mortality rates are high and infections result in increased length of stay as well as increased hospital costs
and charges (Adams-Chapman & Stoll, 2002; Bloom et al.,2003; Clark et al., 2004b; Horbar et al., 2001;
Kilbride et al., 2003a; Sohn et al.,2001; Stoll et al., 2002).

The incidence of health care-associated bacteremia increases with decreasing birth weight. Other risk
factors include central venous catheter use, prolonged time using parenteral nutrition, prolonged time on
mechanical ventilation, use of H2-blocking agents, and overcrowding or heavy staff loads (Adams-Chapman
& Stoll, 2002; Barton et al., 1999; Gaynes et al., 1996; Stoll et al., 2002). The most common causative
organisms are coagulase-negative staphylococci, Staphylococcus aureus, enterococci, Enterobacter sp, and
Escherichia coli (Adams-Chapman & Stoll, 2002; Clark et al., 2004b; Gaynes et al., 1996; Horbar et al., 2001;
Payne et al., 2004; Sohn et al., 2001; Stoll et al., 2002).

Effective preventive measures range from simple hand-washing protocols or closed medication delivery
systems to more elaborate multidisciplinary quality improvement plans involving hand-washing, nutrition,
skin care, respiratory care, vascular access, and diagnostic practices. All of these interventions have been
shown to substantially reduce infection rates, albeit in nonrandomized studies using historical or concurrent
control units (Adams-Chapman & Stoll, 2002; Aly et al., 2005; Bloom et al., 2003; Clark et al., 2004a; Clark et
al., 2004b; Horbar et al., 2001; Lam et al., 2004; Kilbride et al., 2003a; Kilbride et al., 2003b; Ng et al., 2004;
Schelonka et al., 2006). For example, six Vermont Oxford Network NICUs reduced their rates of coagulase-
negative staphylococcus infections from 22.0% in 1994 to 16.6% in 1996 after implementing a quality
improvement model (versus a much smaller decrease from 15.4% to 14.5% at 66 comparison NICUs) (Horbar
et al., 2001). A similar reduction from 24.6% to 16.4% was achieved with a multi-modality, multi-hospital
intervention focusing on hand hygiene with an effective agent before and after every patient contact,
eliminating hand jewelry and artificial nails, using maximal barrier precautions during central venous
catheter insertion, decreasing the number of skin punctures, reducing the duration of intravenous lipid and
deep line use, and improving the diagnosis of health care-associated infections. (Kilbride et al., 2003a;
Kilbride et al., 2003b).

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Given the fragility and susceptibility of the patient population, a baseline level of health care-associated
infections will be expected, even with good protocols in place. However, those centers that have prevention
protocols, and are able to encourage health care workers to adhere to these protocols, will probably have
success in reducing their rates of health care-associated bacteremia in their neonatal population. Indeed,
several quasi-experimental studies have demonstrated that NICUs can lower their infection rates (based on
positive blood cultures) from as high as 13.5 per 1,000 patient days to as low as 3.0 per 1,000 patient days(
Adams-Chapman & Stoll, 2002; Aly et al., 2005; Bloom et al. ,2003; Clark et al., 2004a; Clark et al., 2004b;
Horbar et al., 2001; Lam et al., 2004; Kilbride et al., 2003a; Kilbride et al., 2003b; Ng et al., 2004; Schelonka et
al., 2006).

Type Of Measure: Outcome

Improvement Noted As: Decrease in the rate

Numerator Statement: Newborns with septicemia or bacteremia

Included Populations:

ICD-10-CM Other Diagnosis Codes for newborn septicemia or bacteremia as defined in Appendix A,
Table 11.10 with a Bloodstream Infection Conﬁrmed

ICD-10-CM Other Diagnosis Codes for sepsis as defined in Appendix A, Table 11.10.1 with a
Bloodstream Infection Conﬁrmed

Excluded Populations: None

Data Elements:

Bloodstream Infection Conﬁrmed

ICD-10-CM Other Diagnosis Codes

Denominator Statement: Liveborn newborns

Included Populations:

ICD-10-CM Other Diagnosis Codes for birth weight between 500 and 1499g as defined in Appendix
A, Table 11.12, 11.13 or 11.14 OR Birth Weight between 500 and 1499g

ICD-10-CM Other Diagnosis Codes for birth weight ≥ 1500g as defined in Appendix A, Table 11.15
or 11.16 OR Birth Weight ≥ 1500g who experienced one or more of the following:
Experienced death

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ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for major surgery
as defined in Appendix A, Table 11.18
ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for mechanical
ventilation as defined in Appendix A, Table 11.19
Transferred in from another acute care hospital or health care setting within 2 days of birth

Excluded Populations:

ICD-10-CM Principal Diagnosis Code for septicemias or bacteremias as defined in Appendix A, Table
11.10.2
ICD-10-CM Other Diagnosis Codes for septicemias or bacteremias as defined in Appendix A, Table
11.10.2 or ICD-10-CM Principal or Other Diagnosis Codes for newborn septicemia or bacteremia as
defined in Appendix A, Table 11.10 with a Bloodstream Infection Present on Admission
ICD-10-CM Other Diagnosis Codes for birth weight < 500g as defined in Appendix A, Table 11.20 OR
Birth Weight < 500g
Length of Stay < 2 days

Data Elements:

Admission Date
Birth Weight
Birthdate
Bloodstream Infection Present on Admission
Discharge Date
Discharge Disposition
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code

Risk Adjustment: Yes. This section has been moved to the ORYX Risk Adjustment Guide. This guide is
available to the public on the Joint Commission's website and, in addition, it is available to performance
measurement systems via the Joint Commission's extranet site for measurement systems (PET).

Data Elements:

Birth Weight
Discharge Disposition
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy:

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Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require
evaluation to ensure consistency.
Since Birth Weight is a risk factor for hospital associated blood stream infections in newborns, ICD-
10-CM codes have been provided in Appendix A, Tables 11.12-11.16, 11.20 to assist in identifying
newborns with prematurity and fetal growth retardation to denote birth weight (less than 500 grams
up to birth weight 2000-2499 grams). Therefore, newborns with birth weights greater than or equal to
2500 grams will need to be captured using the data element Birth Weight.
It is important to ensure that all weight conversions from pounds and ounces to grams are accurate
and concise. Birth Weight should not be rounded off i.e., when converting from pounds and ounces to
grams, do not round to the nearest pound before converting the weight to grams.
Discrepancies can occur between Birth Weights obtained from labor and delivery vs. nursery
departments. Organizations should determine which is the most reliable source for this data element
value and consistently obtain it from that source.

Measure Analysis Suggestions: In order to identify areas for improvement, hospitals may want to review
results based on specific ICD-10 codes or patient populations. Data could then be analyzed further
determine specific patterns or trends to help reduce bloodstream infections.

Sampling: No. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Adams-Chapman, I. & Stoll, B.J. (2002). Prevention of nosocomial infections in the neonatal intensive
care unit. Current Opinion in Pediatrics.14 (2):157-64.
Aly, H., Herson, V., Duncan, A., et al. (2005). Is bloodstream infection preventable among premature
infants? A tale of two cities. Pediatrics. 115(6):1513-8.
Barton, L., Hodgman, J.E., & Pavlova, Z. (1999). Causes of death in the extremely low birth weight
infant. Pediatrics. 103(2):446-51.
Bloom, B.T., Craddock, A., Delmore, P.M., et al. (2003). Reducing acquired infections in the NICU:
observing and implementing meaningful differences in process between high and low acquired
infection rate centers. Journal of Perinatology. 23(6):489-92.
Clark, R., Powers, R., White, R., Bloom, B., Sanchez, P., & Benjamin, D.K., Jr. (2004a). Prevention and
treatment of nosocomial sepsis in the NICU. Journal of Perinatology. 4; 24(7):446-53.
Clark, R., Powers, R., White, R., Bloom, B., Sanchez, P., & Benjamin, D.K., Jr. (2004b). Nosocomial
infection in the NICU: a medical complication or unavoidable problem? Journal of Perinatology.
24(6):382-8.
Gaynes, R.P., Edwards, J.R., Jarvis, W.R., Culver, D.H., Tolson, J.S., & Martone, W.J. (1996). Nosocomial
infections among neonates in high-risk nurseries in the United States. National Nosocomial Infections
Surveillance System. Pediatrics. 98(3 Pt 1):357-61.
Horbar, J.D., Rogowski, J., Plsek, P.E., et al. (2001). Collaborative quality improvement for neonatal
intensive care. NIC/Q Project Investigators of the Vermont Oxford Network. Pediatrics. 107(1):14-22.
Kilbride, H.W., Wirtschafter, D.D., Powers, R.J., & Sheehan, M.B. (2003a). Implementation of evidence-
based potentially better practices to decrease nosocomial infections. Pediatrics. 111(4 Pt 2):e519-33.

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Kilbride, H.W., Powers, R., Wirtschafter, D.D., et al. (2003b). Evaluation and development of potentially
better practices to prevent neonatal nosocomial bacteremia. Pediatrics. 111(4 Pt 2):e504-18.
Lam, B.C., Lee, J., & Lau, Y.L. (2004). Hand Hygiene Practices in a Neonatal Intensive Care Unit: A
Multimodal Intervention and Impact on Nosocomial Infection. Pediatrics.114 (5):e565.
Ng, P.C., Wong, H.L., Lyon, D.J., et al. (2004). Combined use of alcohol hand rub and gloves reduces the
incidence of late onset infection in very low birthweight infants. Archives of Disease in Childhood
Fetal & Neonatal Edition. 89(4):F336-40.
Payne, N.R., Carpenter, J.H., Badger, G.J., Horbar, J.D., & Rogowski, J. (2004). Marginal increase in cost
and excess length of stay associated with nosocomial bloodstream infections in surviving very low
birth weight infants. Pediatrics. 114(2):348-55.
Schelonka, R.L., Scruggs, S., Nichols, K., Dimmitt, R.A., & Carlo, W.A. (2006). Sustained reductions in
neonatal nosocomial infection rates following a comprehensive infection control intervention. Journal
of Perinatology. 26(3):176-9.
Sohn, A.H., Garrett, D.O., Sinkowitz-Cochran, R.L., et al. (2001). Prevalence of nosocomial infections in
neonatal intensive care unit patients: Results from the first national point-prevalence survey. Journal
of Pediatrics. 139(6):821-7.
Stoll, B.J., Hansen, N., Fanaroff, A.A., et al. (2002). Late-onset sepsis in very low birth weight neonates:
the experience of the NICHD Neonatal Research Network. Pediatrics. 110(2 Pt 1):285-91.

Original Performance Measure Source / Developer:

Agency for Healthcare Research and Quality

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Perinatal Care (PC)

Set Measure ID: PC-05

Performance Measure Name: Exclusive Breast Milk Feeding

Description: Exclusive breast milk feeding during the newborn's entire hospitalization

The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk
during the entire hospitalization.

Rationale: Exclusive breast milk feeding for the first 6 months of neonatal life has long been the expressed
goal of World Health Organization (WHO), Department of Health and Human Services (DHHS), American
Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). ACOG has
recently reiterated its position (ACOG, 2007). A recent Cochrane review substantiates the benefits (Kramer et
al., 2002). Much evidence has now focused on the prenatal and intrapartum period as critical for the success
of exclusive (or any) BF (Centers for Disease Control and Prevention [CDC], 2007; Petrova et al., 2007; Shealy
et al., 2005; Taveras et al., 2004). Exclusive breast milk feeding rate during birth hospital stay has been
calculated by the California Department of Public Health for the last several years using newborn genetic
disease testing data. Healthy People 2010 and the CDC have also been active in promoting this goal.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Newborns that were fed breast milk only since birth

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Exclusive Breast Milk Feeding

Denominator Statement: Single term newborns discharged alive from the hospital

Included Populations: Liveborn newborns with ICD-10-CM Principal Diagnosis Code for single liveborn
newborn as defined in Appendix A, Table 11.20.1

Excluded Populations:

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Admitted to the Neonatal Intensive Care Unit (NICU) at this hospital during the hospitalization
ICD-10-CM Other Diagnosis Codes for galactosemia as defined in Appendix A, Table 11.21
ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for parenteral nutrition as
defined in Appendix A, Table 11.22
Experienced death
Length of Stay >120 days
Patients transferred to another hospital
Patients who are not term or with < 37 weeks gestation completed

Data Elements:

Admission Date
Admission to NICU
Birthdate
Discharge Date
Discharge Disposition
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
Term Newborn

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: In order to identify areas for improvement in breast milk feeding rates,
hospitals may wish to review documentation for reasons. Education efforts can be targeted based on the
specific reasons identified.

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American Academy of Pediatrics. (2005). Section on Breastfeeding. Policy Statement: Breastfeeding

and the Use of Human Milk. Pediatrics.115:496— 506.
American College of Obstetricians and Gynecologists. (Feb. 2007). Committee on Obstetric Practice
and Committee on Health Care for Underserved Women.Breastfeeding: Maternal and Infant Aspects.
ACOG Committee Opinion 361.

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California Department of Public Health. (2017). Division of Maternal, Child and Adolescent Health,
Breastfeeding Initiative, In-Hospital Breastfeeding Initiation Data, Hospital of Occurrence: Available at:
https://www.cdph.ca.gov/Programs/CFH/DMCAH/Breastfeeding/Pages/In-Hospital-Breastfeeding-
Initiation-Data.aspx
Centers for Disease Control and Prevention. (Aug 3, 2007). Breastfeeding trends and updated national
health objectives for exclusive breastfeeding--United States birth years 2000-2004. MMWR - Morbidity
& Mortality Weekly Report. 56(30):760-3.
Centers for Disease Control and Prevention. (2017). Division of Nutrition, Physical Activity and
Obesity. Breastfeeding Report Card. Available at:
https://www.cdc.gov/breastfeeding/data/reportcard.htm
Ip, S., Chung, M., Raman, G., et al. (2007). Breastfeeding and maternal and infant health outcomes in
developed countries. Rockville, MD: US Department of Health and Human Services. Available at:
https://archive.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf
Kramer, M.S. & Kakuma, R. (2002).Optimal duration of exclusive breastfeeding. [107 refs] Cochrane
Database of Systematic Reviews. (1):CD003517.
Petrova, A., Hegyi, T., & Mehta, R. (2007). Maternal race/ethnicity and one-month exclusive
breastfeeding in association with the in-hospital feeding modality. Breastfeeding Medicine. 2(2):92-8.
Shealy, K.R., Li, R., Benton-Davis, S., & Grummer-Strawn, L.M. (2005).The CDC guide to breastfeeding
interventions. Atlanta, GA: US Department of Health and Human Services, CDC. Available at:
http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf.
Taveras, E.M., Li, R., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego, V.H., Miroshnik, I., & Lieu,
T.A. (2004). Opinions and practices of clinicians associated with continuation of exclusive
breastfeeding. Pediatrics. 113(4):e283-90.
US Department of Health and Human Services. (2007). Healthy People 2010 Midcourse Review.
Washington, DC: US Department of Health and Human Services. Available at:
https://www.healthypeople.gov/2010/data/midcourse/html/default.htm?visit=1
World Health Organization. (2007). Indicators for assessing infant and young child feeding practices.
Washington, DC, USA: World Health Organization. Available at:
http://apps.who.int/iris/bitstream/10665/43895/1/9789241596664_eng.pdf

Original Performance Measure Source / Developer:

California Maternal Quality Care Collaborative

Set Measure ID: PC-06

Set Measure ID Performance Measure Name

PC-06.0 Unexpected Complications in Term Newborns - Overall Rate

PC-06.1 Unexpected Complications in Term Newborns - Severe Rate

PC-06.2 Unexpected Complications in Term Newborns - Moderate Rate

Performance Measure Name: Unexpected Complications in Term Newborns

Description: Unexpected complications among full term newborns with no preexisting conditions.

Severe complications include neonatal death, transfer to another hospital for higher level of care, severe
birth injuries such as intracranial hemorrhage or nerve injury, neurologic damage, severe respiratory and
infectious complications such as sepsis.

Moderate complications include diagnoses or procedures that raise concern but at a lower level than the list
for severe e.g. use of CPAP or bone fracture. Examples include less severe respiratory complications e.g.
Transient Tachypnea of the Newborn, or infections with a longer length of stay not including sepsis, infants
who have a prolonged length of stay of over 5 days.

Rationale: The most important childbirth outcome for families is bringing home a healthy baby. While there
have been measures developed to assess clinical practices and outcomes in preterm infants, there is a lack
of metrics that assess the health outcomes of term infants who represent over 90% of all births. This
measure addresses this gap and gauges adverse outcomes resulting in severe or moderate morbidity in
otherwise healthy term infants without preexisting conditions. This measure also uses length of stay (LOS)
modifiers to guard against overcoding and undercoding of diagnoses. Importantly, this metric also serves as
a balancing measure for other maternal measures such as NTSV Cesarean rates and early elective delivery
rates. The purpose of a balancing measure is to guard against any unanticipated or unintended
consequences of quality improvement activities for these measures.

Type Of Measure: Outcome

Improvement Noted As: Decrease in the rate

Numerator Statement: Newborns with severe complications and moderate complications.

Included Populations:
Severe Complications:

Death

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Transfer to another acute care facility for higher level of care
ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure
Code or ICD-10-PCS Other Procedure Codes for Severe Morbidities as defined in Appendix A, Tables:
11.36 Severe Birth Trauma
11.37 Severe Hypoxia/Asphyxia
11.38 Severe Shock and Resuscitation
11.39 Neonatal Severe Respiratory Complications
11.40 Neonatal Severe Infection
11.41 Neonatal Severe Neurological Complications
11.42 Severe Shock and Resuscitation Procedures
11.43 Neonatal Severe Respiratory Procedures
11.44 Neonatal Severe Neurological Procedures
Patients with Length of Stay greater than 4 days AND an ICD-10-CM Principal Diagnosis Code or ICD-
10-CM Other Diagnosis Codes for Sepsis as defined in Appendix A, Table 11.45 Neonatal Severe
Septicemia

Moderate Complications:

ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure
Code or ICD-10-PCS Other Procedure Codes for moderate complications as defined in Appendix A,
Tables:
11.46 Moderate Birth Trauma
11.47 Moderate Respiratory Complications
11.48 Moderate Respiratory Complications Procedures
ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table
11.20.2 Single Liveborn Newborn-Vaginal AND Length of Stay greater than 2 days
OR
ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table
11.20.3 Single Liveborn Newborn-Cesarean AND Length of Stay greater than 4 days
AND ANY
ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure
Code or ICD-10-PCS Other Procedure Codes for moderate complications as defined in Appendix A,
Tables:
11.49 Moderate Birth Trauma with LOS
11.50 Moderate Respiratory Complications with LOS
11.51 Moderate Neurological Complications with LOS Procedures
11.52 Moderate Respiratory Complications with LOS Procedures
11.53 Moderate Infection with LOS
Patients with Length of Stay greater than 5 days and NO ICD-10-CM Principal Diagnosis Code, ICD-
10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure
Codes for jaundice or social indications as defined in Appendix A, Tables:
11.33 Neonatal Jaundice
11.34 Phototherapy
11.35 Social Indications

Excluded Populations: None

Admission Date
Discharge Date
Discharge Disposition
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code

Denominator Statement: Liveborn single term newborns 2500 gm or over in birth weight.

Included Populations: Single liveborn newborns with ICD-10-CM Principal Diagnosis Code for single
liveborn newborn as defined in Appendix A, Table Number 11.20.1: Single Liveborn Newborn

Excluded Populations:

Patients who are not born in the hospital or are part of multiple gestation pregnancies, with no
ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table
Number 11.20.1: Single Liveborn Newborn
ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for birth weight < 2500g as
defined in Appendix A, Table 11.12, 11.13, 11.14, 11.15, 11.16, 11.20 OR Birth Weight < 2500g
Patients who are not term or with < 37 weeks gestation completed
Patients whose term status or gestational age is missing and birthweight < 3000 gm
ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for congenital
malformations and genetic diseases as defined in Appendix A, Table 11.30 Congenital
Malformations
ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for pre-existing fetal
conditions as defined in Appendix A, Table 11.31 Fetal Conditions
ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for maternal drug use
exposure in-utero as defined in Appendix A, Table 11.32 Maternal Drug Use

Data Elements:

Birth Weight
Birthdate
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
Term Newborn

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

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Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: In order to identify areas for improvement, hospitals may want to review
results based on specific ICD-10 codes or patient populations. Data could then be analyzed further to
determine specific patterns or trends to help reduce unexpected newborn complications.

Sampling: No.

Data Reported As: Aggregate rate generated from count data reported as a rate per 1000 livebirths.

Selected References:

Martin JA, Hamilton BE, Ventura SJ et al. Births: Final data for 2010. National vital statistics reports;
vol 61 no1. Hyattsville, MD: National Center for health Statistics. 2012
Russo, C. A (Thomson Reuters) and Andrews, R.M (AHRQ). Potentially Avoidable Injuries to mothers
and Newborns During Childbirth, 2006. HCUP Statistical Brief # 74. June 2009. Agency for Healthcare
Research and Quality. Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statsbriefs/sb74.pdf.
Gregory KD, Fridman M, Shah S et al. Global measures of quality and patient safety-related childbirth
outcomes: should we monitor adverse or ideal rates? Am J Obstet Gynecol 2009;200:681.e1-681.e7.
Profit J, Zupancic JA, Gould JB et al. Implementing pay-for-performance in the neonatal intensive care
unit. Pediatrics 2007;119:975-82
Operative Vaginal Delivery. Practice Bulletin No. 17. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2000;1-8
Shoulder dystocia. ACOG Practice Bulletin No. 40. American College of Obstetrician and
Gynecologists. Obstet Gynecol 2002;100:1045-50
Centers for Disease Control and Prevention. Prevention of Perinatal Group B Streptococcal Disease.
MMWR 2010;59 (No. RR 10): 1-36 http://www.cdc.gov/mmwr/pdf/rr/rr5910.pdf
Wilmink FA, Hukkelhoven CW, Lunshof, S et al. Neonatal outcome following elective cesarean section
beyond 37 weeks of gestation: a 7- year retrospective analysis of a national registry.2010 Am J Obstet
Gynecol 2002:250.e1-8
Tita AT, Landon MB, Spong CY et al. Timing of Elective Repeat Cesarean Delivery at Term and
Neonatal Outcomes. N Engl J Med 2009;360(2):111-20
Hansen AK, Wisborg K, Uldbjerg N. Risk of respiratory morbidity in term infants delivered by elective
cesarean section: cohort study. BMJ 2008;336:85
Spong CY. Defining “Term” pregnancy: Recommendations from the defining “term” pregnancy
workgroup. JAMA. 2013 Jun 19;309(23):2445-6.
Zhang X and Kramer MS. Variations in Mortality and Morbidity by Gestational Age among Infants Born
at Term. J Pediatr 2009;154:358-62
Fleischman AR, Oinuma M and Clark SL. Rethinking the Definition of “Term Pregnancy”. Obstet
Gynecol 2010;116(1)136-139
Clark SL, Miller DD, Belfort MA, et al. Neonatal and maternal outcomes associated with elective term
delivery. Am J Obstet Gynecol 2009;200:156.e1-156.e4
Reddy UM, Bettegowda VR, Dias T et al. Term Pregnancy: A period of Heterogeneous Risk for Infant
Mortality. Obstet Gynecol 2011;117:1279-1287

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"Unexpected Complications in Term Newborns.” California Maternal Quality Care Collaborative
(CMQCC), 2018, www.cmqcc.org/focus-areas/quality-metrics/unexpected-complications-term-
newborns.

Original Performance Measure Source / Developer:

California Maternal Quality Care Collaborative

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Acute Stroke Ready Inpatient (ASR-IP)

Set Measures

Set Measure ID Measure Short Name

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

General Data Elements

Element Name Collected For

Admission Date All Records,

Birthdate All Records,

Discharge Date All Records, Not collected for HBIPS-2 and

HBIPS-3

Hispanic Ethnicity All Records,

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File, Used in
calculation of the Joint Commission's
aggregate data and in the transmission of
the Hospital Clinical Data file.

Payment Source All Records, Optional for HBIPS-2 and

HBIPS-3

Race All Records,

Sex All Records,

Algorithm Output Data Elements

Element Name Collected For

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File

Element Name Collected For

Antithrombotic Therapy Administered by End of Hospital Day 2 ASR-IP-2

Antithrombotic Therapy Prescribed at Discharge ASR-IP-3

Arrival Date ASR-IP-1, ASR-IP-2

Arrival Time ASR-IP-1

Comfort Measures Only ASR-IP-2, ASR-IP-3

Date Last Known Well ASR-IP-1

Discharge Disposition ASR-IP-3

ED Patient ASR-IP-1

IV Alteplase Initiation ASR-IP-1

IV Alteplase Initiation Date ASR-IP-1

IV Alteplase Initiation Time ASR-IP-1

IV OR IA Alteplase Administered at This Hospital or Within 24 ASR-IP-2

Hours Prior to Arrival

Last Known Well ASR-IP-1

Reason for Extending the Initiation of IV Alteplase ASR-IP-1

Reason for Not Administering Antithrombotic Therapy by End of ASR-IP-2

Hospital Day 2

Reason for Not Initiating IV Alteplase ASR-IP-1

Reason for Not Prescribing Antithrombotic Therapy at Discharge ASR-IP-3

Time Last Known Well ASR-IP-1

ASR-IP Initial Patient Population

The population of the ASR-IP measure set is identified using 4 data elements:

ICD-10-CM Principal Diagnosis Code

Admission Date
Birthdate
Discharge Date

Patients admitted to the hospital for inpatient acute care with an ICD-10-CM Principal Diagnosis Code for
ischemic stroke as defined in Appendix A, Table 8.1, a Patient Age (Admission Date minus Birthdate) greater

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than or equal to 18 years and a Length of Stay (Discharge Date minus Admission Date) less than or equal to
120 days are included in the ASR-IP Initial Patient Population.

Set Measure ID: ASR-IP-1

Performance Measure Name: Thrombolytic Therapy: Inpatient Admission

Description: Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well
and for whom IV alteplase was initiated at this hospital within 3 hours of time last known well (i.e., patients
admitted for inpatient care following initiation of IV alteplase in the emergency department).

Rationale: The administration of IV alteplase to carefully screened, eligible patients with acute ischemic
stroke has been shown to be beneficial in several clinical trials. These included two positive randomized
controlled trials in the United States: The National Institute of Neurological Disorders and Stroke (NINDS)
Studies, Part I and Part II. Based on the results of these studies, the Food and Drug Administration (FDA)
approved the use of intravenous alteplase for the treatment of acute ischemic stroke when given within 3
hours of stroke symptom onset. A large meta-analysis controlling for factors associated with stroke
outcome confirmed the benefit of IV alteplase in patients treated within 3 hours of symptom onset.
Physicians with experience and skill in stroke management and the interpretation of CT scans should
supervise treatment.

The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous thrombolytic
therapy (tPA; rtPA) can be given safely to, and can improve outcomes for, carefully selected patients treated
3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic
therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains
within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom
onset has not been FDA approved.

Although the benefit of IV alteplase has been well established, only a minority of patients with acute
ischemic stroke actually receive this medication across the United States. Recent recommendations from
the American Heart Association/American Stroke Association and FDA remove or make less specific many
previous contraindications and warnings for therapy.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Acute ischemic stroke patients for whom IV alteplase was initiated at this hospital
within 3 hours (less than or equal to 180 minutes) of time last known well.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

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Date Last Known Well
IV Alteplase Initiation
IV Alteplase Initiation Date
IV Alteplase Initiation Time
Time Last Known Well

Denominator Statement: Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or
equal to 120 minutes) of time last known well.

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay greater than 120 days
Time Last Known Well to arrival in the emergency department greater than 2 hours
Patients with a documented Reason For Extending the Initiation of IV Alteplase
Patients with a documented Reason For Not Initiating IV Alteplase

Data Elements:

Admission Date
Arrival Date
Arrival Time
Birthdate
Date Last Known Well
Discharge Date
ED Patient
ICD-10-CM Principal Diagnosis Code
Last Known Well
Reason for Extending the Initiation of IV Alteplase
Reason for Not Initiating IV Alteplase
Time Last Known Well

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the
population of interest. This approach provides opportunities for improvement at the point of care/service.
However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes,
which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Sampling: No.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Adams, H., R. Adams, G. Del Zoppo, L. B. Goldstein, Association Stroke Council of the American Heart,
and Association American Stroke. "Guidelines for the Early Management of Patients with Ischemic
Stroke: 2005 Guidelines Update a Scientific Statement from the Stroke Council of the American Heart
Association/American Stroke Association." [In eng]. Stroke 36, no. 4 (Apr 2005): 916-23.
Adams, H. P., Jr., G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, et al.
"Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline from the American
Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council,
Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular
Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American
Academy of Neurology Affirms the Value of This Guideline as an Educational Tool for Neurologists."
[In eng]. Stroke 38, no. 5 (May 2007): 1655-711.
Albers, G. W., P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke: The Seventh Accp Conference on Antithrombotic and Thrombolytic
Therapy." [In eng]. Chest 126, no. 3 Suppl (Sep 2004): 483S-512S.
Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S.
Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association
(NSA) (2000).
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Del Zoppo, G. J., J. L. Saver, E. C. Jauch, H. P. Adams, Jr., and Council American Heart Association
Stroke. "Expansion of the Time Window for Treatment of Acute Ischemic Stroke with Intravenous
Tissue Plasminogen Activator: A Science Advisory from the American Heart Association/American
Stroke Association." [In eng]. Stroke 40, no. 8 (Aug 2009): 2945-8.
Demaerschalk, B. M., D. O. Kleindorfer, O. M. Adeoye, A. M. Demchuk, et. al., on behalf of the American
Heart Association Stroke Council and Council on Epidemiology and Prevention. “Scientific Rationale
for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: As
Statement for Healthcare Professionals From the American Heart Association/American Stroke
Association.” [In eng]. Stroke, no. 47 (Feb 2016): 581-641.
"Diagnosis and Initial Treatment of Ischemic Stroke." Institute for Clinical Systems Improvement
(2001).
Fagan, S. C., L. B. Morgenstern, A. Petitta, R. E. Ward, B. C. Tilley, J. R. Marler, S. R. Levine, et al. "Cost-
Effectiveness of Tissue Plasminogen Activator for Acute Ischemic Stroke. Ninds Rt-Pa Stroke Study
Group." [In eng]. Neurology 50, no. 4 (Apr 1998): 883-90.
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of
Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.

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Hacke, W., G. Donnan, C. Fieschi, M. Kaste, R. von Kummer, J. P. Broderick, T. Brott, et al. "Association
of Outcome with Early Stroke Treatment: Pooled Analysis of Atlantis, Ecass, and Ninds Rt-Pa Stroke
Trials." [In eng]. Lancet 363, no. 9411 (Mar 6 2004): 768-74.
Hacke, W., M. Kaste, E. Bluhmki, M. Brozman, A. Davalos, D. Guidetti, V. Larrue, et al. "Thrombolysis
with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke." [In eng]. N Engl J Med 359, no. 13 (Sep 25
2008): 1317-29.
Hacke, W., M. Kaste, C. Fieschi, D. Toni, E. Lesaffre, R. von Kummer, G. Boysen, et al. "Intravenous
Thrombolysis with Recombinant Tissue Plasminogen Activator for Acute Hemispheric Stroke. The
European Cooperative Acute Stroke Study (Ecass)." [In eng]. JAMA 274, no. 13 (Oct 4 1995): 1017-25.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Kwiatkowski, T. G., R. B. Libman, M. Frankel, B. C. Tilley, L. B. Morgenstern, M. Lu, J. P. Broderick, et al.
"Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year. National Institute of
Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group."
[In eng]. N Engl J Med 340, no. 23 (Jun 10 1999): 1781-7.
"Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications,
and Discharge Planning. A National Clinical Guideline.".
http://www.sign.ac.uk/guidelines/fulltext/118/.
Marler, J. R., B. C. Tilley, M. Lu, T. G. Brott, P. C. Lyden, J. C. Grotta, J. P. Broderick, et al. "Early Stroke
Treatment Associated with Better Outcome: The Ninds Rt-Pa Stroke Study." [In eng]. Neurology 55, no.
11 (Dec 12 2000): 1649-55.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e18-e25.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Sacco, R. L., R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, et al. "Guidelines
for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: A Statement
for Healthcare Professionals from the American Heart Association/American Stroke Association
Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The
American Academy of Neurology Affirms the Value of This Guideline." [In eng]. Stroke 37, no. 2 (Feb
2006): 577-617.
Saposnik, G., J. Fang, M. K. Kapral, J. V. Tu, M. Mamdani, P. Austin, S. C. Johnston, Network
Investigators of the Registry of the Canadian Stroke, and Group Stroke Outcomes Research Canada
Working. "The Iscore Predicts Effectiveness of Thrombolytic Therapy for Acute Ischemic Stroke." [In
eng]. Stroke 43, no. 5 (May 2012): 1315-22.
"Tissue Plasminogen Activator for Acute Ischemic Stroke. The National Institute of Neurological
Disorders and Stroke Rt-Pa Stroke Study Group." [In eng]. N Engl J Med 333, no. 24 (Dec 14 1995):
1581-7.
Wardlaw, J. M., V. Murray, E. Berge, and G. J. Del Zoppo. "Thrombolysis for Acute Ischaemic Stroke." [In
eng]. Cochrane Database Syst Rev, no. 4 (2009): CD000213.
U.S. Drug and Food Administration. (2015). “Label- Activase-Food and Drug.”

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Measure Information Form
Measure Set: Acute Stroke Ready Inpatient (ASR-IP)

Set Measure ID: ASR-IP-2

Performance Measure Name: Antithrombotic Therapy By End of Hospital Day 2

Description: Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.

Rationale: The effectiveness of antithrombotic agents in reducing stroke mortality, stroke-related morbidity
and recurrence rates has been studied in several large clinical trials. While the use of these agents for
patients with acute ischemic stroke and transient ischemic attacks continues to be the subject of study,
substantial evidence is available from completed studies. Data at this time suggest that antithrombotic
therapy should be administered within 2 days of symptom onset in acute ischemic stroke patients to reduce
stroke mortality and morbidity as long as no contraindications exist.

Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to

prevent recurrent stroke or TIA.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients who had antithrombotic therapy administered by end of
hospital day 2

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Antithrombotic Therapy Administered by End of Hospital Day 2

Denominator Statement: Ischemic stroke patients.

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1.

Excluded Populations:

Patients less than 18 years of age

Patients who have a Duration of Stay less than 2 days
Patients who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented on day of or day after arrival

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Patients discharged prior to the end of hospital day 2
Patients with IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival
Patients with a documented Reason for Not Administering Antithrombotic Therapy by End of
Hospital Day 2

Data Elements:

Admission Date
Arrival Date
Birthdate
Comfort Measures Only
Discharge Date
ICD-10-CM Principal Diagnosis Code
IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival
Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: No.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

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Albers, G. W, P Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke." Chest 119 (2001): 300-20.
Antithrombotic Trialists, Collaboration. "Collaborative Meta-Analysis of Randomised Trials of
Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients."
[In eng]. BMJ 324, no. 7329 (Jan 12 2002): 71-86.
Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S.
Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association
(NSA) (2000).
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Chen, Z. M., P. Sandercock, H. C. Pan, C. Counsell, R. Collins, L. S. Liu, J. X. Xie, C. Warlow, and R. Peto.
"Indications for Early Aspirin Use in Acute Ischemic Stroke : A Combined Analysis of 40 000
Randomized Patients from the Chinese Acute Stroke Trial and the International Stroke Trial. On Behalf
of the Cast and Ist Collaborative Groups." [In eng]. Stroke 31, no. 6 (Jun 2000): 1240-9.
Coull, B. M., L. S. Williams, L. B. Goldstein, J. F. Meschia, D. Heitzman, S. Chaturvedi, K. C. Johnston, et
al. "Anticoagulants and Antiplatelet Agents in Acute Ischemic Stroke: Report of the Joint Stroke
Guideline Development Committee of the American Academy of Neurology and the American Stroke
Association (a Division of the American Heart Association)." [In eng]. Stroke 33, no. 7 (Jul 2002): 1934-
42.
Eccles, M., N. Freemantle, and J. Mason. "North of England Evidence Based Guideline Development
Project: Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in Primary
Care. North of England Aspirin Guideline Development Group." [In eng]. BMJ 316, no. 7140 (Apr 25
1998): 1303-9.
"The European Stroke Prevention Study (Esps). Principal End-Points. The Esps Group." [In eng]. Lancet
2, no. 8572 (Dec 12 1987): 1351-4.
Furie, K. L., S. E. Kasner, R. J. Adams, G. W. Albers, R. L. Bush, S. C. Fagan, J. L. Halperin, et al.
"Guidelines for the Prevention of Stroke in Patients with Stroke or Transient Ischemic Attack: A
Guideline for Healthcare Professionals from the American Heart Association/American Stroke
Association." [In eng]. Stroke 42, no. 1 (Jan 2011): 227-76.
Gaspoz, J. M., P. G. Coxson, P. A. Goldman, L. W. Williams, K. M. Kuntz, M. G. Hunink, and L. Goldman.
"Cost Effectiveness of Aspirin, Clopidogrel, or Both for Secondary Prevention of Coronary Heart
Disease." [In eng]. N Engl J Med 346, no. 23 (Jun 6 2002): 1800-6.
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of
Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.
"The International Stroke Trial (Ist): A Randomised Trial of Aspirin, Subcutaneous Heparin, Both, or
Neither among 19435 Patients with Acute Ischaemic Stroke. International Stroke Trial Collaborative
Group." [In eng]. Lancet 349, no. 9065 (May 31 1997): 1569-81.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Johnson, E. S., S. F. Lanes, C. E. Wentworth, 3rd, M. H. Satterfield, B. L. Abebe, and L. W. Dicker. "A
Metaregression Analysis of the Dose-Response Effect of Aspirin on Stroke." [In eng]. Arch Intern Med

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159, no. 11 (Jun 14 1999): 1248-53.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e30.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Sacco, R. L., R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, et al. "Guidelines
for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: A Statement
for Healthcare Professionals from the American Heart Association/American Stroke Association
Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The
American Academy of Neurology Affirms the Value of This Guideline." [In eng]. Stroke 37, no. 2 (Feb
2006): 577-617.

Set Measure ID: ASR-IP-3

Performance Measure Name: Discharged on Antithrombotic Therapy

Description: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge

Rationale: The effectiveness of antithrombotic agents in reducing stroke mortality, stroke-related morbidity
and recurrence rates has been studied in several large clinical trials. While the use of these agents for
patients with acute ischemic stroke and transient ischemic attacks continues to be the subject of study,
substantial evidence is available from completed studies. Data at this time suggest that antithrombotic
therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and
morbidity as long as no contraindications exist.

For patients with a stroke due to a cardioembolic source (e.g., atrial fibrillation, mechanical heart valve),
warfarin is recommended unless contraindicated. In recent years, novel oral anticoagulants (NOACs) have
been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and
may be considered as an alternative to warfarin for select patients. Anticoagulation therapy is not generally
recommended for secondary stroke prevention in patients presumed to have a non-cardioembolic stroke.

Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to

prevent recurrent ischemic stroke or TIA.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Antithrombotic Therapy Prescribed at Discharge

Denominator Statement: Ischemic stroke patients.

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1.

Excluded Populations:

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Patients less than 18 years of age
Patients who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented
Patients discharged to another hospital
Patients who left against medical advice
Patients who expired
Patients discharged to home for hospice care
Patients discharged to a health care facility for hospice care
Patients with a documented Reason For Not Prescribing Antithrombotic Therapy at Discharge

Data Elements:

Admission Date
Birthdate
Comfort Measures Only
Discharge Date
Discharge Disposition
ICD-10-CM Principal Diagnosis Code
Reason for Not Prescribing Antithrombotic Therapy at Discharge

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: No.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

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Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular
Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American
Academy of Neurology Affirms the Value of This Guideline as an Educational Tool for Neurologists."
[In eng]. Stroke 38, no. 5 (May 2007): 1655-711.
Albers, G. W, P Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke." Chest 119 (2001): 300-20.
Albers, G. W., P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke: The Seventh Accp Conference on Antithrombotic and Thrombolytic
Therapy." [In eng]. Chest 126, no. 3 Suppl (Sep 2004): 483S-512S.
Antithrombotic Trialists, Collaboration. "Collaborative Meta-Analysis of Randomised Trials of
Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients."
[In eng]. BMJ 324, no. 7329 (Jan 12 2002): 71-86.
Bhatt, D. L., K. A. Fox, W. Hacke, P. B. Berger, H. R. Black, W. E. Boden, P. Cacoub, et al. "Clopidogrel and
Aspirin Versus Aspirin Alone for the Prevention of Atherothrombotic Events." [In eng]. N Engl J Med
354, no. 16 (Apr 20 2006): 1706-17.
Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S.
Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association
(NSA) (2000).
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Chen, Z. M., P. Sandercock, H. C. Pan, C. Counsell, R. Collins, L. S. Liu, J. X. Xie, C. Warlow, and R. Peto.
"Indications for Early Aspirin Use in Acute Ischemic Stroke : A Combined Analysis of 40 000
Randomized Patients from the Chinese Acute Stroke Trial and the International Stroke Trial. On Behalf
of the Cast and Ist Collaborative Groups." [In eng]. Stroke 31, no. 6 (Jun 2000): 1240-9.
"Collaborative Overview of Randomised Trials of Antiplatelet Therapy--I: Prevention of Death,
Myocardial Infarction, and Stroke by Prolonged Antiplatelet Therapy in Various Categories of Patients.
Antiplatelet Trialists' Collaboration." [In eng]. BMJ 308, no. 6921 (Jan 8 1994): 81-106.
Committee, Caprie Steering. "A Randomised, Blinded, Trial of Clopidogrel Versus Aspirin in Patients at
Risk of Ischaemic Events (Caprie). Caprie Steering Committee." [In eng]. Lancet 348, no. 9038 (Nov 16
1996): 1329-39.
"A Comparison of Two Doses of Aspirin (30 Mg Vs. 283 Mg a Day) in Patients after a Transient
Ischemic Attack or Minor Ischemic Stroke. The Dutch Tia Trial Study Group." [In eng]. N Engl J Med
325, no. 18 (Oct 31 1991): 1261-6.
Coull, B. M., L. S. Williams, L. B. Goldstein, J. F. Meschia, D. Heitzman, S. Chaturvedi, K. C. Johnston, et
al. "Anticoagulants and Antiplatelet Agents in Acute Ischemic Stroke: Report of the Joint Stroke
Guideline Development Committee of the American Academy of Neurology and the American Stroke
Association (a Division of the American Heart Association)." [In eng]. Stroke 33, no. 7 (Jul 2002): 1934-
42.
Diener, H. C., J. Bogousslavsky, L. M. Brass, C. Cimminiello, L. Csiba, M. Kaste, D. Leys, et al. "Aspirin
and Clopidogrel Compared with Clopidogrel Alone after Recent Ischaemic Stroke or Transient
Ischaemic Attack in High-Risk Patients (Match): Randomised, Double-Blind, Placebo-Controlled Trial."
[In eng]. Lancet 364, no. 9431 (Jul 24-30 2004): 331-7.
Eccles, M., N. Freemantle, and J. Mason. "North of England Evidence Based Guideline Development
Project: Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in Primary

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Care. North of England Aspirin Guideline Development Group." [In eng]. BMJ 316, no. 7140 (Apr 25
1998): 1303-9.
"The European Stroke Prevention Study (Esps). Principal End-Points. The Esps Group." [In eng]. Lancet
2, no. 8572 (Dec 12 1987): 1351-4.
Farrell, B., J. Godwin, S. Richards, and C. Warlow. "The United Kingdom Transient Ischaemic Attack
(Uk-Tia) Aspirin Trial: Final Results." [In eng]. J Neurol Neurosurg Psychiatry 54, no. 12 (Dec 1991):
1044-54.
Gaspoz, J. M., P. G. Coxson, P. A. Goldman, L. W. Williams, K. M. Kuntz, M. G. Hunink, and L. Goldman.
"Cost Effectiveness of Aspirin, Clopidogrel, or Both for Secondary Prevention of Coronary Heart
Disease." [In eng]. N Engl J Med 346, no. 23 (Jun 6 2002): 1800-6.
Gent, M., J. A. Blakely, J. D. Easton, D. J. Ellis, V. C. Hachinski, J. W. Harbison, E. Panak, et al. "The
Canadian American Ticlopidine Study (Cats) in Thromboembolic Stroke." [In eng]. Lancet 1, no. 8649
(Jun 3 1989): 1215-20.
Gorelick, P. B., D. Richardson, M. Kelly, S. Ruland, E. Hung, Y. Harris, S. Kittner, S. Leurgans, and
Investigators African American Antiplatelet Stroke Prevention Study. "Aspirin and Ticlopidine for
Prevention of Recurrent Stroke in Black Patients: A Randomized Trial." [In eng]. JAMA 289, no. 22 (Jun
11 2003): 2947-57.
Group, Esprit Study, P. H. Halkes, J. van Gijn, L. J. Kappelle, P. J. Koudstaal, and A. Algra. "Aspirin Plus
Dipyridamole Versus Aspirin Alone after Cerebral Ischaemia of Arterial Origin (Esprit): Randomised
Controlled Trial." [In eng]. Lancet 367, no. 9523 (May 20 2006): 1665-73.
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of
Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.
Guyatt, G., H. Schunemann, D. Cook, R. Jaeschke, S. Pauker, H. Bucher, and Physicians American
College of Chest. "Grades of Recommendation for Antithrombotic Agents." [In eng]. Chest 119, no. 1
Suppl (Jan 2001): 3S-7S.
Hass, W. K., J. D. Easton, H. P. Adams, Jr., W. Pryse-Phillips, B. A. Molony, S. Anderson, and B. Kamm.
"A Randomized Trial Comparing Ticlopidine Hydrochloride with Aspirin for the Prevention of Stroke in
High-Risk Patients. Ticlopidine Aspirin Stroke Study Group." [In eng]. N Engl J Med 321, no. 8 (Aug 24
1989): 501-7.
"The International Stroke Trial (Ist): A Randomised Trial of Aspirin, Subcutaneous Heparin, Both, or
Neither among 19435 Patients with Acute Ischaemic Stroke. International Stroke Trial Collaborative
Group." [In eng]. Lancet 349, no. 9065 (May 31 1997): 1569-81.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Johnson, E. S., S. F. Lanes, C. E. Wentworth, 3rd, M. H. Satterfield, B. L. Abebe, and L. W. Dicker. "A
Metaregression Analysis of the Dose-Response Effect of Aspirin on Stroke." [In eng]. Arch Intern Med
159, no. 11 (Jun 14 1999): 1248-53.
Kennedy, J., M. D. Hill, K. J. Ryckborst, M. Eliasziw, A. M. Demchuk, A. M. Buchan, and Faster
Investigators. "Fast Assessment of Stroke and Transient Ischaemic Attack to Prevent Early
Recurrence (Faster): A Randomised Controlled Pilot Trial." [In eng]. Lancet Neurol 6, no. 11 (Nov 2007):
961-9.

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Kernan, W.N., B. Ovbiagele, H. R. Black, D. M. Bravata, M. I. Chimowitz, M. D. Ezekowitz, M. C. Fang, M.
Fisher, K. L. Furie, D. V. Heck, S. C. Johnston, S. E. Kasner, S. J. Kittner, P. H. Mitchell, M. W. Rich, D.
Richardson, L. H. Schwamm, J. A. Wilson. “Guidelines for the Prevention of Stroke in Patients with
Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American
Heart Association/American Stroke Association.” [in eng.] Stroke 45, no. 7 (May 2014): 2160-223.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e45-e46.
"A Randomized Trial of Aspirin and Sulfinpyrazone in Threatened Stroke. The Canadian Cooperative
Study Group." [In eng]. N Engl J Med 299, no. 2 (Jul 13 1978): 53-9.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Sacco, R. L., H. C. Diener, S. Yusuf, D. Cotton, S. Ounpuu, W. A. Lawton, Y. Palesch, et al. "Aspirin and
Extended-Release Dipyridamole Versus Clopidogrel for Recurrent Stroke." [In eng]. N Engl J Med 359,
no. 12 (Sep 18 2008): 1238-51.
"Swedish Aspirin Low-Dose Trial (Salt) of 75 Mg Aspirin as Secondary Prophylaxis after
Cerebrovascular Ischaemic Events. The Salt Collaborative Group." [In eng]. Lancet 338, no. 8779 (Nov
30 1991): 1345-9.
"United Kingdom Transient Ischaemic Attack (Uk-Tia) Aspirin Trial: Interim Results. Uk-Tia Study
Group." [In eng]. Br Med J (Clin Res Ed) 296, no. 6618 (Jan 30 1988): 316-20.

Set Measures

Set Measure ID Measure Short Name

ASR-OP-1 Thrombolytic Therapy: Drip and Ship

ASR-OP-2 Door to Transfer to Another Hospital

General Data Elements

Element Name Collected For

Birthdate All Records,

Hispanic Ethnicity All Records,

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File, Used in
calculation of the Joint Commission's
aggregate data and in the transmission of
the Hospital Clinical Data file.

Payment Source All Records, Optional for HBIPS-2 and

HBIPS-3

Race All Records,

Sex All Records,

Algorithm Output Data Elements

Element Name Collected For

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name Collected For

Arrival Time ASR-OP-1, ASR-OP-2

Comfort Measures Only ASR-OP-2

Date Last Known Well ASR-OP-1

Discharge Code ASR-OP-2

E/M Code ASR-OP-1, ASR-OP-2

ED Departure Date ASR-OP-2

ED Departure Time ASR-OP-2

IV Alteplase Initiation ASR-OP-1, ASR-OP-2

IV Alteplase Initiation Date ASR-OP-1

IV Alteplase Initiation Time ASR-OP-1

Last Known Well ASR-OP-1

Outpatient Encounter Date ASR-OP-1, ASR-OP-2

Reason for Extending the Initiation of IV Alteplase ASR-OP-1

Reason for Not Initiating IV Alteplase ASR-OP-1

Time Last Known Well ASR-OP-1

ASR-OP Initial Patient Population

The population of the ASR-OP measure set is identified using 4 data elements:

EM Code
ICD-10-CM Principal Diagnosis Code
Outpatient Encounter Date
Birthdate

Patients admitted to the hospital for outpatient acute care with an EM Code as defined in Appendix A, Table
1.0, and an ICD-10-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as defined in Appendix
A, Table 8.1 or Table 8.2, and a Patient Age (Outpatient Encounter Date minus Birthdate) greater than or
equal to 18 years are included in the ASR-OP Initial Patient Population.

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Measure Information Form
Measure Set: Acute Stroke Ready Outpatient (ASR-OP)

Set Measure ID: ASR-OP-1

Performance Measure Name: Thrombolytic Therapy: Drip and Ship

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Acute ischemic stroke patients for whom IV alteplase therapy was initiated at this
hospital within 3 hours (< 180 min.) of time last known well

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

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Date Last Known Well
IV Alteplase Initiation
IV Alteplase Initiation Date
IV Alteplase Initiation Time
Time Last Known Well

Denominator Statement: Acute ischemic stroke patients whose time of arrival is within 2 hours (< 120 min.)
of time last known well

Included Populations:

Patients with an ICD-10-CM Principal Diagnosis Code for acute ischemic stroke as defined in
Appendix A, Table 8.1, AND
An E/M Code for emergency department encounter as defined in Appendix A, Table 1.0

Excluded Populations:

Patients less than 18 years of age

Time Last Known Well to arrival in ED > 2 hours
Patients with a documented Reason for Extending the Initiation of IV Alteplase
Patients with a documented Reason for Not Initiating IV Alteplase

Data Elements:

Arrival Time
Birthdate
Date Last Known Well
E/M Code
ICD-10-CM Principal Diagnosis Code
Last Known Well
Outpatient Encounter Date
Reason for Extending the Initiation of IV Alteplase
Reason for Not Initiating IV Alteplase
Time Last Known Well

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Sampling: No.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

H., R. Adams, G. Del Zoppo, L. B. Goldstein, Association Stroke Council of the American Heart, and
Association American Stroke. "Guidelines for the Early Management of Patients with Ischemic Stroke:
2005 Guidelines Update a Scientific Statement from the Stroke Council of the American Heart
Association/American Stroke Association." [In eng]. Stroke 36, no. 4 (Apr 2005): 916-23.
Adams, H. P., Jr., G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, et al.
"Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline from the American
Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council,
Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular
Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American
Academy of Neurology Affirms the Value of This Guideline as an Educational Tool for Neurologists."
[In eng]. Stroke 38, no. 5 (May 2007): 1655-711.
Albers, G. W., P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke: The Seventh Accp Conference on Antithrombotic and Thrombolytic
Therapy." [In eng]. Chest 126, no. 3 Suppl (Sep 2004): 483S-512S.
Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S.
Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association
(NSA) (2000).
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Del Zoppo, G. J., J. L. Saver, E. C. Jauch, H. P. Adams, Jr., and Council American Heart Association
Stroke. "Expansion of the Time Window for Treatment of Acute Ischemic Stroke with Intravenous
Tissue Plasminogen Activator: A Science Advisory from the American Heart Association/American
Stroke Association." [In eng]. Stroke 40, no. 8 (Aug 2009): 2945-8.
Demaerschalk, B. M., D. O. Kleindorfer, O. M. Adeoye, A. M. Demchuk, et. al., on behalf of the American
Heart Association Stroke Council and Council on Epidemiology and Prevention. “Scientific Rationale
for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: As
Statement for Healthcare Professionals From the American Heart Association/American Stroke
Association.” [In eng]. Stroke, no. 47 (Feb 2016): 581-641.
"Diagnosis and Initial Treatment of Ischemic Stroke." Institute for Clinical Systems Improvement
(2001).
Fagan, S. C., L. B. Morgenstern, A. Petitta, R. E. Ward, B. C. Tilley, J. R. Marler, S. R. Levine, et al. "Cost-
Effectiveness of Tissue Plasminogen Activator for Acute Ischemic Stroke. Ninds Rt-Pa Stroke Study
Group." [In eng]. Neurology 50, no. 4 (Apr 1998): 883-90.
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of
Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.

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Hacke, W., G. Donnan, C. Fieschi, M. Kaste, R. von Kummer, J. P. Broderick, T. Brott, et al. "Association
of Outcome with Early Stroke Treatment: Pooled Analysis of Atlantis, Ecass, and Ninds Rt-Pa Stroke
Trials." [In eng]. Lancet 363, no. 9411 (Mar 6 2004): 768-74.
Hacke, W., M. Kaste, E. Bluhmki, M. Brozman, A. Davalos, D. Guidetti, V. Larrue, et al. "Thrombolysis
with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke." [In eng]. N Engl J Med 359, no. 13 (Sep 25
2008): 1317-29.
Hacke, W., M. Kaste, C. Fieschi, D. Toni, E. Lesaffre, R. von Kummer, G. Boysen, et al. "Intravenous
Thrombolysis with Recombinant Tissue Plasminogen Activator for Acute Hemispheric Stroke. The
European Cooperative Acute Stroke Study (Ecass)." [In eng]. JAMA 274, no. 13 (Oct 4 1995): 1017-25.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Kwiatkowski, T. G., R. B. Libman, M. Frankel, B. C. Tilley, L. B. Morgenstern, M. Lu, J. P. Broderick, et al.
"Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year. National Institute of
Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group."
[In eng]. N Engl J Med 340, no. 23 (Jun 10 1999): 1781-7.
"Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications,
and Discharge Planning. A National Clinical Guideline.".
http://www.sign.ac.uk/guidelines/fulltext/118/.
Marler, J. R., B. C. Tilley, M. Lu, T. G. Brott, P. C. Lyden, J. C. Grotta, J. P. Broderick, et al. "Early Stroke
Treatment Associated with Better Outcome: The Ninds Rt-Pa Stroke Study." [In eng]. Neurology 55, no.
11 (Dec 12 2000): 1649-55.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e18-e25.

Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.

"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Sacco, R. L., R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, et al. "Guidelines
for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: A Statement
for Healthcare Professionals from the American Heart Association/American Stroke Association
Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The
American Academy of Neurology Affirms the Value of This Guideline." [In eng]. Stroke 37, no. 2 (Feb
2006): 577-617.
Saposnik, G., J. Fang, M. K. Kapral, J. V. Tu, M. Mamdani, P. Austin, S. C. Johnston, Network
Investigators of the Registry of the Canadian Stroke, and Group Stroke Outcomes Research Canada
Working. "The Iscore Predicts Effectiveness of Thrombolytic Therapy for Acute Ischemic Stroke." [In
eng]. Stroke 43, no. 5 (May 2012): 1315-22.
"Tissue Plasminogen Activator for Acute Ischemic Stroke. The National Institute of Neurological
Disorders and Stroke Rt-Pa Stroke Study Group." [In eng]. N Engl J Med 333, no. 24 (Dec 14 1995):
1581-7.
Wardlaw, J. M., V. Murray, E. Berge, and G. J. Del Zoppo. "Thrombolysis for Acute Ischaemic Stroke." [In
eng]. Cochrane Database Syst Rev, no. 4 (2009): CD000213.

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Measure Information Form
Measure Set: Acute Stroke Ready Outpatient (ASR-OP)

Set Measure ID: ASR-OP-2

Set Measure ID Performance Measure Name

ASR-OP-2a Door to Transfer to Another Hospital - Overall Rate

ASR-OP-2b Door to Transfer to Another Hospital - Hemorrhagic Stroke

ASR-OP-2c Door to Transfer to Another Hospital - Ischemic Stroke; Drip and Ship

ASR-OP-2d Door to Transfer to Another Hospital - Ischemic Stroke; No IV Alteplase Prior to Transfer

Performance Measure Name: Door to Transfer to Another Hospital

Description: Median time from hospital arrival in the emergency department to transfer of a hemorrhagic
stroke patient, an ischemic stroke patient (drip and ship), or an ischemic stroke patient (no IV alteplase given
prior to transfer) to another hospital

Rationale: For the past ten years, the organization of acute stroke care in the United States has moved in the
direction of stroke centers; however, many patients with an acute stroke live in areas without ready access to
a Primary (PSC) or Comprehensive Stroke Center (CSC). A third designation of stroke center, the Acute Stroke
Ready Hospital (ASRH), has emerged for hospitals that can provide timely, evidence-based care, i.e., initial
diagnostic services, initial stroke diagnosis, stabilization, emergent care and therapies, to patients with an
acute stroke who are seen in their emergency department.

Most patients with an acute stroke seen initially at an ASRH will require emergent transfer to a PSC or CSC.
The Brain Attack Coalition recommends that such transfers occur within 2 hours of the patient presenting to
the ASRH (Alberts, 2013). Additionally, written transfer agreements between the ASRH and at least one PSC
or CSC and a transportation vendor with both ground and air ambulance transfer options are recommended.
One in four patients are transferred while receiving intravenous (IV) alteplase (Sheth, 2015); others
transferred after initiation of coagulopathy reversal treatment. Reducing the time stroke patients remain in
the emergency department (ED) can improve access to a higher-level of stroke care and advanced intra-
arterial or endovascular treatments, and increase quality of care. A door to needle time goal within 60
minutes should be established for acute ischemic stroke patients treated with IV alteplase. Door to needle
times within 45 minutes may be reasonable for some patients (Powers, 2018). For those stroke patients who
are not transferred to a PSC or CSC, inpatient admission within 3 hours, preferably to a formal stroke unit, is
recommended (Jauch, 2013).

Type Of Measure: Process

Improvement Noted As: Decrease in the median value

Continuous Variable Statement:

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ASR-OP-2b Time (in minutes) from ED arrival to transfer of a hemorrhagic stroke patient to another hospital

ASR-OP-2c Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (drip and ship) to
another hospital

ASR-OP-2d Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV alteplase prior
to transfer) to another hospital

Included Populations:

Patients with an ICD-10-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as
defined in Appendix A, Table 8.1 or Table 8.2

AND

Patients who are transferred to another hospital

AND

An E/M Code for emergency department encounter as defined in Appendix A, Table 1.0

Excluded Populations:

Patients less than 18 years of age

Patients with Comfort Measures Only documented on day of or day after arrival
Patients who expired in the emergency department
Discharges to dispositions other than an acute care facility

Data Elements:

Arrival Time
Birthdate
Comfort Measures Only
Discharge Code
E/M Code
ED Departure Date
ED Departure Time
ICD-10-CM Principal Diagnosis Code
IV Alteplase Initiation
Outpatient Encounter Date

Risk Adjustment: No.

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However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes,
which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: No.

Data Reported As: Aggregate measure of central tendency .

Selected References:

Alberts MJ, Wechsler LR, Jensen MEL, Lachtaw RE, Crocco TJ, George MG, Baranski J, Bass RR, et al.
“Formation and Function of Acute Stroke-Ready Hospitals Within a Stroke System of Care
Recommendations From the Brain Attack Coalition” [In Eng]. Stroke (Nov 12 2013).
Albright KC, Branas CC, Meyer BC, Matherne-Meyer DE, Zivin JA, Lyden PD, Carr BG. “Acute
Cerebrovascular Care in Emergency Stroke Systems.” [In Eng]. Arch Neurol (Oct 2010).
American Heart Association. Acute Stroke Ready Hospital, 2015.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Lyerly MJ, Albright KC, Boehme AK, Shahripour RB, Donnelly JP, Houston JT, Rawal PV, Kapoor N, Alvi
M, Sisson A, Alexandrov AW, Alexandrov AV. “Patient Selection for Drip and Ship Thrombolysis in
Acute Ischemic Stroke”. [In Eng]. South Med J (Jul 2015).
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e8, e10.
Sheth KN, Smith EE, Grau-Sepulveda MV, Kleindorfer D, Fonarow GC, Schwamm LH. "Drip and Ship
Thrombolytic Therapy for Acute Ischemic Stroke: Use, Temporal Trends, and Outcomes.” [In Eng].
Stoke (Mar 2015).

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Advanced Certification Heart Failure (ACHF)

Set Measures

Set Measure Short Name

Measure ID

ACHF-01 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate

Prescribed for LVSD at Discharge)

ACHF-02 Post-Discharge Appointment for Heart Failure Patients

ACHF-03 Care Transition Record Transmitted

ACHF-04 Discussion of Advance Directives/Advance Care Planning

ACHF-05 Advance Directive Executed

ACHF-06 Post-Discharge Evaluation for Heart Failure Patients

General Data Elements

Element Name Collected For

Admission Date All Records,

Birthdate All Records,

Discharge Date All Records, Not collected for HBIPS-2 and

HBIPS-3

Hispanic Ethnicity All Records,

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records

Race All Records,

Sex All Records,

Measure Set Specific Data Elements

Advance Directive Executed ACHF-05

Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate ACHF-01

Prescribed for LVSD at Discharge

Care Transition Record Transmitted ACHF-03

Care Transition Record-Discharge Medications ACHF-03

Care Transition Record-Follow-Up Treatment(s) and Service(s) ACHF-03

Needed

Care Transition Record-Procedures Performed During ACHF-03

Hospitalization

Care Transition Record-Reason for Hospitalization ACHF-03

Care Transition Record-Treatment(s)/Service(s) Provided ACHF-03

Clinical Trial ACHF-01, ACHF-02, ACHF-03, ACHF-06

Comfort Measures Only ACHF

Discharge Disposition ACHF

Discussion of Advance Directives/Advance Care Planning ACHF-04

LVSD < 40% ACHF-01

Post-Discharge Appointment Scheduled Within 7 Days ACHF-02

Post-Discharge Evaluation Conducted Within 72 Hours ACHF-06

Reason for No Bisoprolol, Carvedilol, or Sustained-Release ACHF-01

Metoprolol Succinate Prescribed for LVSD at Discharge

Reason for No Post-Discharge Appointment Within 7 Days ACHF-02

Related Materials

Document Name

Acknowledgement

Appendix A - Code Tables

Appendix C - Medication Tables

Appendix D - Glossary of Terms

Appendix E - Overview of Measure Information Form and Flowchart Formats

Appendix G - Resources

Appendix H - Miscellaneous Tables

Cover Page for the Joint Commission Manual

Data Dictionary

Introduction to the Manual

Missing and Invalid Data

Sampling

Table of Contents

Transmission Alpha Data Dictionary

Transmission Data Processing Flow: Clinical

Transmission Data Processing Flow: Population and Sampling

Transmission of Data

Using the The Joint Commission's National Measure Specifications Manual

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures
consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample cases
MUST submit AT LEAST the minimum required sample size.

Quarterly Sampling

Hospitals performing quarterly sampling for ACHF must ensure that its Initial Patient Population and sample
size meet the following conditions:

Quarterly Sample Size

Based on Initial Patient Population Size for the ACHF Measure Set

Hospital's Measure

Average Quarterly Minimum Required

Initial Patient Population Sample Size
Size “N” “n”

≥ 1516 304

381 -— 1515 20% of Initial Patient Population size

76 —- 380 76

0 —- 75 No sampling; 100% Initial Patient Population required

Monthly Sampling

Hospitals performing monthly sampling for ACHF must ensure that its Initial Patient Population and sample
size meet the following conditions:

Monthly Sample Size

Based on Initial Patient Population Size for the ACHF Measure Set

Hospital's Measure

≥ 506 102

131 -— 505 20% of Initial Patient Population size

26 -— 130 26

<26 No sampling; 100% Initial Patient Population required

Sample Size Examples

Quarterly sampling:
The ACHF Initial Patient Population size for a hospital has been 500 patients per quarter during
the past year. The required quarterly sample size would be 100 (twenty percent of 500) heart
failure patients per quarter -- as this number is smaller than the maximum condition (i.e., 304
cases) and larger than the minimum condition (i.e., 76 cases).
A hospital's ACHF Initial Patient Population size is 1,482 patients during the third quarter. The
required sample size is 20% of the patient population or 297 cases for the quarter (twenty
percent of 1,482 equals 296.4 rounded to the next highest whole number equals 297).

Monthly sampling:
A hospital's ACHF Initial Patient Population size is 25 patients during March. Since this is less
than the minimum condition (i.e., 26 cases), no sampling is allowed or 100% of the patient
population of 25 cases is required.
A hospital's ACHF Initial Patient Population size is 503 patients during July. The required
sample size is 20% of the patient population or 101 cases for the month (twenty percent of 503
equals 100.6 rounded to the next highest whole number equals 101).

Set Measure ID: ACHF-01

Performance Measure Name: Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release

Metoprolol Succinate Prescribed for LVSD at Discharge)

Description: Beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is

prescribed for heart failure patients with LVSD at discharge. For purposes of this measure, LVSD is defined
as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description
of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.

Rationale: Beta-blocker therapy has been recommended for the treatment of patients with heart failure and
reduced left ventricular ejection fraction (LVEF) since the 1970's (HFSA, 2010). Several large-scale clinical
trials have provided unequivocal evidence of important reductions in both morbidity and mortality. The
marked beneficial effects of beta blockade has been well demonstrated in large-scale clinical trials of
symptomatic patients with New York Heart Association (NYHA) class II-IV heart failure and reduced LVEF
using carvedilol, bisoprolol, and sustained-release metoprolol succinate (Hunt et al., 2009). These beta-
blockers, in addition to ACE inhibitors and diuretics, are considered routine therapy for heart failure patients
with reduced LVEF. Beta-blocker therapy is well tolerated by the majority of patients, even those with co-
morbidities such as, diabetes mellitus, chronic obstructive lung disease, and peripheral vascular disease.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol
succinate for LVSD at hospital discharge.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD at Discharge

Denominator Statement: Heart failure patients with current or prior documentation of left ventricular ejection
fraction (LVSD) < 40%.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1,
and

Excluded Populations:

Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during
hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A,
Table 2.2)
Patients less than 18 years of age
Patients who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented
Patients enrolled in a Clinical Trial
Patients discharged to another hospital
Patients who left against medical advice
Patients who expired
Patients discharged to home for hospice care
Patients discharged to a healthcare facility for hospice care
Patients with a documented Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol
Succinate Prescribed for LVSD at Discharge

Data Elements:

Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
Discharge Disposition
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
LVSD < 40%
Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD at
Discharge

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

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Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American College of Cardiology Foundation, American Heart Association, Physician Consortium for
Performance Improvement® (PCPI). Heart Failure Performance Measurement Set. Jan. 2011; 47-56.
Hunt SA, Abraham WT, Chin MH, Felman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini
DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update
incorporated Into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in
adults: a report of the American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and
Lung Transplantation. Circulation. 2009;119(14):e391-e479.
Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, MoserDK,
Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA
2010 Comphrensive Heart Failure Practice Guideline. J Card Fail 2010;16:475-539.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHF-02

Performance Measure Name: Post-Discharge Appointment for Heart Failure Patients

Description: Patients for whom a follow-up appointment for an office or home health visit for management of
heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.

Rationale: Care coordination is important for all patients, but especially for vulnerable populations, such as
patients with heart failure and other chronic diseases. Today, the average Medicare patient sees two primary
care and five specialists per year (NQF, 2010). For patients with multiple chronic conditions, the number of
healthcare providers involved in the care of the patient is even higher.

The exchange of information from one healthcare provider to another should smooth the transition of care
from the inpatient to outpatient setting. According to Bell and colleagues (2008), the separation of hospital
and ambulatory care may result in significant care discontinuities after discharge. Therefore, it is paramount
that discussions between providers summarize the patient's history and communicate the plan for follow-up
care after discharge in order to be effective. When done well, this exchange of information can avoid
conflicting plans of care; overuse, underuse, and misuse of medications, tests and therapies; reduce costs
and potentially adverse events.

The Joint Commission's Disease-Specific Care Advanced Certification Heart Failure standards require: “The
program [to provide] care coordination services across inpatient and outpatient settings.” Scheduling of the
initial follow-up appointment with the primary care provider is a first-step to ensuring continuity of care. In
addition, standards require that care, treatment, and services are provided in a planned and timely manner,
which includes the arrangement of a follow-up appointment with a health care provider to occur within seven
days after discharge.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients for whom a follow-up appointment for an office or home health visit for
management of heart failure was scheduled within 7 days post-discharge and documented including
location, date, and time.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Post-Discharge Appointment Scheduled Within 7 Days

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Denominator Statement: All heart failure patients discharged from a hospital inpatient setting to home or
home care.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1,
and
A discharge to home, home care, or court/law enforcement

Excluded Populations:

Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during
hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A,
Table 2.2)
Patients less than 18 years of age
Patient who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented
Patients enrolled in a Clinical Trial
Patients discharged to locations other than home, home care, or law enforcement
Patients with a documented Reason for No Post-Discharge Appointment Within 7 Days
Patients who left against medical advice (AMA)

Data Elements:

Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
Discharge Disposition
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
Reason for No Post-Discharge Appointment Within 7 Days

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

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Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American College of Cardiology Foundation, American Heart Association, Physician Consortium for
Performance Improvement® (PCPI). Heart Failure Performance Measurement Set. Jan. 2011; 47-56.
Hunt SA, Abraham WT, Chin MH, Felman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini
DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update
incorporated Into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in
adults: a report of the American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and
Lung Transplantation. Circulation. 2009;119(14):e391-e479.
Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, MoserDK,
Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA
2010 Comphrensive Heart Failure Practice Guideline. J Card Fail 2010;16:475-539.
The Joint Commission. The Joint Commission's 2019 Comprehensive Certification Manual for
Disease-Specific Care. Oakbrook Terrace, IL: Author. 2019.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHF-03

Performance Measure Name: Care Transition Record Transmitted

Description: A care transition record is transmitted to a next level of care provider within 7 days of discharge
containing ALL of the following:

Reason for hospitalization

Procedures performed during this hospitalization
Treatment(s)/Service(s) provided during this hospitalization
Discharge medications, including dosage and indication for use
Follow-up treatment and services needed (e.g., post-discharge therapy, oxygen therapy, durable
medical equipment)

Rationale: The hand-over of care from one healthcare provider to another should smooth the transition of
care from the inpatient to outpatient setting (van Walraven et al., 2002). Communication and information
exchange should be completed to allow sufficient time for the receiving provider to treat the patient. The
timeliness of communication should be consistent with the urgency of follow-up required (Kripalani et al.,
2007). Communication and information exchange between providers may be in the form of a phone call, fax,
or other secure vehicle, such as, mutual access to an electronic health record (EHR).

The Joint Commission's Disease-Specific Care Advanced Certification Heart Failure standards require:

That the program includes both inpatient and outpatient services, including transitions.
The provision of care coordination services across inpatient and outpatient settings.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Care transition record transmitted to a next level of care provider within 7 days of
discharge containing ALL of the following:

Reason for hospitalization

Included Populations: Not applicable

Excluded Populations: None

Care Transition Record Transmitted

Care Transition Record-Discharge Medications
Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed
Care Transition Record-Procedures Performed During Hospitalization
Care Transition Record-Reason for Hospitalization
Care Transition Record-Treatment(s)/Service(s) Provided

Denominator Statement: All heart failure patients discharged from a hospital inpatient setting to home or
home care

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1,
and
A discharge to home, home care, or court/law enforcement

Excluded Populations:

Data Elements:

Risk Adjustment: No.

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Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion. Aggregate rate
generated from count data reported as a proportion

Selected References:

Bell CM, Schnipper JL, Auerback AD, Kaboli PJ, Wetterneck TB, Gonzales DV, Arora VM, Zhang JX,
Meltzer DO; Association of communication between hospital-based physicians and Primary care
providers with patient outcomes. J Gen Intern Med. 2008; 24(3):381-386.
Bodenheimer T. Coordinating care a perilous journey through the health care system.NEJM.
2008;358(10): 1064-1071.
Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between
hospital-based and primary care physicians: Implications for patient safety and continuity of care.
JAMA. 2007; 297(8):831-841.
Ravel AN, Marchiori GE, Arnold JMO. Improving the continuity of care following discharge of patients
hospitalized with heart failure: Is the discharge summary adequate? Can J Cardiol. 2003;19(4):365-
370.
van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-
discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.
The Joint Commission. The Joint Commission's 2019 Comprehensive Certification Manual for
Disease-Specific Care: Advanced Certification in Heart Failure Addendum. Oakbrook Terrace, IL:
Author. 2019.

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158
Measure Information Form
Measure Set: Advanced Certification Heart Failure (ACHF)

Set Measure ID: ACHF-04

Performance Measure Name: Discussion of Advance Directives/Advance Care Planning

Description: Patients who have documentation in the medical record of a one-time discussion of advance
directives/advance care planning with a healthcare provider.

According to Heffner and Barbieri, most patients at fourteen cardiac rehabilitation programs across the
United States, presumed the need for life-support at some point in the future and wanted to make their own
decisions about end-of-life care. Most of the patients were aware of advance directives, desired more
information, and preferred to get more information from their lawyers, families, physicians, or cardiac
rehabilitation programs (Perkins, 2000). Despite this receptiveness, only 15% of patients had discussed
advance directives with their physicians, and 10% had confidence that their physicians understood their
wishes (Heffner and Barbieri, 2000).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who have documentation in the medical record of a one-time discussion of
advance directives/advance care planning with a healthcare provider

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Discussion of Advance Directives/Advance Care Planning

Denominator Statement: All heart failure patients

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1
Patients who left against medical advice (AMA)
Patients enrolled in a Clinical Trial

Data Elements:

Admission Date
Birthdate
Comfort Measures Only
Discharge Date
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion. Aggregate rate
generated from count data reported as a proportion

Selected References:

Anderson R, Joy S, Carkido A, Anthony S, Smyntek D, Perrine S, Puet TA, Butler ET. Development of a
Congestive Heart Failure Protocol in a Rehabilitation Setting. Rehab Nursing 2010;35(1);3-7;30.
Hefner JE, Barberi C. End-of-life care preferences of patients enrolled in cardiovascular rehabilitation
programs. Chest. 2000;117(5);1474-1481.

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Kass-Bartelmes BL, Hughes R. Advance Care Planning Preferences for care at the end of life. J Pain
Palliat Care Pharmacother. 2004;18(1):87-109.
Perkins HS. Time to move advance care planning beyond advance directives. Chest. 2000;117(5);128-
1231.
Wilkinson A. Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers. The
Washington Home Center for Palliative Care Studies (A Division of the RAND Corporation). Nov 2002.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHF-05

Performance Measure Name: Advance Directive Executed

Description: Patients who have documentation in the medical record that an advance directive was
executed.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who have documentation in the medical record that an advance directive
was executed.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Advance Directive Executed

Denominator Statement: All heart failure patients.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1,
and
Patients who left against medical advice (AMA)

Excluded Populations:

Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during
hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A,
Table 2.2)
Patients less than 18 years of age
Patients who have a Length of Stay Greater than 120 days
Patients with Comfort Measures Only documented
Patients discharged to another hospital
Patients discharged to home for hospice care
Patients discharged to a health care facility for hospice care
Patients who expire

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Anderson R, Joy S, Carkido A, Anthony S, Smyntek d, Perrine S, Puet TA, Butler ET. Development of a
Congestive Heart Failure Protocol in a Rehabilitation Setting. Rehab Nursing 2010;35(1);3-7;30.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
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164
Hefner JE, Barberi C. End-of-life care preferences of patients enrolled in cardiovascular rehabilitation
programs. Chest. 2000;117(5);1474-1481.
Kass-Bartelmes BL, Hughes R. Advance Care Planning Preferences for care at the end of life. J Pain
Palliat Care Pharmacother. 2004;18(1):87-109.
Perkins HS. Time to move advance care planning beyond advance directives. Chest. 2000;117(5);128-
1231.
Wilkinson A. Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers. The
Washington Home Center for Palliative Care Studies (A Division of the RAND Corporation). Nov 2002.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHF-06

Performance Measure Name: Post-Discharge Evaluation for Heart Failure Patients

Description: Patients who receive a re-evaluation for symptoms worsening and treatment compliance by a
program team member within 72 hours after inpatient discharge.

Rationale: Today, hospitals and providers in the United States are challenged to provide high-quality, cost-
effective healthcare. Preventing readmissions to the hospital is one opportunity to control costs and deliver
quality care. According to Hospital Compare (2010), the national 30-day readmission rate for heart failure is
24.7%. Jha and colleagues (2009) have concluded that data collection for discharge planning and instruction
measures has not reduced unnecessary readmissions. Alternative interventions are needed to meet heart
failure treatment goals post-discharge. Ongoing evaluation of patient symptoms and their functional
consequences may help prevent hospital readmissions.

The Joint Commission's Disease-Specific Care Advanced Certification Heart Failure standards require:

Assessment and reassessment are completed and that the patient is reevaluated within 72 hours
after inpatient discharge.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who have a documented re-evaluation conducted via phone call or home
visit within 72 hours after discharge.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Post-Discharge Evaluation Conducted Within 72 Hours

Denominator Statement: All heart failure patients discharged from a hospital inpatient setting to home or
home care AND patients leaving against medical advice (AMA).

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1,
and

Excluded Populations:

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion. Aggregate rate
generated from count data reported as a proportion

Selected References:

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168
Hoyt RE, Bowling LS. Reducing Readmissions for Congestive Heart Failure. Am Fam Physician
2001;63(8):1593-1598.
Jha AK, Orav EJ, Epstein AM. Public Reporting of Discharge Planning and Rate of Readmissions. N
Eng J Med 2009; 361(27):2637-2645.
The Joint Commission. The Joint Commission's 2019 Comprehensive Certification Manual for
Disease-Specific Care: Advanced Certification in Heart Failure Addendum. Oakbrook Terrace, IL:
Author. 2019.

Set Measures

Set Measure Short Name

Measure
ID

ACHFOP- Hospital Outpatient Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release

01 Metoprolol Succinate Prescribed for LVSD)

ACHFOP- Hospital Outpatient ACEI or ARB Prescribed for LVSD

ACHFOP- Hospital Outpatient Aldosterone Receptor Antagonists Prescribed for LVSD

ACHFOP- Hosptial Outpatient New York Heart Association (NYHA Classification Assessment)
04

ACHFOP- Hospital Outpatient Activity Recommendations

ACHFOP- Hospital Outpatient Discussion of Advance Directives/Advance Care Planning

ACHFOP- Hospital Outpatient Advance Directive Executed

General Data Elements

Element Name Collected For

Birthdate All Records,

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records

Measure Set Specific Data Elements

ACEI Prescribed for LVSD in the Outpatient Setting ACHFOP-02

ARB Prescribed for LVSD in the Outpatient Setting ACHFOP-02

Activity Recommendation — Duration of Activity ACHFOP-05

Activity Recommendation — Intensity of Activity ACHFOP-05

Activity Recommendation — Type of Activity ACHFOP-05

Advance Directive Executed ACHFOP-07

Aldosterone Receptor Antagonist Prescribed for LVSD in the ACHFOP-03

Outpatient Setting

Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed ACHFOP-01

for LVSD in the Outpatient Setting

Clinical Trial ACHFOP-01, ACHFOP-02, ACHFOP-03,

ACHFOP-04, ACHFOP-05

Discharge Code ACHFOP

Discussion of Advance Directives/Advance Care Planning ACHFOP-06

E/M Code ACHFOP

LVSD < 40% ACHFOP-01, ACHFOP-02, ACHFOP-03

New York Heart Association (NYHA) Classification ACHFOP-04

Outpatient Encounter Date ACHFOP

Reason for No ACEI and No ARB Prescribed for LVSD in Outpatient ACHFOP-02
Setting

Reason for No Activity Recommendations in the Outpatient Setting ACHFOP-05

Reason for No Aldosterone Receptor Antagonist Prescribed for ACHFOP-03

LVSD in the Outpatient Setting

Reason for No Bisoprolol, Carvedilol, or Sustained-Release ACHFOP-01

Metoprolol Prescribed for LVSD in the Outpatient Setting

Related Materials

Document Name

Acknowledgement

Appendix A - Code Tables

Appendix C - Medication Tables

Appendix D - Glossary of Terms

Appendix E - Overview of Measure Information Form and Flowchart Formats

Appendix G - Resources

Appendix H - Miscellaneous Tables

Cover Page for the Joint Commission Manual

Data Dictionary

Introduction to the Manual

Missing and Invalid Data

Sampling

Table of Contents

Transmission Alpha Data Dictionary

Transmission Data Processing Flow: Clinical

Transmission Data Processing Flow: Population and Sampling

Transmission of Data

Using the The Joint Commission's National Measure Specifications Manual

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174
ACHF Sample Size Requirements
Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may
choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less
than the minimum number of cases per quarter for the measure set cannot sample.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures
consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample cases
MUST submit AT LEAST the minimum required sample size.

Quarterly Sampling

Hospitals performing quarterly sampling for ACHF must ensure that its Initial Patient Population and sample
size meet the following conditions:

Quarterly Sample Size

Based on Initial Patient Population Size for the ACHF Measure Set

Hospital's Measure

Average Quarterly Minimum Required

Initial Patient Population Sample Size
Size “N” “n”

≥ 1516 304

381 — 1515 20% of Initial Patient Population size

76 — 380 76

0 — 75 No sampling; 100% Initial Patient Population required

Monthly Sampling

Hospitals performing monthly sampling for ACHF must ensure that its Initial Patient Population and sample
size meet the following conditions:

Monthly Sample Size

Based on Initial Patient Population Size for the ACHF Measure Set

Hospital's Measure

≥ 506 102

131 — 505 20% of Initial Patient Population size

26 — 130 26

<26 No sampling; 100% Initial Patient Population required

Sample Size Examples

Set Measure ID: ACHFOP-01

Performance Measure Name: Hospital Outpatient Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or
Sustained-Release Metoprolol Succinate Prescribed for LVSD)

Description: Beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is

prescribed for heart failure patients with LVSD. For purposes of this measure, LVSD is defined as chart
documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left
ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.

Rationale: Beta-blocker therapy has been recommended for the treatment of patients with heart failure and
reduced left ventricular ejection fraction (LVEF) since the 1970's (HFSA, 2010). Several large-scale clinical
trials have provided unequivocal evidence of important reductions in both morbidity and mortality. The
marked beneficial effects of beta blockade has been well demonstrated in large-scale clinical trials of
symptomatic patients with New York Heart Association (NYHA) class II-IV heat failure and reduced LVEF
using carvedilol, bisoprolol, and sustained-release metoprolol succinate (Hunt et al., 2009). These beta-
blockers, in addition to ACE inhibitors and diuretics, are considered routine therapy for heart failure patients
with reduced LVEF. Beta-blocker therapy is well tolerated by the majority of patients, even those with co-
morbidities such as, diabetes mellitus, chronic obstructive lung disease, and peripheral vascular disease.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate

for LVSD when seen in the outpatient setting

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting

Denominator Statement: Heart failure patients with current or prior documentation of left ventricular ejection
fraction (LVSD) < 40%.

Included Populations:

E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0
An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and

Excluded Populations:

Patients enrolled in a Clinical Trial

Patients who had a left ventricular assist device (LVAD) or heart transplant procedure (ICD-10-PCS
Procedure Code for LVAD or heart transplant as defined in Appendix A, Table 2.2)
Patients less than 18 years of age
Patients with a documented Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol
Succinate prescribed for LVSD in the Outpatient Setting

Data Elements:

Birthdate
Clinical Trial
Discharge Code
E/M Code
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Principal Procedure Code
LVSD < 40%
Outpatient Encounter Date
Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the
Outpatient Setting

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American College of Cardiology Foundation, American Heart Association, Physician Consortium for
Performance Improvement® (PCPI). Heart Failure Performance Measurement Set. Jan. 2011; 47-56.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
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178
Hunt SA, Abraham WT, Chin MH, Felman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini
DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update
incorporated Into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in
adults: a report of the American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and
Lung Transplantation. Circulation. 2009;119(14):e391-e479.
Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, MoserDK,
Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA
2010 Comphrensive Heart Failure Practice Guideline. J Card Fail 2010;16:475-539.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHFOP-02

Performance Measure Name: Hospital Outpatient ACEI or ARB Prescribed for LVSD

Description: Heart failure patients with left ventricular systolic dysfunction (LVSD) who are prescribed an
ACEI or ARB in the outpatient setting. For purposes of this measure, LVSD is defined as chart documentation
of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic
(LVS) function consistent with moderate or severe systolic dysfunction.

Rationale: ACE inhibitors reduce mortality and morbidity in patients with heart failure and left ventricular
systolic dysfunction (The SOLVD Investigators, 1991 and CONSENSUS Trial Study Group, 1987) and are
effective in a wide range of patients (Masoudi, 2004). Clinical trials have also established ARB therapy as an
acceptable alternative to ACEI, especially in patients who are ACEI intolerant (Granger, 2003 and Pfeffer,
2003). National guidelines strongly recommend ACEIs for patients hospitalized with heart failure (Jessup,
2009 and HFSA, 2010). Guideline committees have also supported the inclusion of ARBs in performance
measures for heart failure (Executive Council of the Heart Failure Society of America, 2004).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who are prescribed an ACEI or ARB for LVSD when seen in the outpatient
setting

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

ACEI Prescribed for LVSD in the Outpatient Setting

ARB Prescribed for LVSD in the Outpatient Setting

Denominator Statement: Heart failure patients with current or prior documentation of left ventricular ejection
fraction (LVSD) < 40%.

Included Populations:

E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0
An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and
Documentation of LVSD < 40%

Patients renrolled in a Clinical Trial

Patients who had a left ventricular assist device (LVAD) or heart transplant procedure (ICD-10-PCS
Procedure Code for LVAD or heart transplant as defined in Appendix A, Table 2.2)
Patients less than 18 years of age
Patients with a documented Reason for No ACEI or ARB Prescribed for LVSD in the Outpatient
Setting

Data Elements:

Birthdate
Clinical Trial
Discharge Code
E/M Code
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
LVSD < 40%
Outpatient Encounter Date
Reason for No ACEI and No ARB Prescribed for LVSD in Outpatient Setting

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions:

Sampling: Yes. please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Bonow RO, Ganiats TG, Beam CT, Blake K, Casey DE, Goodlin SJ, et al. January 2011. American College
of Cardiology Foundation/ American Heart Association/ Physician Consortium for Performance
Improvement Heart Failure Performance Measurement Set. In American Medical Association.
Retrieved February 2011, from http://www.ama-assn.org/ama1/pub/upload/mm/pcpi/hfset-12-5.pdf.
Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North
Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. N Engl J

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182
Med. 1987;316:1429-1435.
Executive Council of the Heart Failure Society of America. Implications of recent clinical trials for
heart failure performance measures. HFSA Position Statement. J Card Fail. 2004;10:4-5.
Granger CB, McMurray JJ, Yusuf S et al. Effects of candesartan in patients with chronic heart failure
and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors:
the CHARM-Alternative trial. Lancet. 2003;362:772-776.
Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al, writing on behalf of the
2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult
Writing Committee. 2009 focused update: ACCF/AHA guidelines for the diagnosis and management
of heart failure in adults: a report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines. J Am Coll Cardiol. 2009;53:1343— 82.
Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, et al. Executive Summary:
HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:475-539.
Masoudi FA, Rathore SS, Wang Y et al. National patterns of use and effectiveness of angiotensin-
converting enzyme inhibitors in older patients with heart failure and left ventricular systolic
dysfunction. Circulation. 2004;110:724-731.
Pfeffer MA, McMurray JJ, Velazquez EJ et al. Valsartan, captopril, or both in myocardial infarction
complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med. 2003;349:1893-1906.
The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular
ejection fractions and congestive heart failure. N Engl J Med. 1991;325:293-302.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHFOP-03

Performance Measure Name: Hospital Outpatient Aldosterone Receptor Antagonists Prescribed for LVSD

Description: Aldosterone receptor antagonist therapy prescribed for heart failure patients with LVSD. For
purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction
(LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with
moderate or severe systolic dysfunction.

Rationale: Use of aldosterone receptor antagonist in eligible HF patients with LVSD and no documented
contraindications, intolerance, or other medical reason(s) is recommended to reduce heart failure
hospitalization and moratlity. Both ACEIs and ARBs can lower circulating aldosterone with initial therapy;
however, aldosterone suppression may not be sustained over time. Clinical studies have demonstrated that
the addition of spironolactone to ACEI therapy for patients wih NYHA class III or IV symptoms and recent
hospitalization reduced the risk of death from 46% to 35% (30% relative risk reduction) over two years.
Furthermore, a 35% reduction in heart failure hospitalization and improvement in functional class was noted.
A more recent trial of a newer aldosterone antagonist, eplerenone, in patients with LVSD < 40% and clinical
evidence of heart failure or diabetes mellitus within 14 days of myocardial infarction (MI) also demonstrated
a reducation in mortality (13.6% to 11.8% at one year).

Hyperkalemia is a major risk of aldosterone antagonist therapy. Potassium supplements should be

discontinued after the initiation of therapy, and patients should be counseled to avoid high-potassium foods.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who are prescribed an aldosterone receptor antagonist (spironolactone or
eplerenone) when seen in the outpatient setting

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting

Denominator Statement: Heart failure patients with current or prior documentation of left ventricular ejection
fraction (LVSD) < 40%.

Included Populations:

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E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0
An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and
Documentation of LVSD < 40%

Excluded Populations:

Clinical Trial
Patients who had a left ventiricular assist device (LVAD) or heart transplant procedure (ICD-10-
PCS Procedure Code for LVAD or heart transplant as defined in Appendix A, Table 2.2)
Patients less than 18 years of age
Patients with a documented Reason for No Aldosterone Receptor Antagonist Prescribed for LVSD
in the Outpatient Setting

Data Elements:

Birthdate
Clinical Trial
Discharge Code
E/M Code
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
LVSD < 40%
Outpatient Encounter Date
Reason for No Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None.

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Hunt SA, Abraham WT, Chin MH, Felman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini
DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update

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186
incorporated Into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in
adults: a report of the American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and
Lung Transplantation. Circulation. 2009;119(14):e391-e479.
Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, MoserDK,
Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA
2010 Comphrensive Heart Failure Practice Guideline. J Card Fail 2010;16:475-539.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHFOP-04

Performance Measure Name: Hosptial Outpatient New York Heart Association (NYHA Classification
Assessment)

Description: A baseline assessment of functional outcome utilizing the New York Heart Association (NYHA)
classification documented at the time of the initial outpatient visit.

Rationale: Physician-assigned New York Heart Association (NYHA) class has been shown to be predictive of
outcomes in heart failure including hospitalization and mortality (Holland et al., 2010). Classification
involves the physician's subjective interpretation of patient symptoms and clinical data; therefore, variation
in class assignment between different observers is common. To improve objectivity, the pairing of NYHA
class with patient self-assessment of functional status has been recommended by some clinical studies
(Coelho et al., 2005).

Treatment goals for heart failure patients include symptom relief and improved prognosis. Another major
goal is to maximize function in activities of daily living and improve the quality of life within the limits
imposed by the disease (Flynn et al., 2009).

Assessment activities consistent with clinical practice guidelines for a targeted population are an integral
component of diseases-specific patient care. For Advanced Certification in Heart Failure, these activities
should include an assessment of functional capacity (The Joint Commission's Comprehensive Certification
Manual for Disease-Specific Care).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients for whom a New York Heart Association (NYHA) Classification Assessment
was documented at the time of the initial outpatient visit.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

New York Heart Association (NYHA) Classiﬁcation

Denominator Statement: All heart failure patients

Included Populations:

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E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0, and
An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

Excluded Populations:

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Coelho R, Ramos S, Prata J, Bettencourt P, Ferreira A, Cerqueira-Gomes M. Heart failure and health
related quality of life. Clin Pract Epidemiol Ment Health. 2005;1:19.
Flynn KE, Lin L, Ellis SJ, Russell SD, Spertus JA, Whellan DJ, Piña IL, Fine LJ, Schulman KA, Weinfurt
KP; HF-ACTION Investigators. Outcomes, health policy, and managed care: relationships between
patient-reported outcome measures and clinical measures in outpatients with heart failure. Am Heart
J. 2009;158(4 Suppl):S64-71

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Hobbs FD, Kenkre JE, Roalfe AK, Davis RC, Hare R, Davies MK. Impact of heart failure and left
ventricular systolic dysfunction on quality of life: a cross-sectional study comparing common chronic
cardiac and medical disorders and a representative adult population. Eur Heart J. 2002;23(23):1867-
1876.
Holland R, Rechel B, Stepien K, Harvey I, Brooksby I. Patients' self-assessed functional status in heart
failure by New York Heart Association class: a prognostic predictor of hospitalizations, quality of life
and death. J Card Fail. 2010 Feb;16(2):150-156.
Juenger J, Schellberg D, Kraemer S, Haunstetter A, Zugck C, Herzog W, Haass M. Health related quality
of life in patients with congestive heart failure: comparison with other chronic diseases and relation to
functional variables. Heart. 2002;87(3):235-241.
The Joint Commission. The Joint Commission's 2019 Comprehensive Certification Manual for
Disease-Specific Care: Advanced Certification in Heart Failure Addendum. Oakbrook Terrace, IL:
Author. 2019.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHFOP-05

Performance Measure Name: Hospital Outpatient Activity Recommendations

Description: Outpatients who have received a document describing individualized activity recommendations
including type of activity, duration and intensity, tailored to their needs. This document must be present in
the outpatient record.

Rationale: Heart failure is a progressive clinical syndrome in which damage to the myocardium impairs the
ability of the ventricle to effectively pump blood throughout the body. It manifests by fluid congestion or
inadequate blood flow to tissues. Dyspnea and fatigue are cardinal signs of the disease, which may limit
exercise tolerance, and negatively impact the quality of life.

The Committee on Exercise, Rehabilitation, and Prevention of the American Heart Association Council on
Clinical Cardiology has concluded that exercise training in patients with heart failure seems to be safe and
beneficial overall in improving exercise capacity, as measured by peak VO2, peak workload, exercise duration,
and parameters of submaximal exercise performance. Although studies addressing quality of life for heart
failure patients participating in an exercise program are limited, findings suggest that quality of life improves
proportionately with increased exercise capacity. Since there is currently a lack of consensus as to a
universal exercise protocol for all heart failure patients, exercise programs should be tailored to the needs of
the individual. Recommendations for exercise should include the setting, type of activity, duration, and
intensity (Piña et al., 2003).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Outpatients who have received a document describing individualized activity
recommendations including ALL of the following:

Type of activity
Duration of activity
Intensity of activity

This document must be present in the outpatient record.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

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Activity Recommendation — Duration of Activity
Activity Recommendation — Intensity of Activity
Activity Recommendation — Type of Activity

Denominator Statement: All heart failure patients

Included Populations:

E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0, and
An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

Excluded Populations:

Data Elements:

Birthdate
Clinical Trial
Discharge Code
E/M Code
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
Outpatient Encounter Date
Reason for No Activity Recommendations in the Outpatient Setting

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None.

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Selected References:

Hunt SA, Abraham WT, Chin MH, Felman AM, Francis GS, Ganiats TG, Jessup M, Konstan MA, Mancini
DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update
incorporated Into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in
adults: a report of the American College of Cardiology Foundation/American Heart Association Task
Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and
Lung Transplantation. Circulation. 2009;119(14):e391-e479.
Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, MoserDK,
Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA
2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16(6):475-539.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHFOP-06

Performance Measure Name: Hospital Outpatient Discussion of Advance Directives/Advance Care Planning

Description: Outpatients who have documentation in the medical record of a one-time discussion of advance
directives/advance care planning with a healthcare provider.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Outpatients who have documentation in the medical record of a one-time discussion
of advance directives/advance care planning with a healthcare provider.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Discussion of Advance Directives/Advance Care Planning

Denominator Statement: All heart failure patients

Included Populations:

E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0, and
An ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

Data Elements:

Birthdate
Discharge Code
E/M Code
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
Outpatient Encounter Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None.

Sampling: Yes. please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Anderson R, Joy S, Carkido A, Anthony S, Smyntek d, Perrine S, Puet TA, Butler ET. Development of a
Congestive Heart Failure Protocol in a Rehabilitation Setting. Rehab Nursing 2010;35(1);3-7;30.
Hefner JE, Barberi C. End-of-life care preferences of patients enrolled in cardiovascular rehabilitation
programs. Chest. 2000;117(5);1474-1481.
Kass-Bartelmes BL, Hughes R. Advance Care Planning Preferences for care at the end of life. J Pain
Palliat Care Pharmacother. 2004;18(1):87-109.
Perkins HS. Time to move advance care planning beyond advance directives. Chest. 2000;117(5);128-
1231.
Wilkinson A. Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers. The
Washington Home Center for Palliative Care Studies (A Division of the RAND Corporation). Nov 2002.

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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T,
Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE,
Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measure ID: ACHFOP-07

Performance Measure Name: Hospital Outpatient Advance Directive Executed

Description: Outpatients who have documentation in the medical record that an advance directive was
executed.

Rationale: Heart failure is a progressive, debilitating disease which carries with it a poor prognosis over time
and high mortality rate. Physicians should acknowledge the life-threatening nature of the disease and
discuss with patients and/or their caregivers prognosis, quality of life, pharmacologic and device therapies,
self-management, and supportive care options (HFSA, 2010). According to Heffner and Barbieri, most
patients at fourteen cardiac rehabilitation programs across the United States, presumed the need for life-
support at some point in the future and wanted to make their own decisions about end-of-life care. Most of
the patients were aware of advance directives, desired more information, and preferred to get more
information from their lawyers, families, physicians, or cardiac rehabilitation programs (Perkins, 2000).
Despite this receptiveness, only 15% of patients had discussed advance directives with their physicians, and
10% had confidence that their physicians understood their wishes (Heffner and Barbieri, 2000).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Outpatients who have documentation in the medical record that an advance directive
was executed.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Advance Directive Executed

Denominator Statement: All heart failure patients.

Included Populations:

E/M Code for hospital outpatient encounter as defined in Appendix A, Table 2.0, and
ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

Excluded Populations:

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Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during
hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A,
Table 2.2)
Patients less than 18 years of age

Data Elements:

Birthdate
Discharge Code
E/M Code
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
Outpatient Encounter Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluaiton to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

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202
guideline for the management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2013;128:e240–e327.

Set Measures

Set Measure Measure Short Name

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 (Overall Rate)

CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )

CSTK-05 Hemorrhagic Transformation (Overall Rate)

CSTK-06 Nimodipine Treatment Administered

CSTK-07 Median Time to Revascularization

CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)

CSTK-09 Arrival Time to Skin Puncture

CSTK-10 Modified Rankin Score (mRS at 90 Days: Favorable Outcome)

CSTK-11 Timeliness of Reperfusion: Arrival Time to TICI 2B or Higher

CSTK-12 Timeliness of Reperfusion: Skin Puncture to TICI 2B or Higher

General Data Elements

Element Name Collected For

Admission Date All Records,

Birthdate All Records,

Discharge Date All Records, Not collected for HBIPS-2 and

HBIPS-3

Hispanic Ethnicity All Records,

ICD-10-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records

ICD-10-PCS Other Procedure Dates All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File, Used in
calculation of the Joint Commission's
aggregate data and in the transmission of
the Hospital Clinical Data file.

Payment Source All Records, Optional for HBIPS-2 and

HBIPS-3

Race All Records,

Sex All Records,

Algorithm Output Data Elements

Element Name Collected For

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File

Measurement Value Calculation, Transmission, Hospital Clinical

Data File

Measure Set Specific Data Elements

Element Name Collected For

Admitting Diagnosis CSTK-04

Arrival Date CSTK-01, CSTK-03, CSTK-05, CSTK-06, CSTK-

07, CSTK-09, CSTK-11

Arrival Time CSTK-01, CSTK-03, CSTK-05, CSTK-06, CSTK-

07, CSTK-09, CSTK-11

Clinical Trial CSTK-04, CSTK-06

Comfort Measures Only CSTK-01, CSTK-03, CSTK-04, CSTK-06

Delayed Endovascular Rescue Procedure CSTK-09, CSTK-11

Direct Admission CSTK-01, CSTK-03

Discharge Disposition CSTK-02, CSTK-10

Discharge Time CSTK-01, CSTK-03, CSTK-06

ED Patient CSTK-01, CSTK-03

Elective Carotid Intervention CSTK-01, CSTK-02, CSTK-05, CSTK-07, CSTK-

08, CSTK-09, CSTK-10, CSTK-11, CSTK-12

Failed Attempt at Thrombectomy CSTK-08, CSTK-11, CSTK-12

First Pass Date CSTK-07

First Pass Time CSTK-07

First Pass of a Mechanical Reperfusion Device CSTK-07

Highest NIHSS Score Documented Within 36 Hours Following IA CSTK-05

Alteplase or MER Initiation

Highest NIHSS Score Documented Within 36 Hours Following IV CSTK-05

Alteplase Initiation

IA Alteplase or MER Initiation Date CSTK-05

IA Alteplase or MER Initiation Time CSTK-05

IA Route of Alteplase Administration CSTK-05, CSTK-07, CSTK-08, CSTK-09

IA Thrombolytic Initiation CSTK-07

IA Thrombolytic Initiation Date CSTK-07

IA Thrombolytic Initiation Time CSTK-07

ICD-10-PCS Other Procedure Times CSTK-01, CSTK-03

ICD-10-PCS Principal Procedure Time CSTK-01, CSTK-03

INR Value > 1.4 CSTK-04

IV Alteplase Initiation CSTK-05

IV Alteplase Initiation Date CSTK-05

IV Alteplase Initiation Time CSTK-05

IV Alteplase Prior to IA or Mechanical Reperfusion Therapy CSTK-05, CSTK-08, CSTK-10

Initial Blood Glucose Value at Hospital Arrival CSTK-05, CSTK-08, CSTK-10

Initial Blood Pressure at Hospital Arrival CSTK-05, CSTK-08, CSTK-10

Initial Hunt and Hess Scale Date CSTK-03

Initial Hunt and Hess Scale Performed CSTK-03

Initial Hunt and Hess Scale Time CSTK-03

Initial ICH Score Date CSTK-03

Initial ICH Score Performed CSTK-03

Initial ICH Score Time CSTK-03

Initial NIHSS Score Date CSTK-01

Initial NIHSS Score Performed CSTK-01

Initial NIHSS Score Time CSTK-01

Initial NIHSS Score at Hospital Arrival CSTK-05, CSTK-08, CSTK-10

Initial Platelet Count at Hospital Arrival CSTK-05, CSTK-08, CSTK-10

Modified Rankin Score (mRS) CSTK-02, CSTK-10

Modified Rankin Score (mRS) Date CSTK-02, CSTK-10

NIHSS Score Documented Closest to IA Alteplase or MER Initiation CSTK-05

NIHSS Score Documented Closest to IV Alteplase Initiation CSTK-05

Nimodipine Administration CSTK-06

Nimodipine Administration Date CSTK-06

Nimodipine Administration Time CSTK-06

Non-aneurysmal CSTK-03

Positive Brain Image CSTK-05

Positive Brain Image Date CSTK-05

Positive Brain Image Time CSTK-05

Post-Treatment Thrombolysis in Cerebral Infarction (TICI) CSTK-08, CSTK-11, CSTK-12

Reperfusion Grade

Post-Treatment Thrombolysis in Cerebral Infarction (TICI) CSTK-11, CSTK-12

Reperfusion Grade Date

Post-Treatment Thrombolysis in Cerebral Infarction (TICI) CSTK-11, CSTK-12

Reperfusion Grade Time

Pre-Stroke Modified Rankin Score (mRS) CSTK-10

Procoagulant Reversal Agent Initiation CSTK-04

Proximal or Distal Occlusion CSTK-08

Reason for Not Administering Nimodipine Treatment CSTK-06

Reason for Not Administering a Procoagulant Reversal Agent CSTK-04

Site of Primary Vessel Occlusion CSTK-08, CSTK-11, CSTK-12

Skin Puncture CSTK-09, CSTK-12

Skin Puncture Date CSTK-09, CSTK-12

Skin Puncture Time CSTK-09, CSTK-12

Related Materials

Document Name

Acknowledgement

Appendix A - Code Tables

Appendix C - Medication Tables

Appendix D - Glossary of Terms

Appendix E - Overview of Measure Information Form and Flowchart Formats

Appendix G - Resources

Appendix H - Miscellaneous Tables

Cover Page for the Joint Commission Manual

Data Dictionary

Introduction to the Manual

Missing and Invalid Data

Sampling

Table of Contents

Transmission Alpha Data Dictionary

Transmission Data Processing Flow: Clinical

Transmission Data Processing Flow: Population and Sampling

Transmission of Data

Using the The Joint Commission's National Measure Specifications Manual

The CSTK Initial Patient Population is unique in that it is comprised of three distinct subpopulations:
ischemic stroke patients who do not undergo a reperfusion therapy (i.e., procedure), ischemic stroke patients
who undergo a reperfusion therapy (IV t-PA, IA t-PA, or mechanical endovascular reperfusion (MER) therapy),
and hemorrhagic stroke patients.

Ischemic Stroke
The population of the CSTK 1-Ischemic Stroke measures (CSTK-01) are identified using 4 data elements:

Admission Date
Birthdate
Discharge Date
ICD-10-CM-Principal Diagnosis Code

Patients admitted to the hospital for inpatient acute care are included in the CSTK 1-Ischemic Stroke Without
Procedure subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in
Appendix A, Table 8.1, a Patient Age (Admission Date – Birthdate) ≥ 18 years and a Length of Stay
(Discharge Date - Admission Date) ≤ 120 days.

Note: Hospitals are NOT required to sample their data. If sampling offers minimal benefit (e.g., a hospital has
45 cases for the quarter and must select a sample of 42 cases), the hospital may choose to use all cases.

Ischemic Stroke With IV t-PA, IA t-PA, or MER

The population of the CSTK 2-Ischemic Stroke With IV t-PA, IA t-PA, or MER measures (CSTK-01, CSTK-02,
CSTK-05, CSTK-07, CSTK-08, CSTK-09, CSTK-10, CSTK-11, CSTK-12) are identified using 5 data elements:

Admission Date
Birthdate
Discharge Date
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Principal or Other Procedure Codes

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.

Hemorrhagic Stroke
The population of the CSTK 3-Hemorrhagic Stroke measures (CSTK-03, CSTK-04, CSTK-06) are identified
using 4 data elements:

Admission Date
Birthdate

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.

Note: Hospitals are NOT required to sample their data. If sampling offers minimal benefit (e.g., a hospital has
80 cases for the quarter and must select a sample of 75 cases), the hospital may choose to use all cases.

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CSTK Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may
choose to use a larger sample size than is required. Hospitals whose Initial Patient Population size is less
than the minimum number of cases per quarter for the measure set cannot sample. Hospitals that have five
or fewer CSTK discharges (both Medicare and non-Medicare combined) in a quarter are not required to
submit CSTK patient level data to the Joint Commission’s Data Warehouse.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures
consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample cases
MUST submit AT LEAST the minimum required sample size.

Quarterly Sampling

Hospitals performing quarterly sampling for CSTK must ensure that its Initial Patient Population and sample
size meet the following conditions for each sampling group:

Quarterly Sample Size

Based on CSTK Subpopulation 1 for Ischemic Stroke Without Procedure
(CSTK-01 Measure)

Hospital’s Measure (Table 1)

Average Quarterly Minimum Required

Initial Patient Population Size "N" Sample Size "n"

> 420 84

211-419 20% of Patient Population size

43-210 42

≤ 42 No sampling; 100% Patient Population required

Quarterly Sample Size

Based on CSTK Subpopulation 2 for Ischemic Stroke With IV t-PA, IA t-PA,or MER
(CSTK-01, CSTK-02, CSTK-05, CSTK-07, CSTK-08, CSTK-09, CSTK-10, CSTK-11, CSTK-12)

Hospital’s Measure (Table 2)

> 420 84

211-419 20% of Patient Population size

43-210 42

≤ 42 No sampling; 100% Patient Population required

Quarterly Sample Size

Based on CSTK Subpopulation 3 for Hemorrhagic Stroke
(CSTK-03, CSTK-04, CSTK-06)

Hospital’s Measure (Table 3)

Average Quarterly Minimum Required

Initial Patient Population Size "N" Sample Size "n"

> 750 150

376-750 20% of Patient Population size

76-375 75

≤ 75 No sampling; 100% Patient Population required

Monthly Sampling

Hospitals performing monthly sampling for CSTK must ensure that its Initial Patient Population and sample
size meet the following conditions for each sampling group:

Monthly Sample Size

Based on CSTK Subpopulation 1 for Ischemic Stroke Without Procedure
(CSTK-01 Measure)
Hospital’s Measure (Table 4)

Average Monthly Minimum Required

Initial Patient Population Size "N" Sample Size "n"

> 140 28

71-140 20% of Patient Population size

15-70 14

> 140 28

≤ 14 No sampling; 100% Patient Population required

Monthly Sample Size

Based on CSTK Subpopulation 2 for Ischemic Stroke With IV t-PA, IA t-PA, or MER
(CSTK-01, CSTK-02, CSTK-05, CSTK-07, CSTK-08, CSTK-09, CSTK-10, CSTK-11, CSTK-12)
Hospital’s Measure (Table 5) %EDITTABLE{}%

Average Monthly Minimum Required

Initial Patient Population Size "N" Sample Size "n"

> 140 28

71-140 20% of Patient Population size

15-70 14

≤ 14 No sampling; 100% Patient Population required

Monthly Sample Size

Based on CSTK Subpopulation 3 for Hemorrhagic Stroke
(CSTK-03, CSTK-04, CSTK-06)
Hospital’s Measure (Table 6)

Average Monthly Minimum Required

Initial Patient Population Size "N" Sample Size "n"

> 250 50

126-250 20% of Patient Population size

26-125 25

≤ 25 No sampling; 100% Patient Population required

Sample Size Examples

NOTE: Two subpopulations make-up the population for the CSTK-01 measure; CSTK Subpopulation 1 for
Ischemic Stroke Without Procedure and CSTK Subpopulation 2 for Ischemic Stroke With IV t-PA, IA t-PA, or
MER. Both sampling groups must be sampled to meet the minimum sampling requirement for CSTK-01.
Examples:

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A hospital’s ischemic stroke patient population size is 200 patients during the second quarter. Fifty
(50) ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. 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).
A hospital’s ischemic stroke patient population size is 200 patients during March. Twenty (20)
ischemic stroke patients had a procedure for thrombolysis or mechanical clot removal. 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).

Quarterly sampling
CSTK Subpopulation 1 for Ischemic Stroke Without Procedure

A hospital’s ischemic stroke patient population size is 495 cases during the second quarter. Using
the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84
cases for the quarter.
A hospital’s ischemic stroke patient population size is 392 cases during the second quarter. Using
the quarterly sampling table for the ischemic 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).
A hospital’s ischemic stroke patient population size is 200 cases during the second quarter. Using
the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 42
cases for the quarter.
A hospital’s ischemic stroke patient population size is 37 cases during the second quarter. Using the
quarterly sampling table for the ischemic stroke subpopulation, the sample size is less than the
minimum required quarterly sample size, so 100% of the subpopulation or all 37 cases are sampled.

CSTK Subpopulation 2 for Ischemic Stroke With IV t-PA, IA t-PA, or MER

Four-hundred and twenty-eight (428) ischemic stroke cases had IV or IA thrombolysis or a

mechanical clot removal procedure during the second quarter. 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.
Two-hundred and twenty-three (223) ischemic stroke cases had IV or IA thrombolysis or a
mechanical clot removal procedure during the second quarter. 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).
Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure
during the second quarter. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA
t-PA or MER subpopulation, the sample size required is 42 cases for the quarter.
Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal
procedure during the second quarter. Using the quarterly sampling table for the ischemic stroke with

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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.

CSTK Subpopulation 3 for Hemorrhagic Stroke

A hospital’s hemorrhagic stroke patient population size is 795 cases during the second quarter. Using
the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is
150 cases for the quarter.
A hospital’s hemorrhagic stroke patient population size is 392 cases during the second quarter. 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).
A hospital’s hemorrhagic stroke patient population size is 200 cases during the second quarter. Using
the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 75
cases for the quarter.
A hospital’s hemorrhagic stroke patient population size is 67 cases during the second quarter. Using
the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than
the minimum required quarterly sample size, so 100% of the subpopulation or all 67 cases are
sampled.

Monthly sampling
CSTK Subpopulation 1 for Ischemic Stroke Without Procedure

A hospital’s ischemic stroke patient population size is 295 cases during March. Using the monthly
sampling table for the ischemic stroke subpopulation, the sample size required is 28 cases for the
month.
A hospital’s ischemic stroke patient population size is 129 cases during March. 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).
A hospital’s ischemic stroke patient population size is 70 cases during March. Using the monthly
sampling table for the ischemic stroke subpopulation, the sample size required is 14 cases for the
month.
A hospital’s ischemic stroke patient population size is 7 cases during March. Using the monthly
sampling table for the ischemic stroke subpopulation, the sample size is less than the minimum
required monthly sample size, so 100% of the subpopulation or all 7 cases are sampled.

CSTK Subpopulation 2 for Ischemic Stroke With IV t-PA, IA t-PA, or MER

One-hundred and forty-eight (148) ischemic stroke cases had IV or IA thrombolysis or a mechanical
clot removal procedure during March. Using the monthly sampling table for the ischemic stroke with
IV t-PA, IA t-PA or MER subpopulation, the sample size required is 28 cases for the month.

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One-hundred and twenty-three (123) ischemic stroke cases had IV or IA thrombolysis or a mechanical
clot removal procedure during March. Using the monthly 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 25
cases for the month (20% of 123 equals 24.6 rounded to the next highest whole number equals 25).
Sixty (60) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure
during March. 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.
Eleven (11) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure
during March. Using the monthly 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 monthly sample size, so 100% of
the subpopulation or all 11 cases are sampled.

CSTK Subpopulation 3 for Hemorrhagic Stroke

A hospital’s hemorrhagic stroke patient population size is 295 cases during March. Using the
monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 50
cases for the month.
A hospital’s hemorrhagic stroke patient population size is 129 cases during March. 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).
A hospital’s hemorrhagic stroke patient population size is 60 cases during March. Using the monthly
sampling table for the hemorrhagic stroke subpopulation, the sample size required is 25 cases for the
month.
A hospital’s hemorrhagic stroke patient population size is 17 cases during March. 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.

Measure Information Form

Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-01

Performance Measure Name: National Institutes of Health Stroke Scale (NIHSS Score Performed for
Ischemic Stroke Patients)

Description: Ischemic stroke patients for whom an initial NIHSS score is performed prior to any acute
recanalization therapy (i.e., IV alteplase therapy, or IA alteplase therapy, or mechanical endovascular
reperfusion therapy) in patients undergoing recanalization therapy and documented in the medical record,
OR documented within 12 hours of arrival at the hospital emergency department for patients who do not
undergo recanalization therapy.

Rationale: A neurological examination of all patients presenting to the hospital emergency department with
warning signs and symptoms of stroke should be a top priority and performed in a timely fashion. Use of a
standardized stroke scale or scoring tool ensures that the major components of the neurological
examination are evaluated. Clinical practice guidelines from the American Heart Association/American
Stroke Association recommend The National Institutes of Health Stroke Scale (NIHSS) as the preferred
scoring tool for this purpose. Scores obtained aid in the initial diagnosis of the patient, facilitate
communication among healthcare professionals, and identify patient eligibility for various interventions and
the potential for complications.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients for whom a NIHSS score is performed prior to any acute
recanalization therapy in patients undergoing recanalization therapy and documented in the medical record,
OR documented within 12 hours of hospital arrival for patients who do not undergo recanalization therapy.

Included Populations:

Patients with documented thrombolytic (IV or IA alteplase) therapy (ICD-10-PCS Principal or Other
Procedure Codes as defined in Appendix A, Table 8.1a for ICD-10 codes), OR
Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-10-PCS Principal or
Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes)

Excluded Populations: None

Data Elements:

Arrival Date

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Arrival Time
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Other Procedure Times
ICD-10-PCS Principal Procedure Date
ICD-10-PCS Principal Procedure Time
Initial NIHSS Score Date
Initial NIHSS Score Performed
Initial NIHSS Score Time

Denominator Statement: Ischemic stroke patients.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A,
Table 8.1 for ICD-10 codes

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients with Comfort Measures Only documented on the day of or day after hospital arrival
Patients admitted for Elective Carotid Intervention
Patients who do not undergo recanalization therapy and are discharged within 12 hours of arrival
at this hospital

Data Elements:

Admission Date
Birthdate
Comfort Measures Only
Direct Admission
Discharge Date
Discharge Time
ED Patient
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:
1. Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell
C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. Guidelines for the Early
Management of Adults with Ischemic Stroke: A Guideline From the American Heart Association/American
Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention
Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research
Interdisciplinary Working Groups. Stroke. 2007;38:1664-1666.

2. Cote R, Hachinski VC, Shurell BL, Norris JW, Wolfson C. The Canadian Neurological Scale: a preliminary
study in acute stroke. Stroke. 1986; 17:731-737.

3. Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale: extension to non-
neurologists in the context of a clinical trial. Stroke. 1997;28:307-310.

4. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for
the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.

5. Kothari KU, Brott T, Broderick JP, Hamilton CA. Emergency physicians: accuracy in the diagnosis of stroke.
Stroke. 1995;26:2238-2241.

6. Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C,
Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association
Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and
Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for
measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42:857.

7. Morgenstern LB, Lisabeth LD, Mecozzi AC, Smith MA, Longwell PJ, McFarling DA, Risser JM. A population-
based study of acute stroke and TIA diagnosis. Neurology. 2004;62:895-900.

8. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of

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the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with
Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke. 2018 Jan;49:e11-e12.

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Measure Information Form
**SUSPENDED for Comprensive Stroke Centers, Effective January 1, 2018**
Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-02

Performance Measure Name: Modified Rankin Score (mRS at 90 Days)

Description: Ischemic stroke patients treated with intra-venous (IV) or intra-arterial (IA) alteplase therapy or
who undergo mechanical endovascular reperfusion therapy for whom a 90 day (≥75 days and ≤105 days)
mRS is obtained via telephone or in-person

Rationale: The Modified Rankin Scale (mRS) is the accepted standard for assessing recovery post-stroke. As
such, it has become the most widely used clinical outcome measure for stroke clinical trials. Scores are used
to measure the degree of disability or dependence in activities of daily living. Score reliability and
reproducibility are improved through use of a structured interview by a trained evaluator. Interviews may be
conducted in-person or over the phone. According to guideline recommendations from the American Heart
Association/American Stroke Association, standardized interviews to obtain a mRS score should be
conducted for acute ischemic stroke patients treated with IV or IA alteplase therapy or mechanical
endovascular reperfusion therapy at 3 months (90 days); however, recovery may continue well beyond 3
months for many ischemic stroke patients.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients for whom a 90 day (≥75 days and ≤105 days) mRS is
obtained via telephone or in-person

Included Populations: As above

Excluded Populations: None

Data Elements:

Modiﬁed Rankin Score (mRS)

Modiﬁed Rankin Score (mRS) Date

Denominator Statement: Ischemic stroke patients treated with IV or IA alteplase therapy or who undergo
mechanical endovascular reperfusion therapy

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A,
Table 8.1 for ICD-10 codes, AND

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Patients with documented thrombolytic (IV or IA alteplase) therapy (ICD-10-PCS Principal or Other
Procedure Codes as defined in Appendix A, Table 8.1a for ICD-10 codes), OR
Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-10-PCS Principal or
Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes)

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients admitted for Elective Carotid Intervention
Patients who expire during the hospital stay

Data Elements:

Admission Date
Birthdate
Discharge Date
Discharge Disposition
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

1. Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell
C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. Guidelines for the Early
Management of Adults with Ischemic Stroke: A Guideline From the American Heart Association/American
Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention

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Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research
Interdisciplinary Working Groups. Stroke. 2007;38:1675-1678.

2. Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: implications for
stroke clinical trials: a literature review and synthesis. Stroke. 2007:38:2262-2269.

3. Bruno A, Shah N, Lin C, Close B, Hess DC, Davis K, Baute V, Switzer JA, Waller JL, Nichols FT. Simplified
modified Rankin scale questionnaire: reproducibility over the telephone and validation with quality of life.
Stroke. 2011;42:2276-2279.

4. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

5. Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for
Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization
times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38.

6. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for
the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.

7. Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C,
Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association
Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and
Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for
measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42:857.

8. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of
the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with
Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke. 2018 Jan;49:e10-e11.

9. Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the modified Rankin scale. Stroke. 2007:38:e144.

10. Rankin J. Cerebral vascular accidents in patients over the age of 60. Scott Med J. 1957;2(5):200-15.

11. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after
intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

12. Schwamm LH, Holloway RG, Amarenco P. Audebert HJ, Bakas T, Chumbler NR, Handschu R, Jauch EC,
Knight WA IV, Levine SR, Mayberg M, Meyer BC, Meyers PM, Skalabrin E, Wechsler LR; American Heart
Association Stroke Council; Interdisciplinary Council on Peripheral Vascular Disease. A review of the
evidence for the use of telemedicine within stroke systems of care: a scientific statement for the American
Heart Association/American Stroke Association. Stroke. 2009;40:2616-2634.

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13. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue
plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke
rt-PA Stroke Study Group. New England Journal of Medicine 1995;333:1581-1587.

14. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration
first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

15. Wilson JT, Hareendran A, Hendry A, Potter J. Bone I, Muir KW. Reliability of the modified Rankin scale
across multiple raters: benefits of a structured interview. Stroke. 2005;36:777-781.

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-03

Set Measure ID Performance Measure Name

CSTK-03a Hunt and Hess Scale Performed for SAH Patients

CSTK-03b ICH Score Performed for ICH Patients

Performance Measure Name: Severity Measurement Performed for SAH and ICH Patients (Overall Rate)

Description: Subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) stroke patients for whom
a severity measurement (i.e., Hunt and Hess Scale for SAH patients or ICH Score for ICH patients) is
performed prior to surgical intervention (e.g. clipping, coiling, or any surgical intervention) in patients
undergoing surgical intervention and documented in the medical record; OR documented within 6 hours of
arrival at the hospital emergency department for patients who do not undergo surgical intervention.

CSTK-03 SAH and ICH stroke patients for whom a severity measurement is performed prior to surgical
intervention in patients undergoing surgical intervention and documented in the medical record; OR
documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

CSTK-03a SAH stroke patients for whom a severity measurement is performed prior to surgical intervention
in patients undergoing surgical intervention and documented in the medical record; OR documented within 6
hours of hospital arrival for patients who do not undergo surgical intervention.

CSTK-03b ICH stroke patients for whom a severity measurement is performed prior to surgical intervention
in patients undergoing surgical intervention and documented in the medical record; OR documented within 6
hours of hospital arrival for patients who do not undergo surgical intervention.

The CSTK-03 measure is reported as an overall rate which includes SAH and ICH stroke patients for whom a
severity measurement is performed prior to surgical intervention in patients undergoing surgical intervention
and documented in the medical record; OR documented within 6 hours of hospital arrival for patients who do
not undergo surgical intervention; CSTK-03a and CSTK-03b are subsets of the overall rate, and stratified by
the type of stroke patient.

Rationale: Subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) are medical emergencies
requiring rapid diagnosis and assessment. Early deterioration is common in the first few hours after onset,
and associated with increased mortality rates of > 75% compared to 30-day mortality rates of 35%-52%. More
than half of all deaths from these conditions occur within the first two days. According to the American
Heart Association/American Stroke Association, the severity of SAHs should be documented with the Hunt
and Hess Scale, and the severity of ICHs should be documented with ICH score to capture the clinical state
of the patient. The severity of initial neurological injury should be determined and documented in the

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emergency department because it is a useful predictor of outcome and helpful in planning future care with
family and physicians. For both severity methodologies, higher scores are associated with increased
mortality.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement:
CSTK-03: The number of SAH and ICH stroke patients for whom a severity measurement is performed prior
to surgical intervention in patients undergoing surgical intervention and documented in the medical record;
OR documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

CSTK-03a: The number of SAH patients for whom a Hunt and Hess Scale is performed prior to surgical
intervention in patients undergoing surgical intervention and documented in the medical record; OR
documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

CSTK-03b: The number of ICH stroke patients for whom an ICH Score is performed prior to surgical
intervention in patients undergoing surgical intervention and documented in the medical record; OR
documented within 6 hours of hospital arrival for patients who do not undergo surgical intervention.

Included Populations: As above

Excluded Populations: None

Data Elements:

Arrival Date
Arrival Time
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Other Procedure Times
ICD-10-PCS Principal Procedure Date
ICD-10-PCS Principal Procedure Time
Initial Hunt and Hess Scale Date
Initial Hunt and Hess Scale Performed
Initial Hunt and Hess Scale Time
Initial ICH Score Date
Initial ICH Score Performed
Initial ICH Score Time

Data Elements By Measure

CSTK-03 CSTK-03a CSTK-03b

Arrival Date Arrival Date Arrival Date

Arrival Time Arrival Time Arrival Time

Initial Hunt and Hess Scale Date Initial Hunt and Hess Scale Date Initial ICH Score Date

Initial Hunt and Hess Scale Performed Initial Hunt and Hess Scale Performed Initial ICH Score Performed

Initial Hunt and Hess Scale Time Initial Hunt and Hess Scale Time Initial ICH Score Time

Initial ICH Score Date

Initial ICH Score Performed

Initial ICH Score Time

Denominator Statement: SAH and ICH stroke patients

Included Populations: Discharges with ICD-10-CM Principal Diagnosis Code for hemorrhagic stroke as
defined in Appendix A, Table 8.2 for ICD-10 codes (i.e., Table 8.2a and Table 8.2b) with or without
aneurysm repair procedure (ICD-10-PCS Principal or Other Procedure Code as defined in Appendix A, Table
8.2d for ICD-10 codes) or surgical intervention procedure (ICD-10-PCS Principal or Other Procedure Code as
defined in Appendix A, Table 8.2e for ICD-10 codes)

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients with Comfort Measures Only documented on the day of or day after hospital arrival
Non-surgical patients discharged within 6 hours of arrival at this hospital
Patients with admitting diagnosis of traumatic brain injury (TBI), unruptured arteriovenous
malformation (AVM), and non-traumatic subdural hematoma (ICD-10-CM Other Diagnosis Codes as
defined in Appendix A, Table 8.2f for ICD-10 codes)
Patients who have an ICD-10-CM Principal Diagnosis Code in Appendix A, Table 8.2a assigned at
discharge and documentation of non-aneurysmal SAH or SAH related to head trauma any time
during the hospital stay

Data Elements:

Admission Date
Birthdate
Comfort Measures Only
Direct Admission
Discharge Date
Discharge Time
ED Patient
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: Hospitals may wish to identify those patients that did not receive a severity
assessment within the specified timeframe(s), or received a severity assessment that did not match their
diagnosis, or both, so that efforts can be directed toward improving care.

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

1. Broderick J, Connolly ES, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, Morgenstern L, Ogilvy CS,
Vespa P, and Zuccarello M. Guidelines for the management of spontaneous intracerebral hemorrhage in
adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke
Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research
Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline as
an educational toold for neurologists. Stroke. 2007;38:2001-2023.

2. Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ,
Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal
subarachnoid hemorrhage: a guidelines for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2012;43:1-27.

3. Hemphill JC III, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN,
Macdonald L, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the management of spontaneous
intracerebral hemorrhage:a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2015;46:1-29.

4. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms.
J Neurosurg. 1968;28:14-20.

5. Hunt WE, Kosnik EJ. Timing and perioperative care in intracranial aneurysm surgery. Clin Neurosurg.
1974;21:79-89.

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Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and
Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for
measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42:862-63.

7. Matchett SC, Castaldo J, Wasser TE, Baker K, Mathiesen C, and Rodgers J. Predicting mortality after
intracerebral hemorrhage: comparison of scoring systems and influence of withdrawal of care. J Stroke
Cerebrovasc Dis. 2006 Jul-Aug;15(4):144-50.

8. Morgastern LB, Hemphill JC III, Anderson C, Becker K, Broderick JP, Connolly ES Jr, Greenberg SM, Huang
JN, Macdonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ; and on behalf of the American Heart
Association Stroke Council and Council on Cardiovascular Nursing. Guidelines for the management of
spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2010;41:2108-2129.

9. Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocritical
Care. 2005;2:110-118.

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Measure Information Form
Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-04

Performance Measure Name: Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )

Description: Intracerebral hemorrhage (ICH) stroke patients with an INR value > 1.4 at hospital arrival who
are treated with a procoagulant reversal agent (i.e., fresh frozen plasma, recombinant factor VIIa,
prothrombin complex concentrates)

Rationale: Intracerebral hemorrhage (ICH) is a life-threatening disorder. Patients receiving oral

anticoagulants (OACs), as well as those with an acquired or congenital coagulopathy, are at increased risk
for ICH and hemorrhagic expansion with warfarin-associated bleeds comprising 12% to 15% of all
spontaneous hemorrhages. Prompt INR reversal with intravenous infusions of vitamin K and fresh-frozen
plasma (FFP) has been historically recommended; however, normalization with prothrombin complex
concentrates (PCCs) is increasingly recommended because several studies have shown that these agents
can rapidly normalize the INR within minutes. According to the European Union Stroke Initiative (EUSI),
patients with oral anticoagulation treatment (OAT) associated ICH and an INR above 1.4, should have OAT
discontinued and the INR normalized with PCCs or FFP in addition to intravenous infusion of vitamin K.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: ICH stroke patients treated with a procoagulant reversal agent

Included Populations: As above

Excluded Populations: None

Data Elements:

Procoagulant Reversal Agent Initiation

Reason for Not Administering a Procoagulant Reversal Agent

Denominator Statement: ICH stroke patients with INR value > 1.4 at hospital arrival.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for hemorrhagic stroke as defined in Appendix
A, Table 8.2b for ICD-10 codes,
AND
Patients who have an Admitting Diagnosis of primary parenchymal ICH,
AND

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients with Comfort Measures Only documented on day of or after hospital arrival
Patients enrolled in clinical trials

Data Elements:

Admission Date
Admitting Diagnosis
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
ICD-10-CM Principal Diagnosis Code
INR Value > 1.4

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

1. Ansell J, Hirsch J, Hylek E, Jacobson A, Crowther M, Palareti G; American College of Chest Physicians.
Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians
Evidence-Based Clinical Practice Guidleines (8th Edition). Chest. 2008;133(suppl):160S-198S.

2. Fredriksson K, Norrving B, Strömblad, LG. Emergency reversal of anticoagulation after intracerebral

hemorrhage. Stroke. 1992;23:972-977.

3. Frontera JA, Lewin JJ 3rd, Rabinstein AA, Aisiku IP, Alexandrov AW, Cook AM, del Zoppo GJ, Kumar MA,
Peerschke EI, Stiefel MF, Teitelbaum JS, Wartenberg KE, Zerfoss CL. Guideline for reversal of antithrombotics

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in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and
Society of Critical Care Medicine. Neurocrit Care. 2016;24(1):6-46.

4. Goldstein JN, Thomas SH, Frontiero V, Joseph A, Engel C, Snider R, Smith EE, Greenberg SM, Rosand J.
Timing of fresh frozen plasma administration and rapid correction of coagulopathy in warfarin-related
intracerebral hemorrhage. Stroke. 2006;37:151-155.

5. Hanley JP. Warfarin reversal. J Clin Pathol. 2004;57:1132-1139.

6. Hemphill JC III, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN,
Macdonald L, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the management of spontaneous
intracerebral hemorrhage:a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2015;46:1-29.

8. Leissinger CA, Blatt PM, Hoots WK, Ewenstein B. Role of prothrombin complex concentrates in reversing
warfarin anticoagulation: a review of the literature. Am J Hematol. 2008;83:137-143.

9. Morgenstern LB, Hemphill JC III, Anderson C, Becker K, Broderick JP, Connolly ES Jr, Greenberg SM, Huang
JN, Macdonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ; and on behalf of the American Heart
Association Stroke council and Council on Cardiovascular Nursing. Guidelines for the management of
spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2010;41:2111-2114.

10. Nilsson OG, Lindgren A, Ståhl N, Brandt L, Säveland H. Incidence of intracerebral and subarachnoid
hemorrhage in southern Sweden. J Neurol Neurosurg Psychiatry. 2000;69:601-607.

11. Pabinger I, Brenner B, Kalina U, Knaub S, Nagy A, Ostermann H; Beriplex P/N Reversal Study Group.
Prothrombin complex concentrate (Beriplex P/N) for emergency anticoagulation reversal: a prospective
multinational clinical trial. J Thromb Haemost. 2008;6:622-631.

12. Rådberg JA, Olsson JE, Rådberg CT. Prognostic parameters in spontaneous intracerebral hematomas
with special reference to anticoagulant treatment. Stroke. 1991;22:571-576.

13. Reiss H, Meier-Hellman A, Motsch J, Elias M, Kursten FW, Dempfle CE. Prothrombin complex concentrate
(Octaplex) in patients requiring immediate reversal of oral anticoagulation. Thromb Res. 2007;121:9-16.

14. Rosovsky RP, Crowther, MA. What is the evidence for the off-label use of recombinant factor VII (rFVIIa)
in the acute reversal of warfarin? Hematology Am Soc Hematol Educ Program. 2008:36-38.

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15. Sjöblom L, Hårdemark HG, Lindgren A, Norrving B, Fahlén M, Samuelsson M, Stigendal L, Stockelberg D,
Taghavi A, Wallrup L, Wallvik J. Mangement and prognostic features of intracerebral hemorrhage during
anticoagulant therapy: a Swedish multicenter study. Stroke. 2001;32:2567-2574.

16. Steiner T, Kaste M, Katse M, Forsting M, Mendelow D, Kwiecinski H, Szikora I, Juvela S, Marchel A, Chapot
R, Cognard C, Unterberg A. Hacke W. Recommendations for the management of intracranial haemorrhage -
part I: spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the
Writing Committee for the EUSI Executive Committee. Cerebrovascular Diseases. 2006;22(4):294-316.

17. Watson HG, Baglin T, Laidlaw SL, Makris M, Preston FE. A comparison of the efficacy and rate of
response to oral and intravenous vitamin K in reversal of over-anticoagulation with warfarin. Haematol.
2001;115:145-149.

Set Measure ID: CSTK-05

Set Performance Measure Name

Measure
ID

CSTK-05a Hemorrhagic Transformation for Patients Treated with Intra-Venous (IV) Alteplase Therapy Only

CSTK-05b Hemorrhagic Transformation for Patients Treated with Intra-Arterial (IA) Alteplase Therapy or
Mechanical Endovascular Reperfusion Therapy

Performance Measure Name: Hemorrhagic Transformation (Overall Rate)

Description:
CSTK-05 Ischemic stroke patients who develop a symptomatic intracranial hemorrhage (i.e., clinical
deterioration ≥ 4 point increase on NIHSS and brain image finding of parenchymal hematoma, or
subarachnoid hemorrhage, or intraventricular hemorrhage) within (≤) 36 hours after the onset of treatment
with intra-venous (IV) or intra-arterial (IA) alteplase therapy, or mechanical endovascular reperfusion
procedure (i.e., mechanical endovascular thrombectomy with a clot retrieval device).

CSTK-05a Ischemic stroke patients who develop a symptomatic intracranial hemorrhage (i.e., clinical
deterioration ≥ 4 point increase on NIHSS and brain image finding of parenchymal hematoma, or
subarachnoid hemorrhage, or intraventricular hemorrhage) within (≤) 36 hours after the onset of treatment
with intra-venous (IV) alteplase therapy only.

CSTK-05b Ischemic stroke patients who develop a symptomatic intracranial hemorrhage (i.e., clinical
deterioration ≥ 4 point increase on NIHSS and brain image finding of parenchymal hematoma, or
subarachnoid hemorrhage, or intraventricular hemorrhage) within (≤) 36 hours after the onset of treatment
with IA alteplase therapy or mechanical endovascular reperfusion therapy (i.e., mechanical endovascular
thrombectomy with a clot retrieval device).

The CSTK-05 measure is reported as an overall rate which includes ischemic stroke patients who develop a
symptomatic hemorrhage after reperfusion therapy. CSTK-05a and CSTK-05b are subsets of the overall rate,
and stratified by the type of therapy.

Rationale: Intravenous (IV) alteplase therapy for acute ischemic stroke was approved by the US Food and
Drug Administration in 1996, following findings from the National Institute of Neurological Disorders and
Stroke (NINDS) trial which demonstrated favorable outcomes in 31% to 50% of patients treated with
recombinant tissue plasminogen activator (r-tPA), as compared to 20% to 38% of patients treated with
placebo. Intra-arterial (IA) alteplase therapy has since been used to improve recanalization and clinical
outcomes for select patients nonresponsive to IV therapy. Intracranial hemorrhage is the major risk of
thrombolytic therapy with similar rates reported for both IV and IA routes. The NINDS trial found that 6.4% of
patients treated with IV alteplase experienced symptomatic bleeding. Findings from the Prolyse in Acute

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Cerebral Thromboembolism (PROACT II) study found the intracranial hemorrhage with neurological
deterioration within 24 hours occurred in 10% of patients treated with IA recombinant prourokinase. In
addition to these agents, other available thrombolytic drugs include: streptokinase, p-anisoylated lys-
plasminogen-streptokinase activator, and urokinase.

Endovascular reperfusion therapy in acute ischemic stroke comprises a number of pharmacological and
mechanical procedures. Mechanical endovascular thrombectomy is a treatment option for patients with
large vessel occlusions in whom pharmacological thrombolysis is contraindicated or might be ineffective.
For eligible patients, initiation of EVT (e.g., groin puncture) within 6 hours of stroke symptom onset using a
stent retriever is preferred (Powers WJ, et. al., 2015). The use of mechanical thrombectomy devices other
than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some
circumstances (Powers WJ, et. al., 2018). Mechanical endovascular thrombectomy devices are intended to
improve tissue rescue and diminish reperfusion hemorrhage while broadening the population eligible for
therapy. These devices may be used alone or in conjunction with chemical thrombolysis (i.e., IV or IA
alteplase).

Type Of Measure: Outcome

Improvement Noted As: Decrease in the rate

Numerator Statement:
CSTK-05 Ischemic stroke patients who develop a symptomatic intracranial hemorrhage ≤ 36 hours after the
onset of treatment with IV alteplase therapy, or IA alteplase therapy, or mechanical endovascular reperfusion
therapy

CSTK-05a Ischemic stroke patients who develop a symptomatic intracranial hemorrhage ≤ 36 hours after the
onset of treatment with IV alteplase therapy only (IVO)

CSTK-05b Ischemic stroke patients who develop a symptomatic intracranial hemorrhage ≤ 36 hours after the
onset of treatment with IA alteplase therapy or mechanical endovascular reperfusion therapy

Included Populations: As above

Excluded Populations: None

Data Elements:

Arrival Date
Arrival Time
Highest NIHSS Score Documented Within 36 Hours Following IA Alteplase or MER Initiation
Highest NIHSS Score Documented Within 36 Hours Following IV Alteplase Initiation
IA Alteplase or MER Initiation Date
IA Alteplase or MER Initiation Time
IA Route of Alteplase Administration
IV Alteplase Initiation
IV Alteplase Initiation Date

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IV Alteplase Initiation Time
NIHSS Score Documented Closest to IA Alteplase or MER Initiation
NIHSS Score Documented Closest to IV Alteplase Initiation
Positive Brain Image
Positive Brain Image Date
Positive Brain Image Time

Data Elements By Measure

CSTK-05 CSTK-05a CSTK-05b

Arrival Date Arrival Date Arrival Date

Arrival Time Arrival Time Arrival Time

Highest NIHSS Score Documented Highest NIHSS Score Highest NIHSS Score Documented
Within 36 Hours Following IA Documented Within 36 Hours Within 36 Hours Following IA
Alteplase or MER Initiation Following IV Alteplase Initiation Alteplase or MER Initiation

Highest NIHSS Score Documented IV Alteplase Initiation IA Route of Alteplase Administration

Within 36 Hours Following IV
Alteplase Initiation

IA Route of Alteplase Administration IV Alteplase Initiation Date IA Alteplase or MER Initiation Date

IA Alteplase or MER Initiation Date IV Alteplase Initiation Time IA Alteplase or MER Initiation Time

IA Alteplase or MER Initiation Time NIHSS Score Documented NIHSS Score Documented Closest to
Closest to IV Alteplase Initiation IA Alteplase or MER Initiation

IV Alteplase Initiation Positive Brain Image Positive Brain Image

IV Alteplase Initiation Date Positive Brain Date Positive Brain Image Date

IV Alteplase Initiation Time Positive Brain Image Time Positive Brain Image Time

NIHSS Score Documented Closest to

IA Alteplase or MER Initiation

NIHSS Score Documented Closest to

IV Alteplase Initiation

Positive Brain Image

Positive Brain Image Date

Positive Brain Image Time

Denominator Statement: Ischemic stroke patients treated with IV alteplase therapy only (IVO) or IA alteplase
therapy, or who undergo mechanical endovascular reperfusion therapy

Included Populations:

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Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A,
Table 8.1 for ICD-10 codes,
AND
Patients with documented thrombolytic (IV or IA alteplase) therapy (ICD-10-PCS Principal or Other
Procedure Codes as defined in Appendix A, Table 8.1a for ICD-10 codes ),
OR
Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-10-PCS Principal or
Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes)

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients admitted for Elective Carotid Intervention
Patients transferred to this hospital following treatment with IV alteplase therapy or IA alteplase
therapy or mechanical endovascular reperfusion therapy initiated prior to arrival at this hospital
Patients who hemorrhage prior to the onset of treatment with IV alteplase or IA thrombolytic
alteplase or mechanical endovascular reperfusion therapy

Data Elements:

Admission Date
Birthdate
Elective Carotid Intervention
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date

Data Elements:

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: Hospitals may wish to identify those patients who are at higher risk for
hemorrhage following specific therapies, so that efforts can be directed toward improving care.

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

1. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC,
Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. Guidelines for the
Early Management of Adults with Ischemic Stroke: A Guideline From the American Heart
Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular
Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care
Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1664-1666.

2. Adams HP Jr, Brott TG, Furlan AJ, Gomez, CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR,
Torner J, Feinberg W, Mayberg M, Thies W. Guidelines for thrombolytic therapy for acute stroke: a
supplement to the guidleines for the management of patients with acute ischemic stroke.
Circulation.1996;94;1167-1174.

3. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular treatment after intravenous t-PA versus t-PA
alone for stroke. NEJM. 2013;368:893-903.

4. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

5. Ciccone A, Valvassori, Nichelatti M, et. al. Endovascular treatment for acute ischemic stroke. NEJM.
2013;368:904-913.

6. delZoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Gent M, Driscoll RM, and the PROACT Investigators.
The Prolyse in Acute Cerebral Thromboembolism Trial (PROACT): results of 6 mg dose tier. Stroke.
1996;27:164.

7. delZoppo GJ, Higashida RT, Furlan AJ. The case for a phase III trial of cerebral intraarterial fibrinolysis.
AJNR Am J Neuroradiol. 1994; 15:1217-1222.

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8. Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for
Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization
times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38.

9. Donnen GA, Davis SM, Chambers BR, Gates PC, Hankey GJ, McNeil JJ, Rosen D, Stewart-Wynne EG, Tuck
RR. Trials of streptokinase in severe acute ischaemic stroke. Lancet. 1995; 345: 578-579.

10. Fibrinolytic Therapy Trialist's (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected
acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all
randomized trials of more than 1000 patients. Lancet. 1994;343:311-322.

11. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Hoxter G, Mahagne
MH, Hennerici M, for the ECASS Study Group. Intravenous thrmbolysis with recombinant tissue plasminogen
activator for acute hemispheric stroke: the European Cooperative Acute Stroke Study. JAMA. 1995; 274:
1017-1025.

12. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for
the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.

13. Kidwell CS, Jahan R, Gornbein J, et. al. A trial of imaging selection and endovascular treatment for
ischemic stroke. NEJM. 2013;368:914-923.

14. Koh JS, et al: Safety and efficacy of mechanical thrombectomy with Solitaire stent retrieval for acute
ischemic stroke: a systematic review. Neurointervention. 2012;7:1-9.

15. Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C,
Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association
Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and
Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for
measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42:858.

16. Levy DE, Brott TG, Haley EC Jr, Marler JR, Sheppard GL, Barsan W, Broderick JP. Factors related to
intracranial hematoma formation in patients receiving tissue-type plasminogen activator for acute ischemic
stroke. Stroke. 1994;25:291-297.

17. Marder VJ, Sherry S. Thrombolytic therapy: current status. N Engl J Med. 1988;318:1512-1520.

18. Menon BK, Saver JL, Prabhakaran S, Reeves M, Liang L, Olson DWM, Peterson ED, Hernandez AF,
Fonarow GC, Schwamm LH, Smith EE. Risk score for intracranial hemorrhage in patients with acute ischemic
stroke treated with intravenous tissue-type plasminogen activator. Stroke. 2012;43: 1-9.

19. Multicenter Acute Stroke Trail-Italy (MAST-I) Group. Randomised controlled trial of streptokinase, aspirin,
and combination of both in treatment of acute ischaemic stroke. Lancet. 1995;346:1509-1514.

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20. Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS, for the
TREVO 2 Trialists. Trevo versus Merci retrievers for thrombectomy revascularization of large vessel
occlusions in acute ischaemic stroke (TREVO 2): a randomized trial. Lancet. 2012;380:1231-1240.

21. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell
CS, Meschia JF, Ovbiagele B, Yavagal DR, on behalf of the American Heart Association Stroke Council. 2015
AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic
stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2015;46; 3021-3035.

22. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of
the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with
Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke. 2018 Jan;49:e18-e30.

23. Rubiera M, Ribo M, Pagola J, Coscojuela P, Rodrigues-Luna D, Maisterra O, Ibarra B, Piñeiro S, Meler P,

Romero FJ, Alvarez-Sabin J, Molina CA. Bridging intravenous-intra-arterial rescue strategy increases
recanalization and the likelihood of a good outcome in nonresponder intravenous tissue plasminogen
activator-treated patients: a case-control study. Stroke. 2011 Apr;42(4):993-997.

24. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after
intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

25. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO, for the SWIFT
Trialists. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke
(SWIFT): a randomized, parallel-group, non-inferiority trial. Lancet. 2012;380:1241-1249.

26. Sims JR, Gharai R, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical
estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104-2110.

27. Sloan MA, Price TR, Petito CK, Randall AM, Solomon RE, Terrin ML, Gore J, Collen D, Kleiman N, Feit F,
Babb J, Herman M, Roberts WC, Spoko G, Bovill E, Forman S, Knatterud GL, for the TIMI Investigators. Clinical
Features and pathogenesis of intracerebral hemorrhage after rt-PA and heparin therapy for acute myocardial
infarction: the TIMI II pilot and randomisezed clinical trial combined experience. Neurologoy. 1995;45:649-
658.

28. Smith WS, et al. Mechanical thrombectomy for acute ischemic stroke. Stroke. 2008;39:1205-1212.

29. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue
plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-1587.

30. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration
first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-06

Performance Measure Name: Nimodipine Treatment Administered

Description: Subarachnoid hemorrhage (SAH) patients for whom nimodipine treatment was administered
within 24 hours of arrival at this hospital

Rationale: Cerebral vasopasm is a serious complication following SAH, occurring in 30% to 70% of patients
and accounting for nearly 50% of the deaths in patients surviving to treatment. Constriction of the arterial
lumen results in diminished cerebral perfusion distal to the affected artery, which produces a delayed
neurological deficit that may progress to cerebral infarction without early management of the ruptured
aneurysm. The arterial narrowing that occurs in cerebral vasospasm is typically a transient or temporary
event, lasting from a few days up to 3 weeks. Oral nimodipine is a proven and valuable treatment to prevent
or limit the severity of cerebral vasospasm.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: SAH patients for whom nimodipine treatment was administered within 24 hours of
arrival at this hospital.

Included Populations: As above

Excluded Populations: None

Data Elements:

Arrival Date
Arrival Time
Nimodipine Administration
Nimodipine Administration Date
Nimodipine Administration Time
Reason for Not Administering Nimodipine Treatment

Denominator Statement: SAH patients

Included Populations: Discharges with ICD-10-CM Principal Diagnosis Code for subarachnoid
hemorrhage as defined in Appendix A, Table 8.2a for ICD-10 codes.

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients with Comfort Measures Only documented on day of or after hospital arrival
Patients enrolled in clinical trials
Patients discharged within 24 hours of arrival at this hospital

Data Elements:

Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
Discharge Time
ICD-10-CM Principal Diagnosis Code

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

2. Allen GS, Ahn HS, Presiosi TJ, Battye R,Boone SC, Cho SN, Kelly DL, Weir BK, Crabbe RA, Lavik PJ,
Rosenbloom SB, Dorsey FC, Ingram CR, Mellits DE, Bertsch LA, Boisvert DP, Hundley MB, Johnson RK, Strom
JA, Transou CR. Cerebral arterial spasm: a controlled trial of nimodipine in patients with subarachnoid
hemorrhage. N Engl J Med. 1983;308:619-624.

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3. Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel
AB, and Rosenwasser RH. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a
statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart
Association. Stroke. 2009;40:1008-1011.

4. Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ,
Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal
subarachnoid hemorrhage: a guidelines for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2012;43:1-27.

5. Fogelholm R, Palomaki H, Erila T, Rissanen A, Kaste M. Blood pressure, nimodipine, and outcome of
ischemic stroke. Acta Neurol Scand. 2004;109:200-204.

6. Haley EC Jr, Kassell NF, Torner JC, Truskowski LL, Germanson TP. A randomized trial of two doses of
nicardipine in aneurysmal subarachnoid hemorrhage: a report of the Cooperative Aneurysm Study. J
Neurosugr. 1994;80:788-796.

7. Kaste M, Fogelholm R, Erila T, Palomaki H, Murros K, Rissanen A, Sarna S. A randomized, double-blinded,

placebo-controlled trial of nimodipine in acute ischemic hemispheric stroke. Stroke. 1994;25:1348-1353.

8. Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C,
Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association
Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and
Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for
measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42:863-864.

9. Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley EC, Heros RC, Sternau LL, Torner J, Adams HP Jr,
Feinberg W. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for
healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association.
Stroke. 1994;25:2315-2328.

10. Toyota BD. The efficacy of an abbreviated course of nimodipine in patients with good grade aneurysmal
subarachnoid hemorrhage. JNeurosurg. 1999;90(2):203-206.

11. Wahlgren NG, MacMahon DG, DeKeyser J, Indredavik B, Ryman T. Intravenous Nimodipine West
European Stroke Trial (INWEST) of nimodipine in the treatment of acute ischemic stroke. Cerebrovasc Dis.
1994;4:204-210.

12. The American Nimodipine Study Group. Clinical trial of nimodipine in acute ischemic stroke. Stroke.
1992;23:3-8.

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Measure Information Form
**SUSPENDED Effective January 1, 2016**
Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-07

Performance Measure Name: Median Time to Revascularization

Description: Median time from hospital arrival to the start of an intra-arterial (IA) thrombolytic (t-PA) infusion
or the first pass (i.e., deployment) of a mechanical reperfusion device to extract an arterial occlusive lesion
and restore blood flow to brain tissue.

Rationale: Timely recanalization of an occluded intracerebral artery is a strong predictor of improved

functional outcome and reduced mortality in patients with an acute ischemic stroke. Trials of IA lytic agents
and mechanical revascularization devices have historically required start of treatment as long as 6-8 hours
for anterior circulation strokes of the middle cerebral artery with extended times from symptom onset for
vertebrobasilar occulusions. At this time, administration of intra-venous (IV) tissue plasminogen activator (t-
PA) within three hours of time last known well remains the recommended first-line approach. However, the
short therapeutic window and low rates of recanalization with IV thrombolytic (t-PA) therapy has prompted
the investigation of alternative approaches via intra-arterial infusion of a thrombolytic drug or mechanical
recanalization with a clot retrieval device. Endovascular treatment of acute ischemic stroke with intraarterial
(IA) thrombolytic agents or mechanical thrombectomy is a consideration in patients whom IV t-PA fails or
considered likely to fail, who are excluded from IV t-PA treatment, and/or who present with large vessel
occlusion that can be detected directly with brain imaging (e.g., noncontrast CT, CT angiography, magnetic
resonance angiography (MRA) or indirectly by a high National Institutes for Stroke Scale (NIHSS) Score
greater than 10.

Since “time is brain”, the overall speed of the revascularization process is an important and appropriate
measure. In multicenter clinical trials of catheter-directed therapies, the probability of good outcome as
defined by a Modified Rankin Score of 0-2 at 90 days decreased as time to angiographic revascularization
increased. It is estimated that for every 30-minute delay in time to revascularization, there is a 10% decrease
in the likelihood of a good outcome from endovascular reperfusion therapy.

Type Of Measure: Process

Improvement Noted As: Decrease in the median value

Continuous Variable Statement: Time (in minutes) from hospital arrival to the start of an intra-arterial (IA)
thrombolytic (t-PA) infusion or the first pass of a mechanical reperfusion device in patients with acute
ischemic stroke who undergo revascularization therapy.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A,
Table 8.1 for ICD-10 codes,

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AND
Patients with documented Thrombolytic Infusion Therapy (ICD-10-PCS Principal or Other Procedure
Codes as defined in Appendix A, Table 8.1a for ICD-10 codes) OR Mechanical Endovascular
Reperfusion Therapy (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table
8.1b for ICD-10 codes).

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients admitted for Elective Carotid Intervention

Data Elements:

Admission Date
Arrival Date
Arrival Time
Birthdate
Discharge Date
Elective Carotid Intervention
First Pass Date
First Pass Time
First Pass of a Mechanical Reperfusion Device
IA Route of Alteplase Administration
IA Thrombolytic Initiation
IA Thrombolytic Initiation Date
IA Thrombolytic Initiation Time
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Selected References: 1. Adams HP, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T,
Lyden PD, Marler JR, Torner J, et. al. Guidelines for thrombolytic therapy for acute stroke: a supplement to
the guidelines for the management of patients with acute ischemic stroke. Circulation. 1996;94:1167-1174.

2. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the
management of patients with ST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999
Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.

3. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of
the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of
Patients With ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;51:210—-47.

4. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

6. Furlan A, Higashida R, Wechsler L, et. al. Intra-arterial prourokinase for acute ischemic stroke. The
PROACT II study; a randomized controlled trial. Prolyse in Actue Cerebral Thromboembolism. JAMA.
1999;282:2003-2011.

7. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for
the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.

8. Khatari P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA; IMS I and II Investigators. Good
clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009
Sep 29;73(13):1066-72.

9. Khatari P, Hill MD, Palesch YY, et. al. Methodology of the Interventional Manaagement of Stroke III Trial. Int
J Stroke. 2008;3:130-137.

10. Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C,
Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association
Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and
Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for
measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42; 857.

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11. Penumbra Pivotal Stroke Trial Investigators. The penumbra pivotal stroke trial: safety and effectiveness
of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease.
Stroke. 2009;40:2761-2768.

12. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.

13. Sacks D, Black CM, Cognard C, Connors JJ III, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ,
Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines
for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of
Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional
Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of
Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive
Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol.
2013;24:151-163.

14. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after
intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

15. Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute
ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.

16. Smith WS, Sung G, Saver J, et. al. Mechanical thrombectomy for acute ischemic stroke: final results of
the Multi MERCI trial. Stroke. 2008;39:1205-1212.

17. Tarr R, Hsu D, Kulcsar Z, et. al. The POST trial: initial post-market experience of the Penumbra system:
revascularization of large vessel occlusion in acute ischemic stroke in the United States and Europe. _J
Neurointerv Surg. 2010;2:341-344.

18. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration
first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

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Measure Information Form
Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-08

Performance Measure Name: Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)

Description: Ischemic stroke patients with a post-treatment reperfusion grade of TICI 2B or higher in the
vascular territory beyond the target arterial occlusion at the end of treatment with intra-arterial (IA) alteplase
therapy and/or mechanical endovascular reperfusion therapy

Rationale: The Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade is used to measure cerebral
reperfusion. Four results are possible with this scoring system: 0 (no perfusion); 1 (perfusion past the initial
occlusion, but no distal branch filling); 2 (perfusion with incomplete or slow distal branch filling); and , 3 (full
perfusion with filling of all distal branches). Reperfusion past the target arterial occlusion and into the distal
arterial bed and terminal branches, in conjunction with recanalization of the target arterial occlusion,
demonstrates flow restoration or revascularization.

The Interventional Management of Stroke (IMS) I trial suggested that the combined use of reduced-dose
intravenous (IV) alteplase therapy, followed by microcatheter delivered intra-arterial (IA) alteplase therapy,
was safe and effective in selected ischemic stroke patients, as compared to patients treated with full dose IV
alteplase in the National Institute of Neurologic disease and Stroke (NINDS) rt-PA trial. In IMS I, a final TICI
2/3 reperfusion was achieved in 62% of ischemic stroke patients treated.

Endovascular therapy (EVT) is now the standard of care for treatment of acute ischemic stroke due to large-
vessel occlusion (LVO). In 2015, the American Heart Association/American Stroke Association published a
focused update to the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke
regarding endovascular treatment (Powers WJ, et. al., 2015). Endovascular therapy with a stent retriever is
recommended for eligible patients. The use of mechanical thrombectomy devices other than stent retrievers
as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent
retrievers remain the first choice (Powers WJ, et. al., 2018).

Type Of Measure: Outcome

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients with a post-treatment reperfusion grade of TICI 2B or higher

Included Populations: As above

Excluded Populations: None

Data Elements:

Post-Treatment Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade

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Denominator Statement: Ischemic stroke patients treated with IA alteplase therapy and/or mechanical
endovascular reperfusion therapy

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A,
Table 8.1 for ICD-10 codes,
AND
Patients with documented alteplase (IV or IA t-PA) therapy (ICD-10-PCS Principal or Other Procedure
Codes as defined in Appendix A, Table 8.1a for ICD-10 codes),
OR
Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-10-PCS Principal or
Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes),
AND
Patients with documented Failed Attempt at Thrombectomy (ICD-10-PCS Principal or Other
Procedure Codes as defined in Appendix A, Table 8.1c for ICD-10 codes)

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients admitted for Elective Carotid Intervention

Data Elements:

Admission Date
Birthdate
Discharge Date
Elective Carotid Intervention
Failed Attempt at Thrombectomy
IA Route of Alteplase Administration
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date

Data Elements:

Admission Date
Hispanic Ethnicity
Race

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Sex
Birthdate
Initial Blood Glucose Value at Hospital Arrival
Initial NIHSS Score at Hospital Arrival
Initial Platelet Count at Hospital Arrival
Initial Blood Pressure at Hospital Arrival
IV Alteplase Prior to IA or Mechanical Reperfusion Therapy
Proximal or Distal Occlusion
Site of Primary Vessel Occlusion
ICD-10-CM Other Diagnosis Codes

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

1. Adams HP, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR,
Torner J, et. al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the
management of patients with acute ischemic stroke. Circulation. 1996;94:1167-1174.

4. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

7. Khatari P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA; IMS I and II Investigators. Good
clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009
Sep 29;73(13):1066-72.

8. Kole M, Amin B, Marin H, Russman A, Sanders W. Intracranial angioplasty and stent placement for direct
cerebral revascularization o nonacute intracranial occlusions and near occlusions. NeuroSurg Focus. 2009;
26(3): E3.

9. Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C,
Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association
Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and
Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for
measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42; 857.

10. Menon BK, Saver JL, Prabhakaran S, Reeves M, Liang L, Olson DWM, Peterson ED, Hernandez AF,
Fonarow GC, Schwamm LH, Smith EE. Risk score for intracranial hemorrhage in patients with acute ischemic
stroke treated with intravenous tissue-type plasminogen activator. Stroke. 2012;43: 1-9.

11. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell
CS, Meschia JF, Ovbiagele B, Yavagal DR, on behalf of the American Heart Association Stroke Council. 2015
AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic
stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2015;46; 3021-3035.

12. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of
the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with
Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke. 2018 Jan;49:e10-e11, e26-e30.

13. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.

14. Sacks D, Black CM, Cognard C, Connors III JJ, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ,
Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines
for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of
Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional
Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of
Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive

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Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol.
2013;24:151-163.

15. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after
intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

16. Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute
ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.

17. Sims JR, Gharai R, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical
estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104-2110.

18. Tomsick T, Broderick J, Carrosella J, Khatari P, Hill M, Palesch Y, Khoury J; Interventional Management of

Stroke II Investigators. Revascularizaton results in the Interventional Management of Stroke II Trial. American
Journal of Neuroradiology. 2008 Mar; 29(3): 582-587.

19. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration
first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

Set Measure ID: CSTK-09

Performance Measure Name: Arrival Time to Skin Puncture

Description: Median time from hospital arrival to the time of skin puncture to access the artery (e.g., brachial,
carotid, femoral, radial) selected for endovascular treatment (EVT), (i.e., intra-arterial (IA) alteplase infusion
and/or mechanical embolectomy devices), of acute ischemic stroke.

Rationale: Timely recanalization of an occluded intracerebral artery is a strong predictor of improved

functional outcome and reduced mortality in patients with an acute ischemic stroke. Initiation of intra-
venous (IV) alteplase within three hours of time last known well is recommended first before attempting
other treatment; however, endovascular treatment (EVT) with devices and/or intra-arterial (IA) thrombolysis
(alteplase) is also recommended as a second-line therapy after IV thrombolysis failure or lapse of the
therapeutic window. For eligible patients, initiation of EVT (e.g., groin puncture) within 6 hours of stroke
symptom onset using a stent retriever is preferred (Powers WJ, et. al., 2015). Findings from clinical trials
published in 2018 ( i.e., DAWN, DEFUSE 3) have reported the benefits of mechanical thrombectomy in the
extended window up to 24 hours of last known well for select ischemic stroke patients meeting certain
criteria. The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for
mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first
choice (Powers WJ, et. al., 2018).

Since “time is brain”, the overall speed of the revascularization process is an important and appropriate
measure. In multicenter clinical trials of intra-arterial catheter-directed therapies, the probability of good
outcome as defined by a Modified Rankin Score of 0-2 at 90 days decreased as time to angiographic
revascularization increased. It is estimated that for every 30-minute delay in time to revascularization, there
is a 10% decrease in the likelihood of a good outcome from EVT.

Type Of Measure: Process

Improvement Noted As: Decrease in the median value

Continuous Variable Statement: Time (in minutes) from hospital arrival to skin puncture in patients with
acute ischemic stroke who undergo endovascular treatment.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A,
Table 8.1 for ICD-10 codes,
AND
Patients with documented Thrombolytic Infusion Therapy (ICD-10-PCS Principal or Other Procedure
Codes as defined in Appendix A, Table 8.1a for ICD-10 codes) OR Mechanical Endovascular

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Reperfusion Therapy (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table
8.1b for ICD-10 codes).

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients admitted for Elective Carotid Intervention
Patients who have a Delayed Endovascular Rescue Procedure later than 8 hours after hospital
arrival (ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a or
Table 8.1b)

Data Elements:

Admission Date
Arrival Date
Arrival Time
Birthdate
Delayed Endovascular Rescue Procedure
Discharge Date
Elective Carotid Intervention
IA Route of Alteplase Administration
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
Skin Puncture
Skin Puncture Date
Skin Puncture Time

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate measure of central tendency .

2. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et. al. Thrombectomy for stroke
at 6 to 16 hours with selection by perfusion imaging. NEJM. 2018;378(8): 708-718.

3. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the
management of patients with ST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999
Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.

4. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of
the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of
Patients With ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;51:210—-47.

5. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

6. Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for
Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization
times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38.

7. Furlan A, Higashida R, Wechsler L, et. al. Intra-arterial prourokinase for acute ischemic stroke. The
PROACT II study; a randomized controlled trial. Prolyse in Actue Cerebral Thromboembolism. JAMA.
1999;282:2003-2011.

8. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for
the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.

9. Khatari P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA; IMS I and II Investigators. Good
clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009
Sep 29;73(13):1066-72.

10. Khatari P, Hill MD, Palesch YY, et. al. Methodology of the Interventional Manaagement of Stroke III Trial.
Int J Stroke. 2008;3:130-137.

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measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42; 857.

12. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et. al. Thrombectomy 6 to 24 hours
after stroke with a mismatch between deficit and infarct. NEJM. 2018;378(1): 11-21.

13. Penumbra Pivotal Stroke Trial Investigators. The penumbra pivotal stroke trial: safety and effectiveness
of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease.
Stroke. 2009;40:2761-2768.

14. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell
CS, Meschia JF, Ovbiagele B, Yavagal DR, on behalf of the American Heart Association Stroke Council. 2015
AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic
stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke. 2015;46; 3021-3035.

15. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of
the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with
Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke. 2018 Jan;49:e26-e30.

16. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.

17. Sacks D, Black CM, Cognard C, Connors JJ III, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ,
Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines
for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of
Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional
Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of
Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive
Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol.
2013;24:151-163.

18. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after
intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

19. Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute
ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.

20. Smith WS, Sung G, Saver J, et. al. Mechanical thrombectomy for acute ischemic stroke: final results of
the Multi MERCI trial. Stroke. 2008;39:1205-1212.

21. Tarr R, Hsu D, Kulcsar Z, et. al. The POST trial: initial post-market experience of the Penumbra system:
revascularization of large vessel occlusion in acute ischemic stroke in the United States and Europe. _J
Neurointerv Surg. 2010;2:341-344.

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22. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration
first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

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Measure Information Form
Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-10

Performance Measure Name: Modified Rankin Score (mRS at 90 Days: Favorable Outcome)

Description: Ischemic stroke patients treated with intra-venous (IV) or intra-arterial (IA) alteplase therapy or
who undergo mechanical endovascular reperfusion therapy and have a mRS less than or equal to 2 at 90
days (≥75 days and ≤105 days)

Type Of Measure: Outcome

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients with a mRS less than or equal to 2 at 90 days (≥75 days and
≤105 days)

Included Populations: As above

Excluded Populations: None

Data Elements:

Modiﬁed Rankin Score (mRS)

Modiﬁed Rankin Score (mRS) Date

Denominator Statement: Ischemic stroke patients treated with IV or IA alteplase therapy or who undergo
mechanical endovascular reperfusion therapy

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A,
Table 8.1 for ICD-10 codes, AND

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Patients with documented thrombolytic (IV or IA alteplase) therapy (ICD-10-PCS Principal or Other
Procedure Codes as defined in Appendix A, Table 8.1a for ICD-10 codes), OR
Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-10-PCS Principal or
Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes)

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients admitted for Elective Carotid Intervention
Patients and their caregivers who cannot be contacted via phone or in-person at 90 days

Data Elements:

Admission Date
Hispanic Ethnicity
Race
Sex
Birthdate
Initial Blood Glucose Value at Hospital Arrival
Initial NIHSS Score at Hospital Arrival
Initial Platelet Count at Hospital Arrival
Initial Blood Pressure at Hospital Arrival
IV Alteplase Prior to IA or Mechanical Reperfusion Therapy
ICD-10-CM Other Diagnosis Codes
Pre-Stroke Modiﬁed Rankin Score (mRS)

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and, if applicable, medical record documents.

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Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

2. Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: implications for
stroke clinical trials: a literature review and synthesis. Stroke. 2007:38:2262-2269.

4. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

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8. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of
the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with
Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association. Stroke. 2018 Jan;49:e10-e11.

9. Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the modified Rankin scale. Stroke. 2007:38:e144.

10. Rankin J. Cerebral vascular accidents in patients over the age of 60. Scott Med J. 1957;2(5):200-15.

11. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after
intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

13. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue
plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke
rt-PA Stroke Study Group. New England Journal of Medicine 1995;333:1581-1587.

15. Wilson JT, Hareendran A, Hendry A, Potter J. Bone I, Muir KW. Reliability of the modified Rankin scale
across multiple raters: benefits of a structured interview. Stroke. 2005;36:777-781.

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Measure Information Form
Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-11

Performance Measure Name: Timeliness of Reperfusion: Arrival Time to TICI 2B or Higher

Description: Ischemic stroke patients with a large vessel cerebral occlusion (i.e., internal carotid artery (ICA)
or ICA terminus (T-lesion; T-occlusion), middle cerebral artery (MCA) M1 or M2, basilar artery) who receive
mechanical endovascular reperfusion (MER) therapy within 120 minutes (>/= 0 min. and </= 150 min.) of
hospital arrival and achieve TICI 2B or higher at the end of treatment

Rationale: The Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade is used to measure cerebral
reperfusion. Results with this scoring system range between zero and three: 0 (no perfusion); 1 (perfusion
past the initial occlusion, but no distal branch filling); 2 (perfusion with incomplete or slow distal branch
filling); and, 3 (full perfusion with filling of all distal branches). Reperfusion past the target arterial occlusion
and into the distal arterial bed and terminal branches, in conjunction with recanalization of the target arterial
occlusion, demonstrates flow restoration or revascularization.

To ensure benefit, reperfusion to TICI 2B/3 should be achieved as early as possible and within 6 hours of
stroke onset. The DAWN Clinical Trial Investigators (Nogueira RG, et. al., 2018) reported the benefits of
mechanical thrombectomy in the extended window up to 24 hours of last known well for select patients
meeting certain criteria. As with IV alteplase (t-PA), reduced time from symptom onset to reperfusion with
EVT is highly associated with better clinical outcomes. Recent recommendations from the Society of
Vascular and Interventional Neurology (SVIN) offer procedural metrics which include time from hospital
arrival to groin puncture less than 90 minutes, and time from groin puncture to TICI 2B or better or
conclusion of procedure less than 60 minutes (English JD, et. al., 2016).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients who achieve TICI 2B or higher for the primary vessel
occlusion within 120 minutes (>/= 0 min. and </= 150 min.) of hospital arrival

Included Populations: As above

Data Elements:

Arrival Date
Arrival Time
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

Denominator Statement: Ischemic stroke patients treated with mechanical endovascular reperfusion therapy
for a large vessel occlusion (LVO)

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in Appendix A,
Table 8.1 for ICD-10 codes, AND
Patients with documented Mechanical Endovascular Reperfusion Therapy (ICD-10-PCS Principal or
Other Procedure Codes as defined in Appendix A, Table 8.1b for ICD-10 codes) AND
Patients with documented Failed Attempt at Thrombectomy (ICD-10-PCS Principal or Other Procedure
Codes as defined in Appendix A, Table 8.1c for ICD-10 codes)

Excluded Populations:

Patients less than 18 years of age

Data Elements:

Admission Date
Birthdate
Delayed Endovascular Rescue Procedure
Discharge Date
Elective Carotid Intervention
Failed Attempt at Thrombectomy
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
Site of Primary Vessel Occlusion

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

2. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et. al. Thrombectomy for stroke
at 6 to 16 hours with selection by perfusion imaging. NEJM. 2018;378(8): 708-718.

5. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

7. English JD, Yavagal DR, Gupta R, Janardhan V, Zaidat OO, Xavier AR, Nogueira RG, Kirmani JF, Jovin TG.
Mechanical thrombectomy-ready comprehensive stroke center requirements and endovascular stroke
systems of care: recommendations from the endovascular stroke standards committee of the Society of
Vascular and interventional Neurology (SVIN). Intervent Neurol. 2015;4:138-50.

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8. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for
the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.

10. Kole M, Amin B, Marin H, Russman A, Sanders W. Intracranial angioplasty and stent placement for direct
cerebral revascularization o nonacute intracranial occlusions and near occlusions. Applications/LocalApps.
NeuroSurg Focus. 2009; 26(3): E3.

11. Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C,
Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association
Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and
Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for
measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition
comprehensive stroke center recommendations: a statement for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2011;42; 857.

12. Menon BK, Saver JL, Prabhakaran S, Reeves M, Liang L, Olson DWM, Peterson ED, Hernandez AF,
Fonarow GC, Schwamm LH, Smith EE. Risk score for intracranial hemorrhage in patients with acute ischemic
stroke treated with intravenous tissue-type plasminogen activator. Stroke. 2012;43: 1-9.

13. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et. al. Thrombectomy 6 to 24 hours
after stroke with a mismatch between deficit and infarct. NEJM. 2018;378(1): 11-21.

16. Pride GL, Fraser JF, Gupta R, Alberts MJ, Rutledge JN, Fowler R, et. al. Prehospital care delivery and
triage of stroke with emergent large vessel occlusion (LVO): report of the Standards and Guidelines
Committee of the Society of Neurointerventional Surgery (SNIS). Applications/LocalApps. NeuroIntervent
Surg. 2016;0:1-11.

17. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.

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18. Sacks D, Black CM, Cognard C, Connors III JJ, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ,
Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines
for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of
Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional
Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of
Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive
Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol.
2013;24:151-163.

19. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after
intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

20. Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute
ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.

21. Sims JR, Gharai R, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical
estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104-2110.

22. Tomsick T, Broderick J, Carrosella J, Khatari P, Hill M, Palesch Y, Khoury J; Interventional Management of

Stroke II Investigators. Revascularizaton results in the Interventional Management of Stroke II Trial. American
Journal of Neuroradiology. 2008 Mar; 29(3): 582-587.

23. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration
first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

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Measure Information Form
Measure Set: Comprehensive Stroke (CSTK)

Set Measure ID: CSTK-12

Performance Measure Name: Timeliness of Reperfusion: Skin Puncture to TICI 2B or Higher

Description: Ischemic stroke patients with a large vessel cerebral occlusion (i.e., internal carotid artery (ICA)
or ICA terminus (T-lesion; T-occlusion), middle cerebral artery (MCA) M1 or M2, basilar artery) who receive
mechanical endovascular reperfusion (MER) therapy and achieve TICI 2B or higher less than (<) or equal to
60 minutes from the time of skin puncture.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients who achieve TICI 2B or higher for the primary vessel
occlusion less than (<) or equal to 60 minutes from the time of skin puncture

Included Populations: As above

Data Elements:

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
Skin Puncture Date
Skin Puncture Time

Denominator Statement: Ischemic stroke patients treated with mechanical endovascular reperfusion therapy
for a large vessel occlusion (LVO)

Included Populations:

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay > 120 days
Patients admitted for Elective Carotid Intervention
Patients who have a primary cerebral occlusion that is not a large vessel occlusion (LVO)

Data Elements:

Admission Date
Birthdate
Discharge Date
Elective Carotid Intervention
Failed Attempt at Thrombectomy
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Other Procedure Dates
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
Site of Primary Vessel Occlusion
Skin Puncture

Risk Adjustment: No.

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Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

2. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et. al. Thrombectomy for stroke
at 6 to 16 hours with selection by perfusion imaging. NEJM. 2018;378(8): 708-718.

5. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for
ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.

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Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
310
8. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for
the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.

13. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et. al. Thrombectomy 6 to 24 hours
after stroke with a mismatch between deficit and infarct. NEJM. 2018;378(1): 11-21.

17. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
311
18. Sacks D, Black CM, Cognard C, Connors III JJ, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ,
Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines
for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of
Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional
Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of
Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive
Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol.
2013;24:151-163.

19. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after
intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.

21. Sims JR, Gharai R, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical
estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104-2110.

22. Tomsick T, Broderick J, Carrosella J, Khatari P, Hill M, Palesch Y, Khoury J; Interventional Management of

Stroke II Investigators. Revascularizaton results in the Interventional Management of Stroke II Trial. American
Journal of Neuroradiology. 2008 Mar; 29(3): 582-587.

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Palliative Care (PAL)

Set Measures

Set Measure ID Measure Short Name

PAL-01 Pain Screening

PAL-02 Pain Assessment

PAL-03 Dyspnea Screening

PAL-04 Treatment Preferences and Goals of Care

PAL-05 Treatment Preferences Discharge Document

General Data Elements

Element Name Collected For

Admission Date All Records,

Birthdate All Records,

Discharge Date All Records, Not collected for HBIPS-2 and

HBIPS-3

Sex All Records,

Measure Set Specific Data Elements

Element Name Collected For

Discharge Disposition PAL-05

Dyspnea Severity PAL-03

Goals of Care PAL-04

Initial Encounter PAL

Initial Encounter Date PAL

Pain Character PAL-02

Pain Duration PAL-02

Pain Effect PAL-02

Pain Factors PAL-02

Pain Frequency PAL-02

Pain Location PAL-02

Pain Severity PAL-01, PAL-02

Treatment Preferences PAL-04

Treatment Preferences Document PAL-05

Palliative Care (PAL) Initial Patient Population

The PAL Measure Set Population (common to all PAL measures) is defined as all patients who have received
a consultation with any member of the palliative care service team. “Consultation” indicates that the patient
received a face to face encounter visit with any member of the palliative care core interdisciplinary team. The
core interdisciplinary team is comprised of the following: Physician(s); Registered nurse(s) or advanced
practice nurse(s); Chaplain(s) or, spiritual care professional(s); Social worker(s).

The population of the PAL measure set can be identified by using data elements that are common to all of
the performance measures in the set:

Discharge Date
Initial Encounter

While not required for the identification of the initial patient population or the calculation of the measures,
the following data elements are collected for purposes of case identification:

Admission Date
Birthdate
Sex

Note – General Data Elements:

The following General Data Elements are optional for the PAL measure set. Collection of these data elements
is not currently required for the identification of the initial patient population or the calculation of the
measures for purposes of measure submission for certification.

Optional General Data Elements:

Hispanic Ethnicity
ICD-10-CM Other Diagnosis Codes

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ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
Payment Source
Postal Code
Race

Sampling is a process of selecting a representative part of a population to estimate the organization’s

performance without collecting data for its entire population. Using a statistically valid sample, an
organization can measure its performance in an effective and efficient manner. Sampling is a particularly
useful technique for performance measures that require primary data collection from a source, such as the
medical record. Sampling should not be used unless the organization has a large number of cases in the
measure population, because a fairly large number of sample cases is needed to achieve a representative
sample of the population of interest. To obtain statistically valid sample data, the sample size should be
carefully determined, and the sample cases should be randomly selected in such a way that the individual
cases in the population have an equal chance of being selected. Only when the sample data truly represent
the whole population can the sample-based performance measure data be meaningful and useful.

Sampling Approaches

Simple random sampling - selecting a sample size (n) from a population of size (N) in such a way that every
case has the same chance of being selected. Systematic random sampling - selecting every kth record from
a population of size N in such a way that a sample size of n is obtained, where k ≤ N/n. The first sample
record (i.e., the starting point) must be randomly selected before taking every kth record. This is a two-step
process: a) Randomly select the starting point by choosing a number between one and k using a table of
random numbers or a computer-generated random number; and b) Then select every kth record thereafter
until the selection of the sample size is completed. As an example, say the site has 33 cases for the month.
These 33 cases would then be put on a list and numbered from 1 to 33. First we calculate the sampling
interval k as 33/10 which rounds to 3. The site would then randomly choose a number between 1 and 3 to
use as the starting point on the list, sample this case, and then from this point sample every 3rd case on the
list until they come to the end of the list to create their sample.

Monthly Sample Size

Monthly Patient Volume Monthly Sample Size

(number of discharges)” (number of medical records)

1-9 100%

10 - 49 10 cases

50 - 99 20%

=> 100 20 cases

Set Measure ID: PAL-01

Performance Measure Name: Pain Screening

Description: Proportion of palliative care patients who were screened for pain during the palliative care initial
encounter.

Rationale: As described from the University of Chapel Hill PEACE Measure Set project, pain is prevalent and
undertreated for many populations of seriously ill patients, including those patients nearing the end of life.
Poor screening, assessment, and undertreatment of pain is more common for patients with serious illness
who are also of minority race ethnicity. Use of the Pain Screening and Pain Assessment quality measures
will increase reporting and efforts to improve awareness of the presence of pain (screening) and assessment
of severity, etiology and effect on function (assessment) which are the essential first steps required for
quality pain management and treatment. The prevalence of pain ranges from 40-80% in seriously ill patient
populations. As detailed in a systematic review from AHRQ and the American Pain Society Quality of Care
guidelines, pain screening and assessment are the essential steps required to ensure that pain is detected
by clinicians and appropriate treatment implemented. (Wells et al., 2008; Gordon et al. 2005; as cited by
PEACE) Failure to screen, assess, and treat pain results in functional limitations, physiologic stress, and
psychological harms such as social withdrawal and depression. The current quality of pain screening,
assessment, and treatment is poor, as documented in systematic pain prevalence and treatment studies
from hospital, outpatient, cancer and nursing home settings. (Reynolds et al., 2002; Deandria et al., 2008;
Mularski et al., 2006; Erdek et al., 2004; as cited by PEACE) In a systematic review of quality of pain care for
diverse patient populations, Gordon reported high average pain severity (6.17-8.37 on 10 point scale) and
moderate rates of pain severity screening or other assessment (47%-96%). These findings did not vary by
underlying diagnosis. (Gordon et al., 2002) (PEACE, 2015)

The National Consensus Project for Quality Palliative Care (2013) guidelines recommend that the
interdisciplinary team assesses and manages pain in a safe and timely manner to a level acceptable to the
patient or surrogate and that symptom assessment, treatment, side effect and treatment outcome
information should be recorded in the medical record.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who are screened for the presence or absence of pain and its severity using
a standardized quantitative tool during the initial encounter for palliative care.

Included Populations: Not applicable

Excluded Populations: None

Pain Severity

Denominator Statement: Patients receiving specialty palliative care in an acute hospital setting for one (1) or
more days

Included Populations:

Excluded Populations:

Palliative care program length of stay less than 1 day

Data Elements:

Initial Encounter
Initial Encounter Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include
administrative/billing data and medical records. Some hospitals may prefer to gather data concurrently by
identifying patients in the population of interest. This approach provides opportunities for improvement at
the point of care/service. However, complete documentation includes the principal or other ICD-10CM/PCS
diagnosis and procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10CM/PCS codes; therefore, coding practices
may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

CMS Hospice Item Set, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html
Deandria S, Montanri M, Moja L et al. Prevalence of undertreatment of cancer pain: a review of
published literature. Ann Oncol 2008; 19:1985-91.
Erdek MA, Pronovost PA. Improving assessment and treatment of pain in the critically ill. Int J Qual
Health Care 2004; 16:59-64.
Gordon DB, Dahl JL, Miaskowski C et al. American Pain Society recommendations for improving the
quality of acute and cancer pain management. Arch Intern Med 2005; 165:1574-1580.

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322
Gordon DB, Pelliano TA, Miaskowski C et al. A 10-year review of quality improvement monitoring in
pain management: recommendations for standardized outcome measures. Pain Manage Nurs 2002;
4:116-130.
Measuring What Matters, http://aahpm.org/quality/measuring-what-matters
Mularski R, White-Chu F, Overbay D et al. Measuring pain as the 5th vital sign does not improve quality
of pain management. J Gen Intern Med 2006; 6:607-612.
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality
Palliative Care. 3rd ed. Pittsburgh, PA: Author; 2013.
http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf
PEACE Hospice and Palliative Care Quality Measures,
http://www.med.unc.edu/pcare/resources/PEACE-Quality-Measures
Reynolds K, Henderson M, Schulman A, Hanson LC. Needs of the dying in nursing homes. J Pall Med
2002; 5:895-901.
Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and
Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for
Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.

Original Performance Measure Source / Developer:

American Academy of Hospice and Palliative Care (AAHPM) and Hospice and Palliative Nurses Association
(HPNA) Measuring What Matters Project Top Ten Measures That Matter List
CMS Hospice Item Set
PEACE Hospice and Palliative Care Quality Measures Set

Set Measure ID: PAL-02

Performance Measure Name: Pain Assessment

Description: Proportion of palliative care patients who screened positive for pain during the palliative care
initial encounter and received a clinical assessment of pain, which included at least five of seven
components, within one (1) day of screening.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who received a comprehensive clinical assessment, which included at least
five of seven components, within one (1) day of screening positive for pain.

Included Populations: Not applicable

Excluded Populations: None

Pain Character
Pain Duration
Pain Effect
Pain Factors
Pain Frequency
Pain Location
Pain Severity

Denominator Statement: Patients receiving specialty palliative care in an acute hospital setting who report
pain when pain screening is done on the initial palliative care encounter.

Included Populations:

Excluded Populations:

Palliative care program length of stay less than 1 day

Data Elements:

Initial Encounter
Initial Encounter Date
Pain Severity

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10CM/PCS codes; therefore, coding practices
may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
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326
CMS Hospice Item Set, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html
Deandria S, Montanri M, Moja L et al. Prevalence of undertreatment of cancer pain: a review of
published literature. Ann Oncol 2008; 19:1985-91.
Erdek MA, Pronovost PA. Improving assessment and treatment of pain in the critically ill. Int J Qual
Health Care 2004; 16:59-64.
Gordon DB, Dahl JL, Miaskowski C et al. American Pain Society recommendations for improving the
quality of acute and cancer pain management. Arch Intern Med 2005; 165:1574-1580.
Gordon DB, Pelliano TA, Miaskowski C et al. A 10-year review of quality improvement monitoring in
pain management: recommendations for standardized outcome measures. Pain Manage Nurs 2002;
4:116-130.
Measuring What Matters, http://aahpm.org/quality/measuring-what-matters
Mularski R, White-Chu F, Overbay D et al. Measuring pain as the 5th vital sign does not improve quality
of pain management. J Gen Intern Med 2006; 6:607-612.
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality
Palliative Care. 3rd ed. Pittsburgh, PA: Author; 2013.
http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf
PEACE Hospice and Palliative Care Quality Measures,
http://www.med.unc.edu/pcare/resources/PEACE-Quality-Measures
Reynolds K, Henderson M, Schulman A, Hanson LC. Needs of the dying in nursing homes. J Pall Med
2002; 5:895-901.
Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and
Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for
Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.

Original Performance Measure Source / Developer:

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Measure Information Form
Measure Set: Palliative Care (PAL)

Set Measure ID: PAL-03

Performance Measure Name: Dyspnea Screening

Description: Proportion of palliative care patients who were screened for dyspnea during the palliative care
initial encounter.

Rationale: As described from the University of Chapel Hill PEACE Measure Set project, dyspnea is prevalent
and undertreated for many populations of seriously ill patients, including those patients nearing the end of
life. Screening for dyspnea is necessary to determine its presence and severity, and forms the basis for
treatment decision-making. Unlike pain, structured clinical assessment of the symptom is less well-defined,
yet similar to pain, effective treatment is available to alleviate symptom distress. Prevalence of dyspnea in
advanced cancer ranges from 50-70%. Among COPD patients with advanced illness enrolled in the SUPPORT
Study, dyspnea which was moderate to severe at least half of the time was present for at least 65% of
patients throughout the 6 months preceding death. Effective treatment for dyspnea is available, but not
consistently administered. Evidence-based treatments include pharmacologic interventions such as opioids
and inhaled bronchodilators, and non-pharmacologic interventions including oxygen for hypoxic patients,
pulmonary rehabilitation and exercise in COPD, and drainage of pleural effusion. (PEACE, 2015)

National Consensus Project for Quality Palliative Care (2013) guidelines recommend that the
interdisciplinary team assesses and manages pain in a safe and timely manner to a level acceptable to the
patient or surrogate and that symptom assessment, treatment, side effect and treatment outcome
information should be recorded in the medical record

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who are screened for the presence or absence of Dyspnea and its severity
during the initial encounter for palliative care.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Dyspnea Severity

Denominator Statement: Patients receiving specialty palliative care in an acute hospital setting for one (1) or
more days

Excluded Populations:

Palliative care program length of stay less than one (1) day

Data Elements:

Initial Encounter
Initial Encounter Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the
population of interest. This approach provides opportunities for improvement at the point of care/service.
However, complete documentation includes the principal or other ICD-10CM/PCS diagnosis and procedure
codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10CM/PCS codes; therefore, coding practices
may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Bausewin C, Booth S, Gysels M et al. Non-pharmacologic interventions for breathlessness in

advanced stages of malignant and nonmalignant diseases. Cochrane Database Syst Rev 2009. Apr
16; 2:CD005623.
Ben-Aharon I, Gafter-Gvili A, Paul M et al. Interventions for alleviating cancer-related dyspnea: a
systematic review. J Clin Oncol 2008; 26:2396-2404.
CMS Hospice Item Set, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html
Currow DC, Ward AM, Abernethy AP. Advances in the pharmacologic management of breathlessness.
Current Opin Supp Pall Care 2009; 3:103-106.
Dy SM, Lorenz KA, Naeim A et al. Evidence-based recommendations for cancer fatigue, anorexia,
depression and dyspnea. J Clin Onc 2008; 26:3886-3895.
Lorenz KA, Lynn J, Dy SM et al. Evidence for improving palliative care at the end of life: a systematic
review. Ann Intern Med 2008; 148:147-159.
Luce JM, Luce JA. Management of dyspnea in patients with far-advanced lung disease. JAMA 2001;
285:1331-1337.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
331
Measuring What Matters, http://aahpm.org/quality/measuring-what-matters
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality
Palliative Care. 3rd ed. Pittsburgh, PA: Author; 2013.
http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf
PEACE Hospice and Palliative Care Quality Measures,
http://www.med.unc.edu/pcare/resources/PEACE-Quality-Measures
Roberts DK, Thorne SE, Pearson C. Cancer Nurs 1993; 16:310-320.

Original Performance Measure Source / Developer:

Set Measure ID: PAL-04

Performance Measure Name: Treatment Preferences and Goals of Care

Description: Proportion of palliative care patients with medical record documentation of treatment
preferences and goals of care.

Rationale: Seriously ill and dying patients who are given the opportunity to express life-sustaining treatment
preferences are more likely to receive care consistent with their values, and patient and family satisfaction
outcomes improve. Patients and physicians alike hesitate to initiate discussions, while acknowledging their
value and desirability. Use of the Treatment Preferences quality measure will improve attention to this
important practice, in order to enhance patient autonomy, facilitate patient-centered decision-making, and
communicate patient preferences via documentation to other treating providers. Poor communication about
patient preferences has been identified as a major quality concern in palliative and end-of-life care since an
early, comprehensive Institute of Medicine report.(Field et al., 1997; as cited by PEACE) The SUPPORT Study
found marked discrepancies between patient report of treatment preferences and provider awareness of or
use of these preferences to guide treatment.(1995; as cited by PEACE) Patients and families prioritize
communication with providers and control over treatment choices when faced with serious or life-
threatening illness.(Steinhauser et al., 2001; as cited by PEACE) However, physicians and other providers fail
to open the door to these discussions at critical time points in illness progression.(Gysels et al., 2004; as
cited by PEACE) A recent systematic review of communication research found a consistent discrepancy
between the quality and content of communication providers believed they provided, and the quality and
content of communication experienced by seriously ill patients and their families. (Hancock et al., 2007; as
cited by PEACE)

The National Consensus Project for Quality Palliative Care (2013) guidelines recommend that patient or
surrogate’s goals, preferences, and choices be respected and used as the basis for the plan of care within
the limits of laws and standards of care. The palliative care interdisciplinary team discusses achievable
goals with the patient and family using a patient-centered approach that includes the patient values and
preferences and assists with advance care planning documents to communicate patient preferences across
care settings.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients with medical record documentation of treatment preferences and goals of
care.

Included Populations: Not applicable

Excluded Populations: None

Goals of Care
Treatment Preferences

Denominator Statement: Patients receiving specialty palliative care in an acute hospital setting for one (1) or
more days

Included Populations:

Excluded Populations:

Palliative care program length of stay less than one (1) day

Data Elements:

Initial Encounter
Initial Encounter Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the
population of interest. This approach provides opportunities for improvement at the point of care/service.
However, complete documentation includes the principal or other ICD-10CM/PCS diagnosis and procedure
codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10CM/PCS codes; therefore, coding practices
may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

CMS Hospice Item Set, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html
Field MJ, Cassell CK eds. Approaching Death: Improving Care at the End of Life. Washington, DC:
National Academy Press, 1997.
Gysels M, Richardson A, Higginson I. Communication training for health professionals who care for
patients with cancer: a systematic review of effectiveness. Support Care Cancer 2004; 12:692-700.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
335
Hancock K, Clayton JM, Parker SM et al. Discrepant perceptions of end-of-life communication: a
systematic review. J Pain Symptom Manage 2007; 34: 190-200.
Measuring What Matters, http://aahpm.org/quality/measuring-what-matters
PEACE Hospice and Palliative Care Quality Measures,
http://www.med.unc.edu/pcare/resources/PEACE-Quality-Measures
Steinhauser KE, Christakis NA, Clipp EC et al. Preparing for the end of life: references of patients,
families, physicians and other care providers. J Pain Symptom Manage 2001; 22:727-737.
SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized
patients: the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments
(SUPPORT). JAMA 1995; 274:1591-1598.
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality
Palliative Care. 3rd ed. Pittsburgh, PA: Author; 2013.
http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf

Original Performance Measure Source / Developer:

Set Measure ID: PAL-05

Performance Measure Name: Treatment Preferences Discharge Document

Description: Proportion of patients for whom a transition of care document containing information regarding
goals of care and treatment preferences is completed and accompanies the patient to the next level of care
at discharge.

Rationale: Seriously ill and dying patients who are given the opportunity to express life-sustaining treatment
preferences are more likely to receive care consistent with their values, and patient and family satisfaction
outcomes improve. Patients and physicians alike hesitate to initiate discussions, while acknowledging their
value and desirability. According to the PEACE project the use of a Treatment Preferences quality measure
will improve attention to this important practice, in order to enhance patient autonomy, facilitate patient-
centered decision-making, and communicate patient preferences via documentation to other treating
providers. Poor communication about patient preferences has been identified as a major quality concern in
palliative and end-of-life care since an early, comprehensive Institute of Medicine report.(Field et al., 1997; as
cited by PEACE) The SUPPORT Study found marked discrepancies between patient report of treatment
preferences and provider awareness of or use of these preferences to guide treatment.(1995; as cited by
PEACE) Patients and families prioritize communication with providers and control over treatment choices
when faced with serious or life-threatening illness.(Steinhauser et al., 2001; as cited by PEACE) However,
physicians and other providers fail to open the door to these discussions at critical time points in illness
progression.(Gysels et al., 2004; as cited by PEACE) A recent systematic review of communication research
found a consistent discrepancy between the quality and content of communication providers believed they
provided, and the quality and content of communication experienced by seriously ill patients and their
families. (Hancock et al., 2007; as cited by PEACE)

The National Consensus Project for Quality Palliative Care (2013) guidelines recommend that patient’s or
surrogate’s goals, preferences, and choices be respected and used as the basis for the plan of care within
the limits of laws and standards of care. The palliative care interdisciplinary team discusses achievable
goals with the patient and family using a patient-centered approach that includes the patient values and
preferences and assists with advance care planning documents to communicate patient preferences across
care settings

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients for whom a transition of care document containing information regarding
treatment preferences and goals of care is completed and accompanies the patient to the next level of care
at discharge.

Included Populations: Not applicable

Data Elements:

Treatment Preferences Document

Denominator Statement: Patients receiving specialty palliative care in an acute hospital setting for one (1) or
more days

Included Populations:

Excluded Populations:

Patients with discharge disposition of expired or left against medical advice/AMA

Data Elements:

Discharge Disposition
Initial Encounter
Initial Encounter Date

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the
population of interest. This approach provides opportunities for improvement at the point of care/service.
However, complete documentation includes the principal or other ICD-10CM/PCS diagnosis and procedure
codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10CM/PCS codes; therefore, coding practices
may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

CMS Hospice Item Set, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html
Field MJ, Cassell CK eds. Approaching Death: Improving Care at the End of Life. Washington, DC:
National Academy Press, 1997.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
339
Gysels M, Richardson A, Higginson I. Communication training for health professionals who care for
patients with cancer: a systematic review of effectiveness. Support Care Cancer 2004; 12:692-700.
Hancock K, Clayton JM, Parker SM et al. Discrepant perceptions of end-of-life communication: a
systematic review. J Pain Symptom Manage 2007; 34: 190-200.
Measuring What Matters, http://aahpm.org/quality/measuring-what-matters
PEACE Hospice and Palliative Care Quality Measures,
http://www.med.unc.edu/pcare/resources/PEACE-Quality-Measures
Steinhauser KE, Christakis NA, Clipp EC et al. Preparing for the end of life: references of patients,
families, physicians and other care providers. J Pain Symptom Manage 2001; 22:727-737.
SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized
patients: the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments
(SUPPORT). JAMA 1995; 274:1591-1598.
National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality
Palliative Care. 3rd ed. Pittsburgh, PA: Author; 2013.
http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf

Original Performance Measure Source / Developer:

American Academy of Hospice and Palliative Care (AAHPM) and Hospice and Palliative Nurses Association
(HPNA) Measuring What Matters Project Top Ten Measures That Matter List
PEACE Hospice and Palliative Care Quality Measures Set

Set Measures

Set Measure ID Measure Short Name

STK-1 Venous Thromboembolism (VTE Prophylaxis)

STK-10 Assessed for Rehabilitation

STK-2 Discharged on Antithrombotic Therapy

STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter

STK-4 Thrombolytic Therapy

STK-5 Antithrombotic Therapy By End of Hospital Day Two

STK-6 Discharged on Statin Medication

STK-8 Stroke Education

General Data Elements

Element Name Collected For

Admission Date All Records,

Birthdate All Records,

Discharge Date All Records, Not collected for HBIPS-2 and

HBIPS-3

Health Care Organization Identifier All Records, Patient Population Data File,
Hospital Clinical Data File,

Hispanic Ethnicity All Records,

ICD-10-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records

ICD-10-PCS Other Procedure Dates All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File, Used in
calculation of the Joint Commission's
aggregate data and in the transmission of
the Hospital Clinical Data file.

Payment Source All Records, Optional for HBIPS-2 and

HBIPS-3

Race All Records,

Sex All Records,

Algorithm Output Data Elements

Element Name Collected For

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name Collected For

Anticoagulation Therapy Prescribed at Discharge STK-3

Antithrombotic Therapy Administered by End of Hospital Day 2 STK-5

Antithrombotic Therapy Prescribed at Discharge STK-2

Arrival Date STK-4, STK-5

Arrival Time STK-4

Assessed for Rehabilitation Services STK-10

Atrial Fibrillation/Flutter STK-3

Clinical Trial STK

Comfort Measures Only STK-1, STK-10, STK-2, STK-3, STK-5, STK-6,

STK-8

Date Last Known Well STK-4

Discharge Disposition STK-10, STK-2, STK-3, STK-6, STK-8

ED Patient STK-4

Education Addresses Activation of Emergency Medical System STK-8

Education Addresses Follow-up After Discharge STK-8

Education Addresses Medication Prescribed at Discharge STK-8

Education Addresses Risk Factors for Stroke STK-8

Education Addresses Warning Signs and Symptoms of Stroke STK-8

Elective Carotid Intervention STK

IV Alteplase Initiation STK-4

IV Alteplase Initiation Date STK-4

IV Alteplase Initiation Time STK-4

IV OR IA Alteplase Administered at This Hospital or Within 24 STK-5

Hours Prior to Arrival

Last Known Well STK-4

Reason for Extending the Initiation of IV Alteplase STK-4

Reason for No VTE Prophylaxis – Hospital Admission STK-1

Reason for Not Administering Antithrombotic Therapy by End of STK-5

Hospital Day 2

Reason for Not Initiating IV Alteplase STK-4

Reason for Not Prescribing Anticoagulation Therapy at Discharge STK-3

Reason for Not Prescribing Antithrombotic Therapy at Discharge STK-2

Reason for Not Prescribing Statin Medication at Discharge STK-6

Reason for Oral Factor Xa Inhibitor STK-1

Statin Medication Prescribed at Discharge STK-6

Time Last Known Well STK-4

VTE Prophylaxis STK-1

VTE Prophylaxis Date STK-1

Related Materials

Document Name

Acknowledgement

Appendix A - Code Tables

Appendix C - Medication Tables

Appendix D - Glossary of Terms

Appendix E - Overview of Measure Information Form and Flowchart Formats

Appendix G - Resources

Appendix H - Miscellaneous Tables

Cover Page for the Joint Commission Manual

Data Dictionary

Introduction to the Manual

Missing and Invalid Data

Sampling

Table of Contents

Transmission Alpha Data Dictionary

Transmission Data Processing Flow: Clinical

Transmission Data Processing Flow: Population and Sampling

Transmission of Data

Using the The Joint Commission's National Measure Specifications Manual

Stroke (STK) Initial Patient Population

The STK measure set is unique in that there are two distinct Initial Patient Populations (or sub-populations)
within the measure set, each identified by a specific group of diagnosis codes, or lack thereof. The patients
in each sub-population are counted in the Initial Patient Population of multiple measures. Hospitals utilizing
STK for Joint Commission certification purposes will be required to use both the Ischemic and Hemorrhagic
sub-populations.

The population of the STK measure set is identified using 4 data elements:

ICD-10-CM Principal Diagnosis Code

Admission Date
Birthdate
Discharge Date

Measures Initial Patient Population definition

STK-2, 3, 4, 5, and 6 The count of all patients in sub-population 1

STK-1, 8, and 10 The count of all patients in sub-population 1 and 2

STK-1, 2, 3, 4, 5, 6, 8 and 10 are used for TJC Certification program.

Patients admitted to the hospital for inpatient acute care are included in one of the STK ICD sub-populations
and are eligible to be sampled if they have:

1 – Ischemic sub-population – Patients with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1, a Patient Age (Admission Date minus Birthdate) greater than or equal to 18
years and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days are
included in the STK Initial Patient Population and are eligible to be sampled.

2 – Hemorrhagic sub-population – Patients with an ICD-10-CM Principal Diagnosis Code for hemorrhagic
stroke as defined in Appendix A, Table 8.2, a Patient Age (Admission Date minus Birthdate) greater than or
equal to 18 years and a Length of Stay (Discharge Date minus Admission Date) less than or equal to 120
days are included in the STK Initial Patient Population and are eligible to be sampled.

NOTE: For Joint Commission certification purposes, hospitals will be abstracting and submitting data on all
measures in the STK set; therefore, both sub-population 1 (Ischemic patients) and 2 (Hemorrhagic patients)
will be identified by the STK Initial Patient Population to be eligible for sampling.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
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Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
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347
Stroke (STK) Initial Patient Population Algorithm Narrative

Variable Key: Patient Age, Initial Patient Population Reject Case Flag, and Length of Stay.

1. Start STK Initial Patient Population logic sub-routine. Process all cases that have successfully
reached the point in the Transmission Data Processing Flow: Clinical which calls this Initial Patient
Population Algorithm. Do not process cases that have been rejected before this point in the
Transmission Data Processing Flow: Clinical.
2. Calculate Patient Age. Patient Age, in years, is equal to the Admission Date minus the Birthdate. Use
the month and day portion of admission date and birthdate to yield the most accurate age.
3. Check Patient Age:
a. 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. Set the Initial Patient Population
Reject Case Flag to equal Yes. Return to Transmission Data Processing Flow: Clinical in the
Data Transmission section.
b. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to
Length of Stay Calculation.
4. Calculate the Length of Stay. Length of Stay, in days, is equal to the Discharge Date minus the
Admission Date.
5. Check Length of Stay:
a. 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. Set the Initial Patient
Population Reject Case Flag to equal Yes. Return to Transmission Data Processing Flow:
Clinical in the Data Transmission section.
b. If the Length of Stay is less than or equal to 120 days, continue processing and proceed to ICD-
10-CM Principal Diagnosis Code Check.
6. Check ICD-10-CM Principal Diagnosis Code
a. 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. Set the
Initial Patient Population Reject Case Flag to equal No. Include the patient in the Initial Patient
Population for the appropriate measures. Return to Transmission Data Processing Flow:
Clinical in the Data Transmission section.
b. For Joint Commission Only, if submitting data for STK Certification Program: If the ICD-10-CM
Principal Diagnosis Code is on Table 8.2, the patient is in the second Hemorrhagic Stroke sub-
population and is eligible to be sampled for the second STK sub-population. Set the Initial
Patient Population Reject Case Flag to equal No. Include the patient in the Initial Patient
Population for the appropriate measures. Return to Transmission Data Processing Flow:
Clinical in the Data Transmission section.

STK Sample Size Requirements

Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may
choose to use a larger sample size than is required.

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. Hospitals utilizing this measure set with the Joint

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
348
Commission for certification purposes and have five or fewer discharges for the two combined STK sub-
populations (both Medicare and non-Medicare combined) in a quarter are not required to submit STK patient
level data to the Joint Commission’s Data Warehouse.

Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures
consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample cases
MUST submit AT LEAST the minimum required sample size.

Quarterly Sampling

A modified sampling procedure is required for hospitals performing quarterly sampling for STK. The measure
set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. The
two sub-populations must be sampled independently from each other.

Joint Commission certification purposes: To determine if a hospital may choose to not submit STK patient
level data, the count of the discharges, for the quarter, for the two sub-populations must be five or less (i.e.,
the combined count of discharges equals the count of all patients in the Ischemic Patient Sub-population [1]
plus the count of all patients in the Hemorrhagic Patient Sub-population [2].

1.Hospitals selecting sample cases for the Ischemic sub-population must ensure that its Initial Patient
Population and sample size for the Ischemic sub-population meets the following conditions:

Quarterly Sample Size

Based on Initial Patient Population Size
for Ischemic Patient Sub-Population
Hospital’s Measure

Average Quarterly Minimum Required

Initial Patient Population Sample Size
“N” “n”

≥ 900 180

226-899 20% of the Initial Patient Population

45-225 45

6 - 44 No sampling; 100% of the Initial Patient Population is required

0-5 Submission of patient level data is not required;

if submission occurs, 100% Initial Patient Population required.

2.Hospitals submitting STK data for Joint Commission certification purposes will select sample cases for
the Hemorrhagic sub-population, ensuring that its Initial Patient Population and sample size for the

Quarterly Sample Size

Based on Initial Patient Population Size
for Hemorrhagic Patient Sub-Population
Hospital’s Measure

Average Quarterly Minimum Required

Initial Patient Population Sample Size
“N” “n”

≥ 900 180

226-899 20% of the Initial Patient Population

45-225 45

6 - 44 No sampling; 100% of the Initial Patient Population is required

0-5 Submission of patient level data is not required;

if submission occurs, 100% Initial Patient Population required.

Monthly Sampling A modified sampling procedure is required for hospitals performing monthly sampling for
STK. The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic
STK patients. The two sub-populations must be sampled independently from each other.

1. Hospitals selecting sample cases for the Ischemic sub-population must ensure that its Initial Patient
Population and sample size for the Ischemic sub-population meets the following conditions:

Monthly Sample Size

Based on Initial Patient Population Size
for Ischemic Patient Sub-Population
Hospital’s Measure

Average Monthly Minimum Required

Initial Patient Population Sample Size
“N” “n”

≥ 300 60

76-299 20% of the Initial Patient Population

15-75 15

< 15 No sampling; 100% Initial Patient Population required

2. Hospitals submitting STK data for Joint Commission certification purposes will select sample cases for
the Hemorrhagic sub-population, ensuring that its Initial Patient Population and sample size for the
Hemorrhagic sub-population meets the following conditions:

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
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350
Monthly Sample Size
Based on Initial Patient Population Size
for Hemorrhagic Patient Sub-Population
Hospital’s Measure

Average Monthly Minimum Required

Initial Patient Population Sample Size
“N” “n”

≥ 300 60

76-299 20% of the Initial Patient Population

15-75 15

< 15 No sampling; 100% Initial Patient Population required

Sample Size Examples

Note: Hospitals utilizing STK for Joint Commission certification purposes must include all sampled STK sub-
populations in the calculation of all STK measures. All of the STK measures’ specific exclusion criteria are
used to filter out cases that do not belong in the measure denominator.

Quarterly sampling

Quarterly sampling for the Ischemic sub-population:

A hospital’s Ischemic sub-population is 392 during the first quarter. 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)
A hospital’s Ischemic sub-population is 100 during the first quarter. The required quarterly
sample is 45 cases.
If the hospital chooses to submit patient level data: A hospital’s Ischemic sub-population is 5
patients during the first quarter. 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.
Quarterly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes:
A hospital’s Hemorrhagic sub-population is 392 during the first quarter. Using the quarterly
sampling table for the Hemorrhagic 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).
A hospital’s Hemorrhagic sub-population is 3 patients during the first quarter. 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.
A hospital’s Hemorrhagic sub-population is 100 during the first quarter. The required quarterly
sample is 45 cases.
Quarterly sampling for the two combined populations for Joint Commission certification purposes.
The STK Initial Patient Population sizes for a hospital are 392 and 5 patients respectively per
the sub-populations for the quarter. Since the total Initial Patient Population for STK is 397, the

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351
hospital must submit patient level data. The required quarterly sample sizes for each sub-
population would be 79 and 5.
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).
The Hemorrhagic sub-population is less than the minimum required quarterly sample
size, so 100% of this sub-population is sampled.
The STK Initial Patient Population sizes for a hospital are 1 and 3 patients respectively per the
sub-populations for the quarter. Since the total Initial Patient Population for STK is 4, the
hospital may choose to not submit patient level data. If the hospital chooses to submit patient
level data:
The Joint Commission: the required quarterly sample size would be 100% of the patient
population or 4 cases for the quarter.

Monthly Sampling

Monthly sampling for the Ischemic sub-population:

A hospital’s Ischemic sub-population is 228 during March. 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).
A hospital’s Ischemic sub-population is 316 during January. The required quarterly sample is
60 cases.
A hospital’s Ischemic sub-population is 5 patients during February. 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.
Monthly sampling for the Hemorrhagic sub-population for Joint Commission certification purposes:
A hospital’s Hemorrhagic sub-population is 228 during March. 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).
A hospital’s Hemorrhagic sub-population is 3 patients during January. 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.
A hospital’s Hemorrhagic sub-population is 316 during February. The required monthly sample
is 60 cases.

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-1

Performance Measure Name: Venous Thromboembolism (VTE Prophylaxis)

Description: Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation
why no VTE prophylaxis was given the day of or the day after hospital admission

Rationale: Stroke patients are at increased risk of developing venous thromboembolism (VTE). One study
noted proximal deep vein thrombosis in more than a third of patients with moderately severe stroke.
Reported rates of occurrence vary depending on the type of screening used. Prevention of VTE, through the
use of prophylactic therapies, in at risk patients is a noted recommendation in numerous clinical practice
guidelines. For acutely ill stroke patients who are confined to bed, thromboprophylaxis with low-molecular-
weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux is recommended if there
are no contraindications. Aspirin alone is not recommended as an agent to prevent VTE.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have
documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Reason for No VTE Prophylaxis – Hospital Admission

Reason for Oral Factor Xa Inhibitor
VTE Prophylaxis
VTE Prophylaxis Date

Denominator Statement: Ischemic or hemorrhagic stroke patients

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic or
hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2.

Excluded Populations:

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353
Patients less than 18 years of age
Patients who have a Length of Stay less than 2 days
Patients who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented on day of or day after hospital arrival
Patients enrolled in clinical trials
Patients admitted for Elective Carotid Intervention

Data Elements:

Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Adams, H.P., G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, et al. "Guidelines
for the Early Management of Adults with Ischemic Stroke: A Guideline from the American Heart
Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular
Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality
of Care Outcomes in Research Interdisciplinary Working Groups." Stroke 38 (2007): 1655-711.
Albers, G. W, P Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke." Chest 119 (2001): 300-20.
Caprini, J. A., and J. I. Arcelus. "State-of the Art Venous Thromboembolism Prophylaxis." SCOPE on
Phlebology & Lymphology 1 (2005): 228-40.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
354
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Coull, B. M., L. S. Williams, L. B. Goldstein, J. F. Meschia, D. Heitzman, S. Chaturvedi, K. C. Johnston, et
al. "Anticoagulants and Antiplatelet Agents in Acute Ischemic Stroke: Report of the Joint Stroke
Guideline Development Committee of the American Academy of Neurology and the American Stroke
Association (a Division of the American Heart Association)." [In eng]. Stroke 33, no. 7 (Jul 2002): 1934-
42.
Desmukh, M., M. Bisignami, P. Landau, and T. J. Orchard. "Deep Vein Thrombosis in Rehabilitating
Stroke Patients: Incidence, Risk Factors and Prophylaxis." American Journal Physical Medicine
Rehabilitation 70 (1991): 313-16.
Duncan, P. W., R. Zorowitz, B. Bates, J. Y. Choi, J. J. Glasberg, G. D. Graham, R. C. Katz, K. Lamberty,
and D. Reker. "Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline." [In eng].
Stroke 36, no. 9 (Sep 2005): e100-43.
Geerts, W. H., D. Bergqvist, G. F. Pineo, J. A. Heit, C. M. Samama, M. R. Lassen, C. W. Colwell, and
Physicians American College of Chest. "Prevention of Venous Thromboembolism: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)." [In eng]. Chest 133, no. 6
Suppl (Jun 2008): 381S-453S.
Geerts, W. H., J. A. Heit, G. P. Clagett, G. F. Pineo, C. W. Colwell, F. A. Anderson, Jr., and H. B. Wheeler.
"Prevention of Venous Thromboembolism." [In eng]. Chest 119, no. 1 Suppl (Jan 2001): 132S-75S.
Geerts, W. H., G. F. Pineo, J. A. Heit, D. Bergqvist, M. R. Lassen, C. W. Colwell, and J. G. Ray. "Prevention
of Venous Thromboembolism: The Seventh Accp Conference on Antithrombotic and Thrombolytic
Therapy." [In eng]. Chest 126, no. 3 Suppl (Sep 2004): 338S-400S.
Gresham, G. E., P. W. Duncan, W. B. Stason, H. P. Adams, A. M. Adelman, D. N. Alexander, D. S. Bishop et
al. "Post-stroke rehabilitation. Clinical practice guideline, no. 16. Rockville, MD: US Department of
Health and Human Services." Public Health Service, Agency for Health Care Policy and Research
(1995): 95-0062.
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of
Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.
Heit, J. A. "The Epidemiology of Venous Thromboembolism in the Community." [In eng]. Arterioscler
Thromb Vasc Biol 28, no. 3 (Mar 2008): 370-2.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Kase, C. S., G. W. Albers, C. Bladin, C. Fieschi, A. A. Gabbai, W. O'Riordan, G. F. Pineo, and Prevail
Investigators. "Neurological Outcomes in Patients with Ischemic Stroke Receiving Enoxaparin or
Heparin for Venous Thromboembolism Prophylaxis: Subanalysis of the Prevention of Vte after Acute
Ischemic Stroke with Lmwh (Prevail) Study." [In eng]. Stroke 40, no. 11 (Nov 2009): 3532-40.
Kase, C. S., and G. F. Pineo. "Prevention of Venous Thromboembolism after Ischemic Stroke." [In eng].
Curr Opin Pulm Med 14, no. 5 (Sep 2008): 389-96.
Kelly, J., A. Rudd, R. Lewis, and B. J. Hunt. "Venous Thromboembolism after Acute Stroke." [In eng].
Stroke 32, no. 1 (Jan 2001): 262-7.

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Kelly, J., A. Rudd, R. R. Lewis, C. Coshall, A. Moody, and B. J. Hunt. "Venous Thromboembolism after
Acute Ischemic Stroke: A Prospective Study Using Magnetic Resonance Direct Thrombus Imaging." [In
eng]. Stroke 35, no. 10 (Oct 2004): 2320-5.
Kucher, N., S. Koo, R. Quiroz, J. M. Cooper, M. D. Paterno, B. Soukonnikov, and S. Z. Goldhaber.
"Electronic Alerts to Prevent Venous Thromboembolism among Hospitalized Patients." [In eng]. N Engl
J Med 352, no. 10 (Mar 10 2005): 969-77.
"Making Healthcare Safer: A Critical Analysis of Patient Safety Practices.". In Evidence
Report/Technology Assessment # 43. Rockville, MD: Agency for Healthcare Research and Quality, July
2001.
Michota, F. A. "Venous Thromboembolism Prophylaxis in Medical Patients." [In eng]. Curr Opin Cardiol
19, no. 6 (Nov 2004): 570-4.
Naccarato, M., F. Chiodo Grandi, M. Dennis, and P. A. Sandercock. "Physical Methods for Preventing
Deep Vein Thrombosis in Stroke." [In eng]. Cochrane Database Syst Rev, no. 8 (2010): CD001922.
National Heart, Lung, and Blood Institute, and National Institutes of Health. "Stroke Belt Initiative:
Project Accomplishments and Lessons Learned." (1996).
Pineo, G., J. Lin, L. Stern, T. Subrahmanian, and L. Annemans. "Economic Impact of Enoxaparin Versus
Unfractionated Heparin for Venous Thromboembolism Prophylaxis in Patients with Acute Ischemic
Stroke: A Hospital Perspective of the Prevail Trial." [In eng]. J Hosp Med 7, no. 3 (Mar 2012): 176-82.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e37-e38.
Qaseem A., R. Chou, L. L. Humphrey, M. Starkey, P. Shekelle. “Clinical Guidelines Committee of the
American College of Physicians. Venous Thromboembolism Prophylaxis In Hospitalized Patients: A
Clinical Practice Guideline from the American College of Physicians.” [In eng]. Ann Intern Med 155, no.
9 (Nov 2011): 625-32.
Raskob, G. E., R. Silverstein, D. W. Bratzler, J. A. Heit, and R. H. White. "Surveillance for Deep Vein
Thrombosis and Pulmonary Embolism: Recommendations from a National Workshop." [In eng]. Am J
Prev Med 38, no. 4 Suppl (Apr 2010): S502-9.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Sacco, R. L., R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, et al. "Guidelines
for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: A Statement
for Healthcare Professionals from the American Heart Association/American Stroke Association
Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The
American Academy of Neurology Affirms the Value of This Guideline." [In eng]. Stroke 37, no. 2 (Feb
2006): 577-617.
Sandercock, P. A., C. Counsell, and M. C. Tseng. "Low-Molecular-Weight Heparins or Heparinoids
Versus Standard Unfractionated Heparin for Acute Ischaemic Stroke ". Cochrane Database Syst Rev,
no. 3 (2011): CD000119.
Stein, P. D., and F. Matta. "Epidemiology and Incidence: The Scope of the Problem and Risk Factors for
Development of Venous Thromboembolism." [In eng]. Clin Chest Med 31, no. 4 (Dec 2010): 611-28.
Vergouwen, M. D., Y. B. Roos, and P. W. Kamphuisen. "Venous Thromboembolism Prophylaxis and
Treatment in Patients with Acute Stroke and Traumatic Brain Injury." [In eng]. Curr Opin Crit Care 14,
no. 2 (Apr 2008): 149-55.

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Warlow, C., D. Ogston, and A. S. Douglas. "Deep Venous Thrombosis of the Legs after Strokes. Part I--
Incidence and Predisposing Factors." [In eng]. Br Med J 1, no. 6019 (May 15 1976): 1178-81.
Wijdicks, E. F., and J. P. Scott. "Pulmonary Embolism Associated with Acute Stroke." [In eng]. Mayo Clin
Proc 72, no. 4 (Apr 1997): 297-300.

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-10

Performance Measure Name: Assessed for Rehabilitation

Description: Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.

Rationale: Each year about 700,000 people experience a new or recurrent stroke, which is the nation's third
leading cause of death. Approximately two thirds of these individuals survive and require rehabilitation.
Stroke is a leading cause of serious, long-term disability in the United States, with about 4.4 million stroke
survivors alive today. Forty percent of stroke patients are left with moderate functional impairment and 15 to
30 percent with severe disability. More than 60% of those who have experienced stroke, serious injury, or a
disabling disease have never received rehabilitation. Stroke rehabilitation should begin as soon as the
diagnosis of stroke is established and life-threatening problems are under control. Among the high priorities
for stroke are to mobilize the patient and encourage resumption of self-care activities as soon as possible. A
considerable body of evidence indicates better clinical outcomes when patients with stroke are treated in a
setting that provides coordinated, multidisciplinary stroke-related evaluation and services. Effective
rehabilitation interventions initiated early following stroke can enhance the recovery process and minimize
functional disability. The primary goal of rehabilitation is to prevent complications, minimize impairments,
and maximize function.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic or hemorrhagic stroke patients assessed for or who received rehabilitation
services.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Assessed for Rehabilitation Services

Denominator Statement: Ischemic or hemorrhagic stroke patients.

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic or
hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2.

Patients less than 18 years of age

Patients who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented
Patients enrolled in clinical trials
Patients admitted for Elective Carotid Intervention
Patients discharged to another hospital
Patients who left against medical advice
Patients who expired
Patients discharged to home for hospice care
Patients discharged to a health care facility for hospice care

Data Elements:

Admission Date
Birthdate
Clinical Trial
Discharge Date
Discharge Disposition
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Bates, B., J. Y. Choi, P. W. Duncan, J. J. Glasberg, G. D. Graham, R. C. Katz, K. Lamberty, et al. "Veterans
Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke
Rehabilitation Care: Executive Summary." [In eng]. Stroke 36, no. 9 (Sep 2005): 2049-56.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
361
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Duncan, P. W., R. Zorowitz, B. Bates, J. Y. Choi, J. J. Glasberg, G. D. Graham, R. C. Katz, K. Lamberty,
and D. Reker. "Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline." [In eng].
Stroke 36, no. 9 (Sep 2005): e100-43.
Foley, N., R. Teasell, S. Bhogal, and M. Speechley. "The Efficacy of Stroke Rehabilitation." In, (2011): 1-
50.
http://www.ebrsr.com/evidence-review/5-efficacy-stroke-rehabilitation
Gresham, G. E., P. W. Duncan, W. B. Stason, H. P. Adams, A. M. Adelman, D. N. Alexander, D. S. Bishop et
al. "Post-stroke rehabilitation. Clinical practice guideline, no. 16. Rockville, MD: US Department of
Health and Human Services." Public Health Service, Agency for Health Care Policy and Research
(1995): 95-0062.
Kalra, L., A. Evans, I. Perez, M. Knapp, C. Swift, and N. Donaldson. "A Randomised Controlled
Comparison of Alternative Strategies in Stroke Care." [In eng]. Health Technol Assess 9, no. 18 (May
2005): iii-iv, 1-79.
Keith, R. A. "Rehabilitation after Stroke: Cost-Effectiveness Analyses." [In eng]. J R Soc Med 89, no. 11
(Nov 1996): 631-3.
Langhorne, P., B. O. Williams, W. Gilchrist, and K. Howie. "Do Stroke Units Save Lives?" [In eng]. Lancet
342, no. 8868 (Aug 14 1993): 395-8.
"Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications,
and Discharge Planning. A National Clinical Guideline." In, (2002).
http://www.nhsggc.org.uk/content/mediaassets/pdf/HSD/sign64.pdf.
Management of Stroke Rehabilitation Working Group. VA/DoD clinical practice guideline for the
management of stroke rehabilitation. Washington (DC): Veterans Health Administration, Department
of Defense; 2010.
Moodie, M., D. Cadilhac, D. Pearce, C. Mihalopoulos, R. Carter, S. Davis, G. Donnan, and Scopes Study
Group. "Economic Evaluation of Australian Stroke Services: A Prospective, Multicenter Study
Comparing Dedicated Stroke Units with Other Care Modalities." [In eng]. Stroke 37, no. 11 (Nov 2006):
2790-5.
Noorani, H. Z., B. Brady, L. McGahan, R. Teasell, B. Skidmore, and T. J. Doherty. "Stroke Rehabilitation
Services: Systematic Reviews of the Clinical and Economic Evidence." In Ottawa: Canadian
Coordinating, Office for Health Technology Assessment, 2003.
Ottenbacher, K. J., and S. Jannell. "The Results of Clinical Trials in Stroke Rehabilitation Research." [In
eng]. Arch Neurol 50, no. 1 (Jan 1993): 37-44.
"Outcomes in Stroke Rehabilitation." Topics in Stroke Rehabilitation 12, no. 4 (Fall 2005): 1-10, 11-19,
20-27, 28-36, 37-49.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e39.
"Rehabilitation Helps Stroke Patients Recover Skills ". American Academy of Physical Medicine and
Rehabilitation, http://www.aapmr.org/patients/conditions/neurologic/Pages/recover.aspx.
Saka, O., V. Serra, Y. Samyshkin, A. McGuire, and C. C. Wolfe. "Cost-Effectiveness of Stroke Unit Care
Followed by Early Supported Discharge." [In eng]. Stroke 40, no. 1 (Jan 2009): 24-9.

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Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
362
Stroke, National Institute of Neurological Disorders and. "Post-Stroke Rehabilitation Fact Sheet."
http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm.
"Urgency Key but Perseverance Pays Off." American Academy of Physical Medicine and
Rehabilitation. http://www.zoominfo.com/CachedPage/?
archive_id=0&page_id=389260562&page_url=//www.aapmr.org/condtreat/rehab/strokeusa.htm&page_
07-28T02:27:25&firstName=Charles&lastName=Levy

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-2

Performance Measure Name: Discharged on Antithrombotic Therapy

Description: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge

Rationale: The effectiveness of antithrombotic agents in reducing stroke mortality, stroke-related morbidity
and recurrence rates has been studied in several large clinical trials. While the use of these agents for
patients with acute ischemic stroke and transient ischemic attacks continues to be the subject of study,
substantial evidence is available from completed studies. Data at this time suggest that antithrombotic
therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and
morbidity as long as no contraindications exist.

Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to

prevent recurrent ischemic stroke or TIA.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Antithrombotic Therapy Prescribed at Discharge

Denominator Statement: Ischemic stroke patients.

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1.

Patients less than 18 years of age

Data Elements:

Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
Discharge Disposition
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code
Reason for Not Prescribing Antithrombotic Therapy at Discharge

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

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Adams, H., R. Adams, G. Del Zoppo, L. B. Goldstein, Association Stroke Council of the American Heart,
and Association American Stroke. "Guidelines for the Early Management of Patients with Ischemic
Stroke: 2005 Guidelines Update a Scientific Statement from the Stroke Council of the American Heart
Association/American Stroke Association." [In eng]. Stroke 36, no. 4 (Apr 2005): 916-23.
Adams, H. P., Jr., G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, et al.
"Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline from the American
Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council,
Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular
Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American
Academy of Neurology Affirms the Value of This Guideline as an Educational Tool for Neurologists."
[In eng]. Stroke 38, no. 5 (May 2007): 1655-711.
Albers, G. W, P Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke." Chest 119 (2001): 300-20.
Albers, G. W., P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke: The Seventh Accp Conference on Antithrombotic and Thrombolytic
Therapy." [In eng]. Chest 126, no. 3 Suppl (Sep 2004): 483S-512S.
Antithrombotic Trialists, Collaboration. "Collaborative Meta-Analysis of Randomised Trials of
Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients."
[In eng]. BMJ 324, no. 7329 (Jan 12 2002): 71-86.
Bhatt, D. L., K. A. Fox, W. Hacke, P. B. Berger, H. R. Black, W. E. Boden, P. Cacoub, et al. "Clopidogrel and
Aspirin Versus Aspirin Alone for the Prevention of Atherothrombotic Events." [In eng]. N Engl J Med
354, no. 16 (Apr 20 2006): 1706-17.
Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S.
Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association
(NSA) (2000).
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Chen, Z. M., P. Sandercock, H. C. Pan, C. Counsell, R. Collins, L. S. Liu, J. X. Xie, C. Warlow, and R. Peto.
"Indications for Early Aspirin Use in Acute Ischemic Stroke : A Combined Analysis of 40 000
Randomized Patients from the Chinese Acute Stroke Trial and the International Stroke Trial. On Behalf
of the Cast and Ist Collaborative Groups." [In eng]. Stroke 31, no. 6 (Jun 2000): 1240-9.
"Collaborative Overview of Randomised Trials of Antiplatelet Therapy--I: Prevention of Death,
Myocardial Infarction, and Stroke by Prolonged Antiplatelet Therapy in Various Categories of Patients.
Antiplatelet Trialists' Collaboration." [In eng]. BMJ 308, no. 6921 (Jan 8 1994): 81-106.
Committee, Caprie Steering. "A Randomised, Blinded, Trial of Clopidogrel Versus Aspirin in Patients at
Risk of Ischaemic Events (Caprie). Caprie Steering Committee." [In eng]. Lancet 348, no. 9038 (Nov 16
1996): 1329-39.
"A Comparison of Two Doses of Aspirin (30 Mg Vs. 283 Mg a Day) in Patients after a Transient
Ischemic Attack or Minor Ischemic Stroke. The Dutch Tia Trial Study Group." [In eng]. N Engl J Med
325, no. 18 (Oct 31 1991): 1261-6.
Coull, B. M., L. S. Williams, L. B. Goldstein, J. F. Meschia, D. Heitzman, S. Chaturvedi, K. C. Johnston, et
al. "Anticoagulants and Antiplatelet Agents in Acute Ischemic Stroke: Report of the Joint Stroke
Guideline Development Committee of the American Academy of Neurology and the American Stroke
Association (a Division of the American Heart Association)." [In eng]. Stroke 33, no. 7 (Jul 2002): 1934-
42.

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Diener, H. C., J. Bogousslavsky, L. M. Brass, C. Cimminiello, L. Csiba, M. Kaste, D. Leys, et al. "Aspirin
and Clopidogrel Compared with Clopidogrel Alone after Recent Ischaemic Stroke or Transient
Ischaemic Attack in High-Risk Patients (Match): Randomised, Double-Blind, Placebo-Controlled Trial."
[In eng]. Lancet 364, no. 9431 (Jul 24-30 2004): 331-7.
Eccles, M., N. Freemantle, and J. Mason. "North of England Evidence Based Guideline Development
Project: Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in Primary
Care. North of England Aspirin Guideline Development Group." [In eng]. BMJ 316, no. 7140 (Apr 25
1998): 1303-9.
"The European Stroke Prevention Study (Esps). Principal End-Points. The Esps Group." [In eng]. Lancet
2, no. 8572 (Dec 12 1987): 1351-4.
Farrell, B., J. Godwin, S. Richards, and C. Warlow. "The United Kingdom Transient Ischaemic Attack
(Uk-Tia) Aspirin Trial: Final Results." [In eng]. J Neurol Neurosurg Psychiatry 54, no. 12 (Dec 1991):
1044-54.
Gaspoz, J. M., P. G. Coxson, P. A. Goldman, L. W. Williams, K. M. Kuntz, M. G. Hunink, and L. Goldman.
"Cost Effectiveness of Aspirin, Clopidogrel, or Both for Secondary Prevention of Coronary Heart
Disease." [In eng]. N Engl J Med 346, no. 23 (Jun 6 2002): 1800-6.
Gent, M., J. A. Blakely, J. D. Easton, D. J. Ellis, V. C. Hachinski, J. W. Harbison, E. Panak, et al. "The
Canadian American Ticlopidine Study (Cats) in Thromboembolic Stroke." [In eng]. Lancet 1, no. 8649
(Jun 3 1989): 1215-20.
Gorelick, P. B., D. Richardson, M. Kelly, S. Ruland, E. Hung, Y. Harris, S. Kittner, S. Leurgans, and
Investigators African American Antiplatelet Stroke Prevention Study. "Aspirin and Ticlopidine for
Prevention of Recurrent Stroke in Black Patients: A Randomized Trial." [In eng]. JAMA 289, no. 22 (Jun
11 2003): 2947-57.
Group, Esprit Study, P. H. Halkes, J. van Gijn, L. J. Kappelle, P. J. Koudstaal, and A. Algra. "Aspirin Plus
Dipyridamole Versus Aspirin Alone after Cerebral Ischaemia of Arterial Origin (Esprit): Randomised
Controlled Trial." [In eng]. Lancet 367, no. 9523 (May 20 2006): 1665-73.
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of
Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.
Guyatt, G., H. Schunemann, D. Cook, R. Jaeschke, S. Pauker, H. Bucher, and Physicians American
College of Chest. "Grades of Recommendation for Antithrombotic Agents." [In eng]. Chest 119, no. 1
Suppl (Jan 2001): 3S-7S.
Hass, W. K., J. D. Easton, H. P. Adams, Jr., W. Pryse-Phillips, B. A. Molony, S. Anderson, and B. Kamm.
"A Randomized Trial Comparing Ticlopidine Hydrochloride with Aspirin for the Prevention of Stroke in
High-Risk Patients. Ticlopidine Aspirin Stroke Study Group." [In eng]. N Engl J Med 321, no. 8 (Aug 24
1989): 501-7.
"The International Stroke Trial (Ist): A Randomised Trial of Aspirin, Subcutaneous Heparin, Both, or
Neither among 19435 Patients with Acute Ischaemic Stroke. International Stroke Trial Collaborative
Group." [In eng]. Lancet 349, no. 9065 (May 31 1997): 1569-81.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Johnson, E. S., S. F. Lanes, C. E. Wentworth, 3rd, M. H. Satterfield, B. L. Abebe, and L. W. Dicker. "A
Metaregression Analysis of the Dose-Response Effect of Aspirin on Stroke." [In eng]. Arch Intern Med

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Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
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159, no. 11 (Jun 14 1999): 1248-53.
Kennedy, J., M. D. Hill, K. J. Ryckborst, M. Eliasziw, A. M. Demchuk, A. M. Buchan, and Faster
Investigators. "Fast Assessment of Stroke and Transient Ischaemic Attack to Prevent Early
Recurrence (Faster): A Randomised Controlled Pilot Trial." [In eng]. Lancet Neurol 6, no. 11 (Nov 2007):
961-9.
Kernan, W.N., B. Ovbiagele, H. R. Black, D. M. Bravata, M. I. Chimowitz, M. D. Ezekowitz, M. C. Fang, M.
Fisher, K. L. Furie, D. V. Heck, S. C. Johnston, S. E. Kasner, S. J. Kittner, P. H. Mitchell, M. W. Rich, D.
Richardson, L. H. Schwamm, J. A. Wilson. “Guidelines for the Prevention of Stroke in Patients with
Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American
Heart Association/American Stroke Association.” [in eng.] Stroke 45, no. 7 (May 2014): 2160-223.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e45-e46.
"A Randomized Trial of Aspirin and Sulfinpyrazone in Threatened Stroke. The Canadian Cooperative
Study Group." [In eng]. N Engl J Med 299, no. 2 (Jul 13 1978): 53-9.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Sacco, R. L., H. C. Diener, S. Yusuf, D. Cotton, S. Ounpuu, W. A. Lawton, Y. Palesch, et al. "Aspirin and
Extended-Release Dipyridamole Versus Clopidogrel for Recurrent Stroke." [In eng]. N Engl J Med 359,
no. 12 (Sep 18 2008): 1238-51.
"Swedish Aspirin Low-Dose Trial (Salt) of 75 Mg Aspirin as Secondary Prophylaxis after
Cerebrovascular Ischaemic Events. The Salt Collaborative Group." [In eng]. Lancet 338, no. 8779 (Nov
30 1991): 1345-9.
"United Kingdom Transient Ischaemic Attack (Uk-Tia) Aspirin Trial: Interim Results. Uk-Tia Study
Group." [In eng]. Br Med J (Clin Res Ed) 296, no. 6618 (Jan 30 1988): 316-20.

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-3

Performance Measure Name: Anticoagulation Therapy for Atrial Fibrillation/Flutter

Description: Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation
therapy at hospital discharge.

Rationale: Nonvalvular atrial fibrillation (NVAF) is a common arrhythmia and an important risk factor for
stroke. It is one of several conditions and lifestyle factors that have been identified as risk factors for stroke.
It has been estimated that over 2 million adults in the United States have NVAF. While the median age of
patients with atrial fibrillation is 75 years, the incidence increases with advancing age. For example, The
Framingham Heart Study noted a dramatic increase in stroke risk associated with atrial fibrillation with
advancing age, from 1.5% for those 50 to 59 years of age to 23.5% for those 80 to 89 years of age.
Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of
high stroke risk within the population of patients with atrial fibrillation. Therefore, much emphasis has been
placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke.
Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial
fibrillation. Analysis of five placebo-controlled clinical trials investigating the efficacy of warfarin in the
primary prevention of thromboembolic stroke, found the relative risk of thromboembolic stroke was reduced
by 68% for atrial fibrillation patients treated with warfarin. In recent years, novel oral anticoagulant agents
(NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke
prevention, and may be considered as an alternative to warfarin for select patients. The administration of
anticoagulation therapy, unless there are contraindications, is an established effective strategy in preventing
recurrent stroke in high stroke risk-atrial fibrillation patients with TIA or prior stroke.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients prescribed anticoagulation therapy at hospital discharge.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Anticoagulation Therapy Prescribed at Discharge

Denominator Statement: Ischemic stroke patients with documented atrial fibrillation/flutter.

Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as defined in
Appendix A, Table 8.1
Patients with documented Atrial Fibrillation/Flutter

Excluded Populations:

Patients less than 18 years of age

Data Elements:

Admission Date
Atrial Fibrillation/Flutter
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
Discharge Disposition
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code
Reason for Not Prescribing Anticoagulation Therapy at Discharge

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

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372
Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Berge, E., M. Abdelnoor, P. H. Nakstad, and P. M. Sandset. "Low Molecular-Weight Heparin Versus
Aspirin in Patients with Acute Ischaemic Stroke and Atrial Fibrillation: A Double-Blind Randomised
Study. Haest Study Group. Heparin in Acute Embolic Stroke Trial." [In eng]. Lancet 355, no. 9211 (Apr 8
2000): 1205-10.
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Connolly, S. J., M. D. Ezekowitz, S. Yusuf, J. Eikelboom, J. Oldgren, A. Parekh, J. Pogue, et al.
"Dabigatran Versus Warfarin in Patients with Atrial Fibrillation." [In eng]. N Engl J Med 361, no. 12 (Sep
17 2009): 1139-51.
Fuster, V., L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, et al.
"Acc/Aha/Esc Guidelines for the Management of Patients with Atrial Fibrillation: Executive Summary.
A Report of the American College of Cardiology/ American Heart Association Task Force on Practice
Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy
Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial
Fibrillation): Developed in Collaboration with the North American Society of Pacing and
Electrophysiology." [In eng]. J Am Coll Cardiol 38, no. 4 (Oct 2001): 1231-66.
Fuster, V., L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, et al.
"Acc/Aha/Esc 2006 Guidelines for the Management of Patients with Atrial Fibrillation: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines and
the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise
the 2001 Guidelines for the Management of Patients with Atrial Fibrillation): Developed in
Collaboration with the European Heart Rhythm Association and the Heart Rhythm Society." [In eng].
Circulation 114, no. 7 (Aug 15 2006): e257-354.
Goldstein, L. B., R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, et al.
"Primary Prevention of Ischemic Stroke: A Guideline from the American Heart Association/American
Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease
Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council;
Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research
Interdisciplinary Working Group: The American Academy of Neurology Affirms the Value of This
Guideline." [In eng]. Stroke 37, no. 6 (Jun 2006): 1583-633.
Gorelick, P. B., R. L. Sacco, D. B. Smith, M. Alberts, L. Mustone-Alexander, D. Rader, J. L. Ross, et al.
"Prevention of a First Stroke: A Review of Guidelines and a Multidisciplinary Consensus Statement
from the National Stroke Association." [In eng]. JAMA 281, no. 12 (Mar 24-31 1999): 1112-20.
Hart, R. G., O. Benavente, R. McBride, and L. A. Pearce. "Antithrombotic Therapy to Prevent Stroke in
Patients with Atrial Fibrillation: A Meta-Analysis." [In eng]. Ann Intern Med 131, no. 7 (Oct 5 1999): 492-
501.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for

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373
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Kernan, W.N., B. Ovbiagele, H. R. Black, D. M. Bravata, M. I. Chimowitz, M. D. Ezekowitz, M. C. Fang, M.
Fisher, K. L. Furie, D. V. Heck, S. C. Johnston, S. E. Kasner, S. J. Kittner, P. H. Mitchell, M. W. Rich, D.
Richardson, L. H. Schwamm, J. A. Wilson. “Guidelines for the Prevention of Stroke in Patients with
Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American
Heart Association/American Stroke Association.” [in eng.] Stroke 45, no. 7 (May 2014): 2160-223.
Lin, H. J., P. A. Wolf, M. Kelly-Hayes, A. S. Beiser, C. S. Kase, E. J. Benjamin, and R. B. D'Agostino.
"Stroke Severity in Atrial Fibrillation. The Framingham Study." [In eng]. Stroke 27, no. 10 (Oct 1996):
1760-4.
Penado, S., M. Cano, O. Acha, J. L. Hernandez, and J. A. Riancho. "Atrial Fibrillation as a Risk Factor for
Stroke Recurrence." [In eng]. Am J Med 114, no. 3 (Feb 15 2003): 206-10.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e31-e32.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Saxena, R., and P. J. Koudstaal. "Anticoagulants for Preventing Stroke in Patients with Nonrheumatic
Atrial Fibrillation and a History of Stroke or Transient Ischemic Attack (Review). ." Cochrane Database
Syst Rev, no. 4 (2011): CD000185.
Saxena, R., S. Lewis, E. Berge, P. A. Sandercock, and P. J. Koudstaal. "Risk of Early Death and
Recurrent Stroke and Effect of Heparin in 3169 Patients with Acute Ischemic Stroke and Atrial
Fibrillation in the International Stroke Trial." [In eng]. Stroke 32, no. 10 (Oct 2001): 2333-7.
van Walraven, C., R. G. Hart, D. E. Singer, A. Laupacis, S. Connolly, P. Petersen, P. J. Koudstaal, Y. Chang,
and B. Hellemons. "Oral Anticoagulants Vs Aspirin in Nonvalvular Atrial Fibrillation: An Individual
Patient Meta-Analysis." [In eng]. JAMA 288, no. 19 (Nov 20 2002): 2441-8.
Wann, L. S., A. B. Curtis, K. A. Ellenbogen, N. A. Estes, 3rd, M. D. Ezekowitz, W. M. Jackman, C. T.
January, et al. "2011 Accf/Aha/Hrs Focused Update on the Management of Patients with Atrial
Fibrillation (Update on Dabigatran): A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines." [In eng]. J Am Coll
Cardiol 57, no. 11 (Mar 15 2011): 1330-7.

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-4

Performance Measure Name: Thrombolytic Therapy

The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous rtPA can be given
safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke;
however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better
the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last
known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA
approved.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Acute ischemic stroke patients for whom IV alteplase was initiated at this hospital
within 3 hours (less than or equal to 180 minutes) of time last known well.

Included Populations: Not applicable

Excluded Populations: None

Date Last Known Well

IV Alteplase Initiation
IV Alteplase Initiation Date
IV Alteplase Initiation Time
Time Last Known Well

Denominator Statement: Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or
equal to 120 minutes) of time last known well.

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay greater than 120 days
Patients enrolled in clinical trials
Patients admitted for Elective Carotid Intervention
Time Last Known Well to arrival in the emergency department greater than 2 hours
Patients with a documented Reason For Extending the Initiation of IV Alteplase
Patients with a documented Reason For Not Initiating IV Alteplase

Data Elements:

Admission Date
Arrival Date
Arrival Time
Birthdate
Clinical Trial
Date Last Known Well
Discharge Date
ED Patient
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code
Last Known Well
Reason for Extending the Initiation of IV Alteplase
Reason for Not Initiating IV Alteplase
Time Last Known Well

Risk Adjustment: No.

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377
However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes,
which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Adams, H., R. Adams, G. Del Zoppo, L. B. Goldstein, Association Stroke Council of the American Heart,
and Association American Stroke. "Guidelines for the Early Management of Patients with Ischemic
Stroke: 2005 Guidelines Update a Scientific Statement from the Stroke Council of the American Heart
Association/American Stroke Association." [In eng]. Stroke 36, no. 4 (Apr 2005): 916-23.
Adams, H. P., Jr., G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, et al.
"Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline from the American
Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council,
Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular
Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American
Academy of Neurology Affirms the Value of This Guideline as an Educational Tool for Neurologists."
[In eng]. Stroke 38, no. 5 (May 2007): 1655-711.
Albers, G. W., P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke: The Seventh Accp Conference on Antithrombotic and Thrombolytic
Therapy." [In eng]. Chest 126, no. 3 Suppl (Sep 2004): 483S-512S.
Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S.
Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association
(NSA) (2000).
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Del Zoppo, G. J., J. L. Saver, E. C. Jauch, H. P. Adams, Jr., and Council American Heart Association
Stroke. "Expansion of the Time Window for Treatment of Acute Ischemic Stroke with Intravenous
Tissue Plasminogen Activator: A Science Advisory from the American Heart Association/American
Stroke Association." [In eng]. Stroke 40, no. 8 (Aug 2009): 2945-8.
Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, et. al., on behalf of the American Heart
Association Stroke Council and Council on Epidemiology and Prevention. “Scientific Rationale for the
Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for
Healthcare Professionals From the American Heart Association/American Stroke Association.” [In
eng]. Stroke, no. 47 (Feb 2016): 581-641.
"Diagnosis and Initial Treatment of Ischemic Stroke." Institute for Clinical Systems Improvement
(2001).

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378
Fagan, S. C., L. B. Morgenstern, A. Petitta, R. E. Ward, B. C. Tilley, J. R. Marler, S. R. Levine, et al. "Cost-
Effectiveness of Tissue Plasminogen Activator for Acute Ischemic Stroke. Ninds Rt-Pa Stroke Study
Group." [In eng]. Neurology 50, no. 4 (Apr 1998): 883-90.
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of
Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.
Hacke, W., G. Donnan, C. Fieschi, M. Kaste, R. von Kummer, J. P. Broderick, T. Brott, et al. "Association
of Outcome with Early Stroke Treatment: Pooled Analysis of Atlantis, Ecass, and Ninds Rt-Pa Stroke
Trials." [In eng]. Lancet 363, no. 9411 (Mar 6 2004): 768-74.
Hacke, W., M. Kaste, E. Bluhmki, M. Brozman, A. Davalos, D. Guidetti, V. Larrue, et al. "Thrombolysis
with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke." [In eng]. N Engl J Med 359, no. 13 (Sep 25
2008): 1317-29.
Hacke, W., M. Kaste, C. Fieschi, D. Toni, E. Lesaffre, R. von Kummer, G. Boysen, et al. "Intravenous
Thrombolysis with Recombinant Tissue Plasminogen Activator for Acute Hemispheric Stroke. The
European Cooperative Acute Stroke Study (Ecass)." [In eng]. JAMA 274, no. 13 (Oct 4 1995): 1017-25.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Kwiatkowski, T. G., R. B. Libman, M. Frankel, B. C. Tilley, L. B. Morgenstern, M. Lu, J. P. Broderick, et al.
"Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year. National Institute of
Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group."
[In eng]. N Engl J Med 340, no. 23 (Jun 10 1999): 1781-7.
"Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications,
and Discharge Planning. A National Clinical Guideline.".
http://www.sign.ac.uk/guidelines/fulltext/118/.
Marler, J. R., B. C. Tilley, M. Lu, T. G. Brott, P. C. Lyden, J. C. Grotta, J. P. Broderick, et al. "Early Stroke
Treatment Associated with Better Outcome: The Ninds Rt-Pa Stroke Study." [In eng]. Neurology 55, no.
11 (Dec 12 2000): 1649-55.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e18-e25.

Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.

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Working. "The Iscore Predicts Effectiveness of Thrombolytic Therapy for Acute Ischemic Stroke." [In
eng]. Stroke 43, no. 5 (May 2012): 1315-22.
"Tissue Plasminogen Activator for Acute Ischemic Stroke. The National Institute of Neurological
Disorders and Stroke Rt-Pa Stroke Study Group." [In eng]. N Engl J Med 333, no. 24 (Dec 14 1995):
1581-7.
Wardlaw, J. M., V. Murray, E. Berge, and G. J. Del Zoppo. "Thrombolysis for Acute Ischaemic Stroke." [In
eng]. Cochrane Database Syst Rev, no. 4 (2009): CD000213.
U.S. Drug and Food Administration. (2015). “Label- Activase-Food and Drug.”

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-5

Performance Measure Name: Antithrombotic Therapy By End of Hospital Day Two

Description: Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients who had antithrombotic therapy administered by end of
hospital day 2.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Antithrombotic Therapy Administered by End of Hospital Day 2

Denominator Statement: Ischemic stroke patients.

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1.

Excluded Populations:

Patients less than 18 years of age

Patients who have a Duration of Stay less than 2 days
Patients who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented on day of or day after arrival
Patients enrolled in clinical trials

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Patients admitted for Elective Carotid Intervention
Patients discharged prior to the end of hospital day 2
Patients with IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival
Patients with a documented Reason for Not Administering Antithrombotic Therapy by End of
Hospital Day 2

Data Elements:

Admission Date
Arrival Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code
IV OR IA Alteplase Administered at This Hospital or Within 24 Hours Prior to Arrival
Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

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Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular
Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American
Academy of Neurology Affirms the Value of This Guideline as an Educational Tool for Neurologists."
[In eng]. Stroke 38, no. 5 (May 2007): 1655-711.
Albers, G. W, P Amarenco, J. D. Easton, R. L. Sacco, and P. Teal. "Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke." Chest 119 (2001): 300-20.
Antithrombotic Trialists, Collaboration. "Collaborative Meta-Analysis of Randomised Trials of
Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients."
[In eng]. BMJ 324, no. 7329 (Jan 12 2002): 71-86.
Brott, T. G., W. M. Clark, S. C. Fagan, J. C. Grotta, L. N. Hopkins, E. C. Jauch, R. E. Latchaw, and S.
Starkman. "Stroke: The First Hours. Guidelines for Acute Treatment." National Stroke Association
(NSA) (2000).
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Chen, Z. M., P. Sandercock, H. C. Pan, C. Counsell, R. Collins, L. S. Liu, J. X. Xie, C. Warlow, and R. Peto.
"Indications for Early Aspirin Use in Acute Ischemic Stroke : A Combined Analysis of 40 000
Randomized Patients from the Chinese Acute Stroke Trial and the International Stroke Trial. On Behalf
of the Cast and Ist Collaborative Groups." [In eng]. Stroke 31, no. 6 (Jun 2000): 1240-9.
Coull, B. M., L. S. Williams, L. B. Goldstein, J. F. Meschia, D. Heitzman, S. Chaturvedi, K. C. Johnston, et
al. "Anticoagulants and Antiplatelet Agents in Acute Ischemic Stroke: Report of the Joint Stroke
Guideline Development Committee of the American Academy of Neurology and the American Stroke
Association (a Division of the American Heart Association)." [In eng]. Stroke 33, no. 7 (Jul 2002): 1934-
42.
Eccles, M., N. Freemantle, and J. Mason. "North of England Evidence Based Guideline Development
Project: Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in Primary
Care. North of England Aspirin Guideline Development Group." [In eng]. BMJ 316, no. 7140 (Apr 25
1998): 1303-9.
"The European Stroke Prevention Study (Esps). Principal End-Points. The Esps Group." [In eng]. Lancet
2, no. 8572 (Dec 12 1987): 1351-4.
Furie, K. L., S. E. Kasner, R. J. Adams, G. W. Albers, R. L. Bush, S. C. Fagan, J. L. Halperin, et al.
"Guidelines for the Prevention of Stroke in Patients with Stroke or Transient Ischemic Attack: A
Guideline for Healthcare Professionals from the American Heart Association/American Stroke
Association." [In eng]. Stroke 42, no. 1 (Jan 2011): 227-76.
Gaspoz, J. M., P. G. Coxson, P. A. Goldman, L. W. Williams, K. M. Kuntz, M. G. Hunink, and L. Goldman.
"Cost Effectiveness of Aspirin, Clopidogrel, or Both for Secondary Prevention of Coronary Heart
Disease." [In eng]. N Engl J Med 346, no. 23 (Jun 6 2002): 1800-6.
Guyatt, G. H., E. A. Akl, M. Crowther, D. D. Gutterman, H. J. Schuunemann, Therapy American College of
Chest Physicians Antithrombotic, and Panel Prevention of Thrombosis. "Executive Summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines." [In eng]. Chest 141, no. 2 Suppl (Feb 2012): 7S-47S.
"The International Stroke Trial (Ist): A Randomised Trial of Aspirin, Subcutaneous Heparin, Both, or
Neither among 19435 Patients with Acute Ischaemic Stroke. International Stroke Trial Collaborative
Group." [In eng]. Lancet 349, no. 9065 (May 31 1997): 1569-81.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for

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Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Johnson, E. S., S. F. Lanes, C. E. Wentworth, 3rd, M. H. Satterfield, B. L. Abebe, and L. W. Dicker. "A
Metaregression Analysis of the Dose-Response Effect of Aspirin on Stroke." [In eng]. Arch Intern Med
159, no. 11 (Jun 14 1999): 1248-53.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e30.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Sacco, R. L., R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, et al. "Guidelines
for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack: A Statement
for Healthcare Professionals from the American Heart Association/American Stroke Association
Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The
American Academy of Neurology Affirms the Value of This Guideline." [In eng]. Stroke 37, no. 2 (Feb
2006): 577-617.

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**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Stroke (STK)

Set Measure ID: STK-6

Performance Measure Name: Discharged on Statin Medication

Description: Ischemic stroke patients who are prescribed statin medication at hospital discharge.

Rationale: There is an extensive and consistent body of evidence supporting the use of statins for secondary
prevention in patients with clinically evident atherosclerotic cardiovascular disease (ASCVD), which includes
individuals with ischemic stroke due to large artery atherosclerosis, individuals with ischemic stroke due to
intrinsic small vessel disease, and individuals with ischemic stroke not directly due to atherosclerosis but
with clinically evident atherosclerotic disease in an uninvolved cerebral or noncerebral bed. Both women and
men with clinical ASCVD are at increased risk for recurrent ASCVD and ASCVD death. High-intensity statin
therapy should be initiated or continued as first-line therapy in women and men less than or equal to 75
years of age who have clinical ASCVD, unless contraindicated. In patients with clinical ASCVD and a
contraindication to high-intensity statin therapy, moderate-intensity therapy should be considered as an
alternative if it can be tolerated. In individuals greater than 75 years of age, the potential for ASCVD risk
reduction benefits, adverse effects, drug-drug interactions, and patient preferences should be considered,
and statin therapy individualized based on these considerations (Stone, 2013).

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic stroke patients prescribed statin medication at hospital discharge.

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Statin Medication Prescribed at Discharge

Denominator Statement: Ischemic stroke patients

Included Populations: Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic stroke as
defined in Appendix A, Table 8.1

Excluded Populations:

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Patients less than 18 years of age
Patients who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented
Patients enrolled in clinical trials
Patients admitted for Elective Carotid Intervention
Patients discharged to another hospital
Patients who left against medical advice
Patients who expired
Patients discharged to home for hospice care
Patients discharged to a health care facility for hospice care
Patients with a Reason for Not Prescribing Statin Medication at Discharge

Data Elements:

Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Date
Discharge Disposition
ICD-10-CM Principal Diagnosis Code
Reason for Not Prescribing Statin Medication at Discharge

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data
and medical record documents. Some hospitals may prefer to gather data concurrently by identifying
patients in the population of interest. This approach provides opportunities for improvement at the point of
care/service. However, complete documentation includes the principal or other ICD-10 diagnosis and
procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Amarenco, P., J. Bogousslavsky, A. Callahan, 3rd, L. B. Goldstein, M. Hennerici, A. E. Rudolph, H.

Sillesen, et al. "High-Dose Atorvastatin after Stroke or Transient Ischemic Attack." [In eng]. N Engl J
Med 355, no. 6 (Aug 10 2006): 549-59.

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Biffi, A., W. J. Devan, C. D. Anderson, L. Cortellini, K. L. Furie, J. Rosand, and N. S. Rost. "Statin
Treatment and Functional Outcome after Ischemic Stroke: Case-Control and Meta-Analysis." [In eng].
Stroke 42, no. 5 (May 2011): 1314-9.
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Chan, P. S., B. K. Nallamothu, H. S. Gurm, R. A. Hayward, and S. Vijan. "Incremental Benefit and Cost-
Effectiveness of High-Dose Statin Therapy in High-Risk Patients with Coronary Artery Disease." [In
eng]. Circulation 115, no. 18 (May 8 2007): 2398-409.
Culver, A. L., I. S. Ockene, R. Balasubramanian, B. C. Olendzki, D. M. Sepavich, J. Wactawski-Wende, J.
E. Manson, et al. "Statin Use and Risk of Diabetes Mellitus in Postmenopausal Women in the Women's
Health Initiative." [In eng]. Arch Intern Med 172, no. 2 (Jan 23 2012): 144-52.
Feher, A., G. Pusch, K. Koltai, A. Tibold, B. Gasztonyi, L. Szapary, and G. Feher. "Statintherapy in the
Primary and the Secondary Prevention of Ischaemic Cerebrovascular Diseases." [In eng]. Int J Cardiol
148, no. 2 (Apr 14 2011): 131-8.
Grundy, S. M., J. I. Cleeman, C. N. Merz, H. B. Brewer, Jr., L. T. Clark, D. B. Hunninghake, R. C. Pasternak,
et al. "Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult
Treatment Panel III Guidelines." [In eng]. Circulation 110, no. 2 (Jul 13 2004): 227-39.
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., et. al. “Guideline on
the Management of Blood Cholesterol: A Report of the American College of Cardiology/American
Heart Association Task Force on Clinical Practice Guidelines." [In eng]. Journal of the American
College of Cardiology (2018), doi: https://doi.org/10.1016/j.jacc.2018.11.003.
Kernan, W.N., B. Ovbiagele, H. R. Black, D. M. Bravata, M. I. Chimowitz, M. D. Ezekowitz, M. C. Fang, M.
Fisher, K. L. Furie, D. V. Heck, S. C. Johnston, S. E. Kasner, S. J. Kittner, P. H. Mitchell, M. W. Rich, D.
Richardson, L. H. Schwamm, J. A. Wilson. “Guidelines for the Prevention of Stroke in Patients with
Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American
Heart Association/American Stroke Association.” [in eng.] Stroke 45, no. 7 (May 2014): 2160-223.
Kostis, W. J., J. Q. Cheng, J. M. Dobrzynski, J. Cabrera, and J. B. Kostis. "Meta-Analysis of Statin
Effects in Women Versus Men." [In eng]. J Am Coll Cardiol 59, no. 6 (Feb 7 2012): 572-82.
Lazar, L. D., M. J. Pletcher, P. G. Coxson, K. Bibbins-Domingo, and L. Goldman. "Cost-Effectiveness of
Statin Therapy for Primary Prevention in a Low-Cost Statin Era." [In eng]. Circulation 124, no. 2 (Jul 12
2011): 146-53.
Mitka, M. "Some Question Use of Statins to Reduce Cardiovascular Risks in Healthy Women." [In eng].
JAMA 307, no. 9 (Mar 7 2012): 893-4.
National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Adults Treatment
of High Blood Cholesterol in Adults."Third Report of the National Cholesterol Education Program
(Ncep) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel Iii) Final Report." [In eng]. Circulation 106, no. 25 (Dec 17 2002): 3143-421.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e44, e47.
Rodriguez-Yanez, M., J. Agulla, R. Rodriguez-Gonzalez, T. Sobrino, and J. Castillo. "Statins and Stroke."
[In eng]. Ther Adv Cardiovasc Dis 2, no. 3 (Jun 2008): 157-66.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In

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eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Schellinger, P. D., R. N. Bryan, L. R. Caplan, J. A. Detre, R. R. Edelman, C. Jaigobin, C. S. Kidwell, et al.
"Evidence-Based Guideline: The Role of Diffusion and Perfusion MRI for the Diagnosis of Acute
Ischemic Stroke: Report of the Therapeutics and Technology Assessment Subcommittee of the
American Academy of Neurology." [In eng]. Neurology 75, no. 2 (Jul 13 2010): 177-85.
Squizzato, A., E. Romualdi, F. Dentali, and W. Ageno. "Statins for Acute Ischemic Stroke." [In eng].
Cochrane Database Syst Rev, no. 8 (2011): CD007551.
Stone NJ, Robinson J, Lichtenstein AH, Noel Bairey Merz C, Blum CB, Eckel RH, Goldberg AC, Gordon
D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero Jr, ST, Smith SC, Watson K, Wilson PWF.
“Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease in
Adults: A Report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. [In eng]. Circulation 11, (Nov 2013): 1-84.
Van Dis, F. J., L. M. Keilson, C. A. Rundell, and M. W. Rawstron. "Direct Measurement of Serum Low-
Density Lipoprotein Cholesterol in Patients with Acute Myocardial Infarction on Admission to the
Emergency Room." [In eng]. Am J Cardiol 77, no. 14 (Jun 1 1996): 1232-4.
Weiss, R., M. Harder, and J. Rowe. "The Relationship between Nonfasting and Fasting Lipid
Measurements in Patients with or without Type 2 Diabetes Mellitus Receiving Treatment with 3-
Hydroxy-3-Methylglutaryl-Coenzyme a Reductase Inhibitors." [In eng]. Clin Ther 25, no. 5 (May 2003):
1490-7.

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Measure Information Form
Measure Set: Stroke (STK)

Set Measure ID: STK-8

Performance Measure Name: Stroke Education

Description: Ischemic or hemorrhagic stroke patients or their caregivers who were given educational
materials during the hospital stay addressing all of the following: activation of emergency medical system,
need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning
signs and symptoms of stroke.

Rationale: There are many examples of how patient education programs for specific chronic conditions have
increased healthful behaviors, improved health status, and/or decreased health care costs of their
participants. Clinical practice guidelines include recommendations for patient and family education during
hospitalization as well as information about resources for social support services. Some clinical trials have
shown measurable benefits in patient and caregiver outcomes with the application of education and support
strategies. The type of stroke experienced and the resulting outcomes will play a large role in determining
not only the course of treatment but also what education will be required. Patient education should include
information about the event (e.g., cause, treatment, and risk factors), the role of various medications or
strategies, as well as desirable lifestyle modifications to reduce risk or improve outcomes. Family/caregivers
will also need guidance in planning effective and realistic care strategies appropriate to the patient’s
prognosis and potential for rehabilitation.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Ischemic or hemorrhagic stroke patients with documentation that they or their
caregivers were given educational material addressing all of the following:
1. Activation of emergency medical system
2. Follow-up after discharge
3. Medications prescribed at discharge
4. Risk factors for stroke
5. Warning signs and symptoms of stroke

Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Education Addresses Activation of Emergency Medical System

Education Addresses Follow-up After Discharge
Education Addresses Medication Prescribed at Discharge

Denominator Statement: Ischemic stroke or hemorrhagic stroke patients discharged home.

Included Populations:

Discharges with an ICD-10-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as
defined in Appendix A, Table 8.1 or Table 8.2.

AND

A discharge to home, home care or court/law enforcement

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay greater than 120 days
Patients with Comfort Measures Only documented
Patients enrolled in clinical trials
Patients admitted for Elective Carotid Intervention

Data Elements:

Admission Date
Birthdate
Clinical Trial
Discharge Date
Discharge Disposition
Elective Carotid Intervention
ICD-10-CM Principal Diagnosis Code

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

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Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

Anderson, R. T., F. Camacho, A. I. Iaconi, C. H. Tegeler, and R. Balkrishnan. "Enhancing the

Effectiveness of Community Stroke Risk Screening: A Randomized Controlled Trial." [In eng]. J Stroke
Cerebrovasc Dis 20, no. 4 (Jul-Aug 2011): 330-5.
Boysen, G., L. H. Krarup, X. Zeng, A. Oskedra, J. Korv, G. Andersen, C. Gluud, et al. "Exstroke Pilot Trial
of the Effect of Repeated Instructions to Improve Physical Activity after Ischaemic Stroke: A
Multinational Randomised Controlled Clinical Trial." [In eng]. BMJ 339 (2009): b2810.
Byers, A. M., L. Lamanna, and A. Rosenberg. "The Effect of Motivational Interviewing after Ischemic
Stroke on Patient Knowledge and Patient Satisfaction with Care: A Pilot Study." [In eng]. J Neurosci
Nurs 42, no. 6 (Dec 2010): 312-22.
Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability
among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009):
421-6.
Chan, Y. F., R. Lavery, N. Fox, R. Kwon, S. Zinzuwadia, R. Massone, and D. Livingston. "Effect of an
Educational Video on Emergency Department Patient Stroke Knowledge." [In eng]. J Emerg Med 34,
no. 2 (Feb 2008): 215-20.
Davis, S. M., D. Martinelli, B. Braxton, K. Kutrovac, and T. Crocco. "The Impact of the Extended Parallel
Process Model on Stroke Awareness: Pilot Results from a Novel Study." [In eng]. Stroke 40, no. 12 (Dec
2009): 3857-63.
Dromerick, A. W., M. C. Gibbons, D. F. Edwards, D. E. Farr, M. L. Giannetti, B. Sanchez, N. M. Shara, et al.
"Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of
Columbia." [In eng]. Int J Stroke 6, no. 5 (Oct 2011): 454-60.
Duncan, P. W., R. Zorowitz, B. Bates, J. Y. Choi, J. J. Glasberg, G. D. Graham, R. C. Katz, K. Lamberty,
and D. Reker. "Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline." [In eng].
Stroke 36, no. 9 (Sep 2005): e100-43.
Eames, S., T. Hoffmann, L. Worrall, and S. Read. "Delivery Styles and Formats for Different Stroke
Information Topics: Patient and Carer Preferences." [In eng]. Patient Educ Couns 84, no. 2 (Aug 2011):
e18-23.
Eames, S., T. Hoffmann, L. Worrall, and S. Read. "Stroke Patients' and Carers' Perception of Barriers to
Accessing Stroke Information." [In eng]. Top Stroke Rehabil 17, no. 2 (Mar-Apr 2010): 69-78.
Evans, R. L., A. L. Matlock, D. S. Bishop, S. Stranahan, and C. Pederson. "Family Intervention after
Stroke: Does Counseling or Education Help?" [In eng]. Stroke 19, no. 10 (Oct 1988): 1243-9.
Furie, K. L., S. E. Kasner, R. J. Adams, G. W. Albers, R. L. Bush, S. C. Fagan, J. L. Halperin, et al.
"Guidelines for the Prevention of Stroke in Patients with Stroke or Transient Ischemic Attack: A
Guideline for Healthcare Professionals from the American Heart Association/American Stroke
Association." [In eng]. Stroke 42, no. 1 (Jan 2011): 227-76.
Goldstein, L. B., C. D. Bushnell, R. J. Adams, L. J. Appel, L. T. Braun, S. Chaturvedi, M. A. Creager, et al.
"Guidelines for the Primary Prevention of Stroke: A Guideline for Healthcare Professionals from the
American Heart Association/American Stroke Association." [In eng]. Stroke 42, no. 2 (Feb 2011): 517-
84.

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Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
397
Gresham, G. E., P. W. Duncan, W. B. Stason, H. P. Adams, A. M. Adelman, D. N. Alexander, D. S. Bishop et
al. "Post-stroke rehabilitation. Clinical practice guideline, no. 16. Rockville, MD: US Department of
Health and Human Services." Public Health Service, Agency for Health Care Policy and Research
(1995): 95-0062.
Hafsteinsdottir, T. B., M. Vergunst, E. Lindeman, and M. Schuurmans. "Educational Needs of Patients
with a Stroke and Their Caregivers: A Systematic Review of the Literature." [In eng]. Patient Educ
Couns 85, no. 1 (Oct 2011): 14-25.
Harrington, R., G. Taylor, S. Hollinghurst, M. Reed, H. Kay, and V. A. Wood. "A Community-Based
Exercise and Education Scheme for Stroke Survivors: A Randomized Controlled Trial and Economic
Evaluation." [In eng]. Clin Rehabil 24, no. 1 (Jan 2010): 3-15.
"Kaiser Permanente Clinical Practice Guidelines for Acute Stroke Quartet III Inpatient Management."
The Permanente Medical Group, http://www.kaiserpapers.org/cajud/acutestroke/inpaman.html.
Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al.
"Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for
Healthcare Professionals from the American Heart Association/American Stroke Association." [In
Eng]. Stroke (Jan 31 2013).
Lindsay, M. P., G. Gubitz, M. Bayley, M. D. Hill, C. Davies-Schinkel, S. Singh, and S. Phillips. "Canadian
Best Practice Recommendations for Stroke Care (Update 2010)." In, The Canadian Stroke Strategy
(2010): 17-20, 129-50. http://www.strokebestpractices.ca/wp-
content/uploads/2011/04/2010BPR_ENG.pdf
Lorig, K. R., D. S. Sobel, A. L. Stewart, B. W. Brown, Jr., A. Bandura, P. Ritter, V. M. Gonzalez, D. D.
Laurent, and H. R. Holman. "Evidence Suggesting That a Chronic Disease Self-Management Program
Can Improve Health Status While Reducing Hospitalization: A Randomized Trial." [In eng]. Med Care
37, no. 1 (Jan 1999): 5-14.
Maasland, L., D. Brouwer-Goossensen, H. M. den Hertog, P. J. Koudstaal, and D. W. Dippel. "Health
Education in Patients with a Recent Stroke or Transient Ischaemic Attack: A Comprehensive Review."
[In eng]. Int J Stroke 6, no. 1 (Feb 2011): 67-74.
Ostwald, S. K., S. Davis, G. Hersch, C. Kelley, and K. M. Godwin. "Evidence-Based Educational
Guidelines for Stroke Survivors after Discharge Home." [In eng]. J Neurosci Nurs 40, no. 3 (Jun 2008):
173-9, 91.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf
of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of
Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e48.
Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al.
"Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In
eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
Smith, J., A. Forster, A. House, P. Knapp, J. Wright, and J. Young. "Information Provision for Stroke
Patients and Their Caregivers." [In eng]. Cochrane Database Syst Rev, no. 2 (2008): CD001919.
Yvonne Chan, Y. F., R. Nagurka, L. D. Richardson, S. B. Zaets, M. B. Brimacombe, and S. R. Levine.
"Effectiveness of Stroke Education in the Emergency Department Waiting Room." [In eng]. J Stroke
Cerebrovasc Dis 19, no. 3 (May 2010): 209-15.

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Stroke Outpatient (STK-OP)

Set Measures

Set Measure ID Measure Short Name

STK-OP-1 Door to Transfer to Another Hospital

General Data Elements

Element Name Collected For

Birthdate All Records,

Hispanic Ethnicity All Records,

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File, Used in
calculation of the Joint Commission's
aggregate data and in the transmission of
the Hospital Clinical Data file.

Payment Source All Records, Optional for HBIPS-2 and

HBIPS-3

Race All Records,

Sex All Records,

Algorithm Output Data Elements

Element Name Collected For

Measure Category Assignment All Records, Calculation, Transmission,

Hospital Clinical Data File

Measure Set Specific Data Elements

Element Name Collected For

Arrival Time STK-OP-1

Comfort Measures Only STK-OP-1

Discharge Code STK-OP-1

E/M Code STK-OP-1

ED Departure Date STK-OP-1

ED Departure Time STK-OP-1

IV Alteplase Initiation STK-OP-1

Large Vessel Occlusion (LVO) STK-OP-1

MER Eligibility STK-OP-1

Outpatient Encounter Date STK-OP-1

Related Materials

Document Name

Acknowledgement

Appendix A - Code Tables

Appendix D - Glossary of Terms

Appendix E - Overview of Measure Information Form and Flowchart Formats

Appendix G - Resources

Cover Page for the Joint Commission Manual

Data Dictionary

Introduction to the Manual

Missing and Invalid Data

Sampling

Table of Contents

Transmission Alpha Data Dictionary

Transmission Data Processing Flow: Clinical

Transmission Data Processing Flow: Population and Sampling

Transmission of Data

Using the The Joint Commission's National Measure Specifications Manual

STK-OP Initial Patient Population

The population of the STK-OP measure set is identified using 4 data elements:

EM Code
ICD-10-CM Principal Diagnosis Code
Outpatient Encounter Date
Birthdate

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Measure Information Form
Measure Set: Stroke Outpatient (STK-OP)

Set Measure ID: STK-OP-1

Set Measure ID Performance Measure Name

STK-OP-1b Hemorrhagic Stroke

STK-OP-1c Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship)

STK-OP-1d Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible

STK-OP-1e Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible

STK-OP-1f Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO

STK-OP-1a Overall Rate (Not Reported)

Performance Measure Name: Door to Transfer to Another Hospital

Description: Median time from hospital arrival in the emergency department to transfer of a hemorrhagic
stroke patient or an ischemic stroke patient to another hospital.

Rationale: Hemorrhagic stroke is a life-threatening condition caused by a rupture in a weakened blood vessel
in the brain. Surgical intervention to repair a ruptured aneurysm may be indicated and necessitate urgent
transfer of the patient, if the hospital is unable to provide advanced neurological treatments and services.

The benefits of both IV altelplase and mechanical thrombectomy for the treatment of acute ischemic stroke
are time dependent. The earlier the treatment within the time window, the greater the benefit to patients.
Initiation of IV alteplase at a primary stroke center (PSC) and rapid transport to an advanced center capable
of performing endovascular treatment may lead to faster and more complete reperfusion for certain patients
eligible for these treatments (Powers, 2018).

The Brain Attack Coalition recommends that such transfers occur within 2 hours of patient arrival at the
transferring stroke center (Alberts, 2013). Reducing the time stroke patients remain in the emergency
department (ED) can improve access to a higher-level of stroke care and surgical intervention or advanced
intra-arterial endovascular treatments, and increase quality of care. For those stroke patients who are not
transferred to a TSC or CSC, inpatient admission within 3 hours, preferably to a formal stroke unit, is
recommended (Jauch, 2013).

Type Of Measure: Process

Improvement Noted As: Decrease in the median value

Continuous Variable Statement:

STK-OP-1b Time (in minutes) from ED arrival to transfer of a hemorrhagic stroke patient to another hospital

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STK-OP-1c Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (drip and ship) to
another hospital

STK-OP-1d Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV t-PA prior to
transfer, LVO and MER eligible) to another hospital

STK-OP-1e Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV t-PA given prior
to transfer, LVO and not MER eligible) to another hospital

STK-OP-1f Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV t-PA given prior
to transfer, no LVO) to another hospital

Included Populations:

Patients with an ICD-10-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as defined
in Appendix A, Table 8.1 or Table 8.2

AND

Patients who are transferred to another hospital

AND

An E/M Code for emergency department encounter as defined in Appendix A, Table 1.0

Excluded Populations:

Patients less than 18 years of age

Patients with Comfort Measures Only documented on day of or day after arrival
Patients who expired in the emergency department
Discharges to dispositions other than an acute care facility

Data Elements:

Arrival Time
Birthdate
Comfort Measures Only
Discharge Code
E/M Code
ED Departure Date
ED Departure Time
ICD-10-CM Principal Diagnosis Code
IV Alteplase Initiation
Large Vessel Occlusion (LVO)
MER Eligibility
Outpatient Encounter Date

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: No.

Data Reported As: Aggregate measure of central tendency .

Selected References:

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Total Hip and Total Knee Replacement Inpatient
(THKR-IP)

Set Measures

Set Measure ID Measure Short Name

THKR-IP-1 Regional Anesthesia

THKR-IP-2 Postoperative Ambulation on Day of Surgery

THKR-IP-3 Discharged to Home

THKR-IP-4 Preoperative Functional/Health Status Assessment

General Data Elements

Element Name Collected For

Admission Date All Records,

Birthdate All Records,

Discharge Date All Records, Not collected for HBIPS-2 and

HBIPS-3

Hispanic Ethnicity All Records,

ICD-10-CM Other Diagnosis Codes All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-CM Principal Diagnosis Code All Records, Optional for HBIPS-2, HBIPS-3

ICD-10-PCS Other Procedure Codes All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Code All Records, Optional for All HBIPS Records

ICD-10-PCS Principal Procedure Date All Records, Optional for All HBIPS Records

Payment Source All Records, Optional for HBIPS-2 and

HBIPS-3

Race All Records,

Sex All Records,

Measure Set Specific Data Elements

Ambulation THKR-IP-2

Ambulation Date THKR-IP-2

Ambulation Time THKR-IP-2

Discharge Disposition THKR-IP-2, THKR-IP-3

PACU Discharge Date THKR-IP-2

PACU Discharge Time THKR-IP-2

Postoperative ICU Admit or Transfer THKR-IP-2

Preoperative Assessments Completed THKR-IP-4

Preoperative Assessments Completion Date THKR-IP-4

Reason for No Regional Anesthesia THKR-IP-1

Reason for Not Ambulating the Day of Surgery THKR-IP-2

Reason for Not Discharging Patient to Home THKR-IP-3

Regional Anesthesia THKR-IP-1

Resident of Other Health Care Facility THKR-IP-3

THKR-IP Initial Patient Population

The THKR measure set is unique in that there are two distinct strata within the measure set, each identified
by a specific group of principal procedure codes, or lack thereof. The patients in each stratum are counted in
the Initial Patient Population of multiple measures.

The population of the THKR measure set is identified using 6 data elements:

ICD-10-PCS principal procedure code

Admission Date
Birthdate
Discharge Date
ICD-10-PCS Other procedure code
ICD-10-CM Principal or Other Diagnosis Code

Patients admitted to the hospital for inpatient care are included in THKR-IP Measure set if they have:

An ICD-10-PCS Principal procedure Code as defined in Appendix A, Table 14.01a, 14.02a , a Patient Age
(Admission Date minus Birthdate) greater than or equal to 18 years and a Length of Stay (Discharge Date
minus Admission Date) less than or equal to 120 days, ICD-10-PCS Other procedure codes are all missing or

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none on Table 14.05a, 14.06a, 14.07a, and no ICD-10-CM Principal or Other Diagnosis Codes on Table 14.08,
14.09.

And are eligible to be sampled for:

1 – Stratum 1 – If patients have an ICD-10-PCS Principal Procedure Code as defined in Appendix A, Table
14.01a are included in the THKR stratum-1 and are eligible to be sampled.

2 – Stratum 2 – If patients have an ICD-10-PCS Principal Procedure Code as defined in Appendix A, Table
14.02a are included in the THKR stratum-2 and are eligible to be sampled.

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Total Hip and Total Knee Replacement Inpatient (THKR-IP) Initial Patient Population
Algorithm Narrative

Variable Key: Patient Age, Initial Patient Population Reject Case Flag, and Length of Stay.

1. Start THKR Initial Patient Population logic sub-routine. Process all cases that have successfully
reached the point in the Transmission Data Processing Flow: Clinical which calls this Initial Patient
Population Algorithm. Do not process cases that have been rejected before this point in the
Transmission Data Processing Flow: Clinical.
2. Check ICD-10-PCS Principal Procedure code
a. If the ICD-10-PCS Principal Procedure code is not on Table 14.01a, 14.02a, the patient is not in
the THKR Inpatient Initial Patient Population and is not eligible to be sampled for the THKR
Inpatient measure set. Set the Initial Patient Population Reject Case Flag to equal Yes. Return
to Transmission Data Processing Flow: Clinical in the Data Transmission section.
b. If the ICD-10-PCS Principal Procedure code is on Table 14.01a, 14.02a, continue processing and
proceed to Patient Age Calculation.
3. Calculate Patient Age. Patient Age, in years, is equal to the Admission Date minus the Birthdate. Use
the month and day portion of admission date and birthdate to yield the most accurate age.
4. Check Patient Age:
a. If the Patient Age is less than 18 years, the patient is not in the THKR Inpatient Initial Patient
Population and is not eligible to be sampled for the THKR Inpatient measure set. Set the Initial
Patient Population Reject Case Flag to equal Yes. Return to Transmission Data Processing
Flow: Clinical in the Data Transmission section.
b. If the Patient Age is greater than or equal to 18 years, continue processing and proceed to
Length of Stay Calculation.
5. Calculate the Length of Stay. Length of Stay, in days, is equal to the Discharge Date minus the
Admission Date.
6. Check Length of Stay:
a. If the Length of Stay is greater than 120 days, the patient is not in the THKR Inpatient Initial
Patient Population and is not eligible to be sampled for the THKR Inpatient measure set. Set
the Initial Patient Population Reject Case Flag to equal Yes. Return to Transmission Data
Processing Flow: Clinical in the Data Transmission section.
b. If the Length of Stay is less than or equal to 120 days, continue processing and proceed to ICD-
10-PCS Other procedure code Check.
7. Check ICD-10-PCS Other procedure code
a. If there is at least one ICD-10-PCS Other procedure code on Table 14.05a, 14.06a, 14.07a, the
patient is not in the THKR Inpatient Initial Patient Population and is not eligible to be sampled
for the THKR Inpatient measure set. Set the Initial Patient Population Reject Case Flag to equal
Yes. Return to Transmission Data Processing Flow: Clinical in the Data Transmission section.
b. If the ICD-10-PCS Other procedure code is all missing or none on Table 14.05a, 14.06a, 14.07a,
continue processing and proceed to ICD-10-CM Principal or Other Diagnosis Code Check.
8. Check ICD-10-CM Principal or Other Diagnosis Code
a. If there is at least one ICD-10-CM Principal or Other Diagnosis Code on Table 14.08, 14.09, the
patient is not in the THKR Inpatient Initial Patient Population and is not eligible to be sampled
for the THKR Inpatient measure set. Set the Initial Patient Population Reject Case Flag to equal
Yes. Return to Transmission Data Processing Flow: Clinical in the Data Transmission section.

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b. If there is no ICD-10-CM Principal or Other Diagnosis Code on Table 14.08, 14.09, the patient is
in the THKR Initial Patient Population. Set the Initial Patient Population Reject Case Flag to
equal No. Proceed to ICD-10-PCS Principal procedure code check to determine the
stratification.
9. Check ICD-10-PCS Principal procedure code
a. If the ICD-10-PCS Principal procedure code on Table 14.01a, the patient is in the 1st THKR
Inpatient stratum and patient is eligible to be sampled for the 1st THKR Inpatient Stratum.
Include the patient in the Initial Patient Population for the appropriate measures. Return to
Transmission Data Processing Flow: Clinical in the Data Transmission section.
b. If the ICD-10-PCS Principal procedure code on Table14.02a, the patient is in the 2nd THKR
Inpatient stratum and patient is eligible to be sampled for the 2nd THKR Inpatient Stratum.
Include the patient in the Initial Patient Population for the appropriate measures. Return to
Transmission Data Processing Flow: Clinical in the Data Transmission section.

Sampling / Sample Size Requirements

Abstract a minimum of 10 inpatient hip cases and 10 inpatient knee cases per month (e.g. 20 cases for July,
20 cases for August, etc.).

If a site has a monthly population of 10 or less inpatient hip cases, abstract all inpatient hip cases.
Similarly, if 10 or less inpatient knee cases per month were performed, abstract all inpatient knee
cases.
If a site has a monthly population of greater than 10 inpatient hip cases, it is acceptable to abstract a
sample of 10 hip cases. Similarly, if more than 10 inpatient knee cases per month were performed, it is
acceptable to abstract a sample of 10 knee cases.

Sampling is a process of selecting a representative part of a population in order to estimate the

organization’s performance, without collecting data for its entire population. Using a statistically valid
sample, an organization can measure its performance in an effective and efficient manner. Sampling is a
particularly useful technique for performance measures that require primary data collection from a source
such as the medical record. Sampling should not be used unless the organization has a large number of
cases in the Initial Patient Population because a fairly large number of sample cases are needed to achieve a
representative sample of the population. For the purpose of sampling the project measures, the terms
“sample” and “case” are defined as: “sample” is the fraction of the population that is selected for further
study; “case” refers to a single record (or an episode of care [EOC]) within the population. Organizations are
NOT required to sample their data. If sampling offers minimal benefit (i.e., a hospital has 13 cases for the
month and must select a sample of 10 cases), the organization may choose to use all cases.

Sampling Approaches Simple random sampling - selecting a sample size (n) from a population of size (N) in
such a way that every case has the same chance of being selected. Systematic random sampling - selecting
every kth record from a population of size N in such a way that a sample size of n is obtained, where k ≤ N/n.
The first sample record (i.e., the starting point) must be randomly selected before taking every kth record.
This is a two-step process: a) randomly select the starting point by choosing a number between one and k

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using a table of random numbers or a computer-generated random number; and b) then select every kth
record thereafter until the selection of the sample size is completed.

Set Measure ID: THKR-IP-1

Set Measure ID Performance Measure Name

THKR-IP-1a Regional Anesthesia - Hip and Knee Overall

THKR-IP-1b Regional Anesthesia - Hip

THKR-IP-1c Regional Anesthesia - Knee

Performance Measure Name: Regional Anesthesia

Description: Patients undergoing a total hip or total knee replacement with regional anesthesia attempted or
performed. Regional anesthesia includes neuraxial anesthesia (spinal and epidural blocks) as well as
peripheral nerve blocks.

Rationale: Regional anesthesia is associated with fewer postoperative complications and deaths than
general anesthesia. Research shows that patients who received neuraxial anesthesia had statistically
significant decreases in 30-day mortality and in-hospital complications including pneumonia, kidney failure
and the need for mechanical ventilation.1 Additional studies show decrease in operative blood loss and need
for blood transfusions.2-3 Additionally, evidence supports the overall beneficial effects of neuraxial
anesthesia versus general anesthesia in decreasing the development of surgical site infections after total
hip and knee arthroplasty.4 Several factors, such as compromised cardiopulmonary function, anticoagulative
therapy, or anatomical deformity, may prevent general anesthesia and neuraxial blockade from being
conducted in total joint replacement surgery.5 Peripheral nerve blocks (PNBs) can be used as the primary
anesthetic for total knee replacement facilitating faster postoperative recovery than general anesthesia.6

In December, 2015, The American Academy of Orthopaedic Surgeons (AAOS) published Surgical
Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guidelines. Per the guidelines,
evidence supports that neuraxial anesthesia could be used to improve select perioperative outcomes and
complication rates compared to general anesthesia.7 In March, 2017, AAOS published Management of
Osteoarthritis of the Hip Evidence-Based Clinical Practice Guidelines. These guidelines state evidence
supports the use of neuraxial anesthesia compared to general anesthesia to reduce complications in
patients undergoing total hip arthroplasty.8 According to the American College of Surgeons National
Surgical Quality Improvement Program, from 2005-2011, 52% of knee replacements and 60% of hip
replacements were performed under general anesthesia.

Some surgeons avoid using regional anesthesia due to concerns that regional anesthesia may cause motor
weakness, making patients more likely to fall when they are walking postoperatively. Peripheral nerve
blockade did not alter the risk of inpatient fall, whereas use of neuraxial anesthesia reduced the risk by 30%

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compared with general anesthesia. The type of anesthesia may represent a modifiable risk factor and the
use of neuraxial over general anesthesia may be considered in the context of a fall-prevention program.9

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients undergoing a total hip or total knee replacement with regional anesthesia
attempted or performed.

Included Populations: Patients receiving any of the following or documentation of a failed attempt of any
of the following during the operative episode:

Epidural anesthesia
Epidural block
Peripheral nerve block (single injection or continuous infusion)
Spinal anesthesia
Spinal block
Subarachnoid block

Excluded Populations: None

Data Elements:

Regional Anesthesia

Denominator Statement: Patients undergoing a total hip or total knee replacement.

Included Populations:

Patients with an ICD-10-PCS Principal Procedure Code as defined in Appendix A: Table 14.01a
Total Hip Replacements or Table 14.02a Total Knee Replacements

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay greater than 120 days
Patients with an ICD-10-PCS Other Procedure Code as defined in Appendix A: Table 14.05A (partial
hip and partial knee replacements), or Table 14.06a (revision and resurfacing procedures), or Table
14.07a (removal of implanted devices/prostheses)
Patients with an ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Code as
defined in Appendix A: Table 14.08 (Complication of Internal Fixation Device/Prosthesis), or Table
14.09 (malignant neoplasm of the pelvis, sacrum, coccyx, lower limbs, or bone/bone marrow or a
disseminated malignant neoplasm.
Documented contraindication by physician/APN/PA (e.g. anticoagulated patients, coagulopathies,
neurologic condition, previous spinal fusion) clearly indicated as reason for no regional

Data Elements:

Admission Date
Birthdate
Discharge Date
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
Reason for No Regional Anesthesia

Risk Adjustment: No.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion. Proportion for hip
replacements, proportion for knee replacements and aggregated proportion for hip & knee replacements.

Selected References:

1 Memtsoudis SG, Xuming S.; Ya-Lin Chiu, et al. Perioperative Comparative Effectiveness of
Anesthetic Technique in Orthopedic Patients, Anesthesiology 05 2013, Vol.118, 1046-1058.
2 Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for
elective total hip replacement: a metaanalysis. Anesth. Analg. 2006; 103: 1018–25.
3 Hu S, Zhang Z-Y, Hua Y-Q, Li J, Cai Z-D. A comparison of regional and general anaesthesia for total
replacement of the hip or knee: a metaanalysis. J. Bone Joint Surg. Br. 2009; 91: 935–42.
4 Zorrilla-Vaca A, Grant MC, Mathur V, Li J, Wu CL. The Impact of Neuraxial Versus General Anesthesia
on the Incidence of Postoperative Surgical Site Infections Following Knee or Hip Arthroplasty: A Meta-
Analysis. Regional Anesthesia & Pain Medicine: September/October 2016 - Volume 41 - Issue 5 - p
555–563.

Specifications Manual for Joint Commission National Quality Measures v2019A. CPT® only copyright 2019 American Medical Association.
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19) All rights reserved
420
5 Kim JH, Cho MR, et al. A comparison of femoral/sciatic nerve block with lateral femoral cutaneous
nerve block and combined spinal epidural anesthesia for total knee replacement arthroplasty. Korean
J Anesthesiol 2012 May 62(5): 448-453.
6 Liu JL, Yuan WX, et al. Peripheral nerve blocks versus general anesthesia for total knee replacement
in elderly patients on the postoperative quality of recovery. Clinical Interventions in Aging 2014:9 341-
350.
7 Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline.
Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 12/4/2015.
8 Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline. Adopted by the
American Academy of Orthopaedic Surgeons Board of Directors, 3.13.17.
9 Memtsoudis SG, Thomas Danninger, Rehana Rasul, Jashvant Poeran, Philipp Gerner, Ottokar
Stundner, Edward R. Mariano, Madhu Mazumdar. Inpatient Falls after Total Knee Arthroplasty.
Anesthesiology, 2014; 120 (3): 551-563.
Nielsen PT, Jørgensen LN, Albrecht-Beste E, LeffersA, RasmussenLS. Lower thrombosis risk with
epidural blockade in knee arthroplasty. Acta Orthopaedica Scandinavica, 1990,61:1, 29-31
Mitchell D, Friedman, RJ, Baker DJ, Cooke JE, Darcy, MD, Miller MC. Prevention of thromboembolic
disease following total knee arthroplasty: Epidural versus general anesthesia. Clinical Orthopaedics &
Related Research, August 1991; 269:109-112.
Jorgensen LN, Rasmussen LS, Nielsen PT, Leffers A, Albrecht-Beste E. Antithrombotic efficacy of
continuous extradural analgesia after knee replacement. Br J Anaesth. 1991/1; 1: 8-12
Soohoo NF, Lieberman JR, et al. Development of Quality of Care Indicators for Patients Undergoing
THR/TKR. BMJ Qual Saf 2011;20:153-157
Basques BA, Toy JO, Bohl, DD, Golinvaux, NS, Grauer, JN. General Compared with Spinal Anesthesia for
Total Hip Arthroplasty. The Journal of Bone and Joint Surgery 2015;97:455-61
Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW. 90
day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry
for England and Wales: a retrospective analysis, Lancet. 2013 Sep 28;382(9898):1097-104
Premier-IHI Integrated Care Pathway for Total Joint Arthroplasty (April 2013)
Williams-Russo P, Sharrock NE, Haas SB, et al. Randomized Trial of Epidural Versus General
Anesthesia: Outcomes After Primary Total Knee Replacement. Clinical Orthopaedics & Related
Research. 331:199-208, October, 1996.
National Surgical Quality Improvement Project database
FORCE-Total Joint Registry database

Set Measure ID: THKR-IP-2

Set Measure ID Performance Measure Name

THKR-IP-2a Postoperative Ambulation on Day of Surgery - Hip & Knee Overall

THKR-IP-2b Postoperative Ambulation on Day of Surgery - Hip

THKR-IP-2c Postoperative Ambulation on Day of Surgery - Knee

Performance Measure Name: Postoperative Ambulation on Day of Surgery

Description: Patients undergoing total hip or total knee replacement who ambulated postoperatively the day
of surgery or ambulated in the PACU or within 4 hours of discharge from the PACU.

Rationale: Early ambulation as close to the time of surgery as possible can reduce the risk of complications
associated with bed rest such as deep vein thrombosis, pulmonary embolism, atelectasis, pneumonia and
urinary retention. Additionally, early ambulation results in a decreased length of stay, lowering the patient’s
risk for hospital acquired infections and other complications. Early ambulation leads to improvement in
outcomes (range of motion, gait, balance, muscle strength and pain) without an increase in adverse events.1
Studies demonstrating positive results showed that rapid ambulation can be achieved as early as in the
PACU.2

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients undergoing total hip or total knee replacement who ambulated
postoperatively the day of surgery or ambulated in the PACU or within 4 hours of discharge from the PACU.

Included Populations:

Postoperative ambulation (walking) on the day of surgery

Postoperative ambulation (walking) in the PACU or within 4 hours of discharge from the PACU

Excluded Populations: None

Data Elements:

Ambulation
Ambulation Date
Ambulation Time

Denominator Statement: Patients undergoing a total hip or total knee replacement.

Included Populations:

Patients with an ICD-10-PCS Principal Procedure Code as defined in Appendix A: Table 14.01a
Total Hip Replacement or Table 14.02a Total Knee Replacement

Excluded Populations:

Patients less than 18 years of age

Patients who have a Length of Stay greater than 120 days
Patients with an ICD-10-PCS Other Procedure Code as defined in Appendix A: Table 14.05a (partial
hip and partial knee replacements), or Table 14.06a (revision and resurfacing procedures, or Table
14.07a (removal of implanted devices/prostheses)
Patients with an ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Code as
defined in Appendix A: Table 14.08 (complication of Internal Fixation Device/Prosthesis) or Table
14.09 (malignant neoplasm of the pelvis, sacrum, coccyx, lower limbs, or bone/bone marrow or a
disseminated malignant neoplasm), or Table 14.10 (femur, hip, pelvic fracture)
Postoperative patients who are admitted to ICU on Principal Procedure Date or PACU Discharge
Date
Patient expired on Principal Procedure Date
Patient expired on PACU Discharge Date
Patient left AMA on PACU Discharge Date
Documented contraindication by physician/APN/PA/nurse/physical therapist/occupational
therapist for not ambulating on day of surgery (e.g. nerve block has not worn off, hypotensive
upon standing, patient is vomiting)

Data Elements:

Admission Date
Birthdate
Discharge Date
Discharge Disposition
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
ICD-10-PCS Principal Procedure Date
PACU Discharge Date
Postoperative ICU Admit or Transfer
Reason for Not Ambulating the Day of Surgery

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may
require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional
information see the Population and Sampling Specifications Section.

Selected References:

1Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint
replacement reduces length of stay in hospital: A systematic review. Clin Rehabil. 2014 Dec 1.
2Tayrose G, Newman D, Slover J, Jaffe F, Hunter T, Bosco J. Rapid Mobilization Decreases Length