Comprehensive Stroke Performance Measurement Implementation Guide

Transcription

1 Comprehensive Stroke Performance Measurement Implementation Guide Release Notes Version: 2015Jan Release Notes Completed: November 14, 2014 Guidelines for Using Release Notes Release Notes 2015Jan provide modifications to the Comprehensive Stroke Performance Measurement Implementation Guide. The Release Notes are provided as a reference tool and are not intended to be used to program abstraction tools. Please refer to the complete and current technical specifications and abstraction information. The notes are organized to follow the order of the Table of Contents. The implementation date is , unless otherwise specified. The headings are described below: Impacts - used to identify the impacted measures and portion(s) of the Manual Section. (i.e., Alphabetical Data Dictionary, Measure Information Form (MIF) and Flowchart (Algorithm)). Description of Changes - used to identify the section within the document where the change occurs, e.g., Definition, Data Collection Question, Allowable Values, and Denominator Statement - Data Elements. Rationale - provided for the change being made. Data elements that cross multiple measures and contain the same changes will be consolidated. 1

2 Table of Contents SECTION 1 Data Dictionary... 3 Data Element Updates... 3 SECTION 2 Measurement Information... 6 SECTION 3 Missing and Invalid Data... 9 SECTION 4 Population and Sampling Specifications... 9 SECTION 5 Data Transmission APPENDICES

3 SECTION 1 Data Dictionary Data Element Updates First Pass Time Rationale: This change is to provide abstractor clarification for cases with procedure notes/reports with various different times documented. Anesthesia start time Groin puncture time Procedure start time Highest NIHSS Score Documented Within 36 Hours Following IA t-pa or MER Initiation Rationale: This change is to provide abstractor clarification about NIHSS score documentation. Modified NIHSS scores Estimated NIHSS scores Scoring methodologies other than NIHSS Highest NIHSS Score Documented Within 36 Hours Following IV Thrombolytic Initiation Rationale: This change is to provide abstractor clarification about NIHSS score documentation. Modified NIHSS scores Estimated NIHSS scores Scoring methodologies other than NIHSS 3

4 ICD-9-CM Other Procedure Times Rationale: Correct typo. Format Occurs: 24 IA Route of t-pa Administration Rationale: This change is to provide abstractor clarification for cases with intra-arterial administration of thrombolytic agents. IA administration of thrombolytic agents not listed as inclusions. IA Thrombolytic Initiation Rationale: This change is to provide abstractor clarification for cases with IA Route of t-pa Administration YES. Notes for Abstraction: If the data element IA Route of t-pa Administration is YES, select YES for this data element. IA administration of thrombolytic agents not listed as inclusions. Initial Blood Pressure at Hospital Arrival Rationale: Correct typo. Format Length: 7 Initial NIHSS Score at Hospital Arrival 4

5 Rationale: This change is to provide abstractor clarification about NIHSS score documentation. Modified NIHSS scores Estimated NIHSS scores Scoring methodologies other than NIHSS Modified Rankin Score Rationale: This change is to provide abstractor clarification for cases when the caregiver is a nursing home or extended or immediate care facility. Notes For Abstraction If documentation reflects that the mrs could not be obtained because the patient is a resident of a nursing home or extended/immediate care facility, and the facility refuses to provide patient information due to HIPPA regulations or other reasons, select allowable value 7. NIHSS Score Documented Closest to IA t-pa or MER Initiation Rationale: This change is to provide abstractor clarification about NIHSS score documentation. Modified NIHSS scores Estimated NIHSS scores Scoring methodologies other than NIHSS NIHSS Score Documented Closest to IV Thrombolytic Initiation Rationale: This change is to provide abstractor clarification about NIHSS score documentation. Modified NIHSS scores Estimated NIHSS scores 5

6 Scoring methodologies other than NIHSS SECTION 2 Measurement Information Measure(s) CSTK-06 Rationale: Correct simple error. Selected References 4. Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dio 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. Measure(s) CSTK-01, CSTK-03 Rationale: Correct simple error. Data Elements (Numerator) ICD-9-CM Other Procedure Dates ICD-9-CM Other Procedure Times ICD-9-CM Principal Procedure Date ICD-9-CM Principal Procedure Time Data Elements (Denominator) Remove: ICD-9-CM Other Procedure Dates ICD-9-CM Other Procedure Times ICD-9-CM Principal Procedure Date ICD-9-CM Principal Procedure Time Algorithms Measure(s) CSTK-01, CSTK-03 6

7 Rationale: This change adds a note box to define the earliest procedure date and the earliest procedure time in order to handle the cases with multiple procedure codes. CSTK-01, CSTK-03 Note box: ICD-9-CM Principal or Other Procedure Date and Time CSTK-03 Measurement Date and Measurement Time process box under Initial Hunt and Hess Scale Time decision point If Initial Hunt and Hess Scale Time is Non-UTD value, then The Measurement Date = Initial Hunt and Hess Scale Date The Measurement Time = Initial Hunt and Hess Scale Time Measurement Date and Measurement Time process box under Initial ICH Score Time decision point If Initial ICH Score Time is Non-UTD value, then The Measurement Date = Initial ICH Score Date The Measurement Time = Initial ICH Score Time CSTK-01, CSTK-02, CSTK-03, CSTK-06 Rationale: Discharge Date is a required data element and does not need a decision box within a measure algorithm. Remove: Discharge Date decision box and all associate logic CSTK-05 Rationale: Correction of Measure Category Assignments for outputs throughout the measure because it is an inverse measure. Change: All measure category assignments of D are changed to E and all E s are changed to D s. CSTK-07 Rationale: This change corrects algorithm dead end when IA t-pa and MER therapies are performed. 1. Initial MER flag and IA flag to N under ICD-9-CM Principal or Other Procedure Codes decision point 2. Check ICD-9-CM Principal or Other Procedure Codes 7

8 If None of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1a, case flows to Step 3 and re-check ICD-9-CM Principal or Other Procedure Codes If Any of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1a, case flows to Step 4 and check IA Route of t-pa Administration 3. Re-check ICD-9-CM Principal or Other Procedure Codes If Any of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1b, set MER flag to Y, case flows MER branch 4. Check IA Route of t-pa Administration If IA Route of t-pa Administration is missing, case flows to Measure Category Assignment of X If IA Route of t-pa Administration is N, case flows to Step 3 and re-check ICD-9-CM Principal or Other Procedure Codes If IA Route of t-pa Administration is Y, case flows to Step 5 and re-check ICD-9-CM Principal or Other Procedure Codes 5. Re-check ICD-9-CM Principal or Other Procedure Codes If Any of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1b, set MER flag and IA flag to Y, case flow down IAMER branch If None of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1b, set IA flag to Y, case flow to IA branch CSTK-08 Rationale: This change corrects algorithm dead end when IA t-pa and MER therapies are performed. Re-check ICD-9-CM Principal or Other Procedure Codes decision point logic If None of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1b, case flows to check IA Route of t-pa Administration decision point If Any of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1b, case flows down CSTK-01, CSTK-02, CSTK-03, CSTK-05, CSTK-07, CSTK-08 Rationale: This change adjusts the method of handling cases without procedure code in the required tables. ICD-9-CM Principal or Other Procedure Codes decision point logic 8

9 If All missing or None of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1a or 8.1b, case flows to Measure Category Assignment of B If Any of ICD-9-CM Principal or Other Procedure Codes is on Table 8.1a or 8.1b, case flows down CSTK-03 If All missing or None of ICD-9-CM Principal or Other Procedure Codes is on Table 8.2d or 8.2e, case flows to Measure Category Assignment of B If Any of ICD-9-CM Principal or Other Procedure Codes is on Table 8.2d or 8.2e, case flows down CSTK-07 Rationale: This change corrects a simple error. First Pass Date and IA Thrombolytic Initiation Date decision point logic If First Pass Date or IA Thrombolytic Initiation Date is UTD, case flows to Measure Category Assignment of Y If First Pass Date or IA Thrombolytic Initiation Date is Non-UTD value, case flows down First Pass Time and IA Thrombolytic Initiation Time decision point logic If First Pass Time or IA Thrombolytic Initiation Time is UTD, case flows to Measure Category Assignment of Y If First Pass Time or IA Thrombolytic Initiation Time is Non-UTD value, case flows down SECTION 3 Missing and Invalid Data Hospital Clinical Data (HCD) submission for CSTK data, Edits, Algorithms Rationale: The CSTK data will be submitted by vendors starting July 2015 for discharge data 1/1/2015 and are processed using The Joint Commission HCD application. This new section of Missing and Invalid Data is added to the guide to define the terms and the protocol of reporting and processing of missing or invalid data. SECTION 4 Population and Sampling Specifications 9

10 Population and Sampling (PaS) CSTK data submission Rationale: The CSTK data will be submitted by vendors starting July 2015 for discharge data 1/1/2015 and are processed using The Joint Commission HCD application. This new section of Population and Sampling Specifications is added to the guide to define the terms and the methodology of sampling and provide general examples of sampling for different topics/measure sets. SECTION 5 Data Transmission Population and Sampling (PaS) data submission, Hospital Clinical Data (HCD) data submission Rationale: The CSTK data will be submitted by vendors starting July 2015 for discharge data 1/1/2015 and are processed using The Joint Commission's Hospital Clinical Data (HCD) and Population and Sampling (PaS) applications. This new section of Data Transmission is added to the guide related to the transmission and processing of CSTK data for the Joint Commission s Data Warehouse. Guidance is added to provide details on Transmission Data Elements and expected file formats to submit data to The Joint Commission, using HCD and PaS applications, and explains the processing steps taken by each application. This section also provides details and examples on submission of data for CSTK discharge measures (discharge file) and CSTK follows-up measure (event file). APPENDICES Appendix A ICD-9-CM Code Tables No updates in this section. 10