Performance Measurement Network

Question: Stroke Module

Our hospital customer is telling us that they had to show timing measures (time from order to results for lab, EKG, x-ray, etc.) for initial stroke center survey this year. It was our understanding that the stroke disease certification measures and the TJC stroke core measures were aligned in January 2010 and the timing measures were no longer required. Is this correct?

NOTE: Currently, our stroke module doesn't include the timing measures in the program.


That's correct. The measures were aligned in 2010. The above is not a performance measure and unrelated to data collection/submission for the eight core stroke measures.

The above requirement is found in The Joint Commission DSC Primary Stroke Measure Standards for program management, i.e. DSPR.8 on page PSC-7 of the 2011 Disease-Sepcific Care Certification Manual. The standard is scored by the stroke reviewer at the time of the on-site certification visit, along with all the other standards required for DSC certification, which determines the certification decision rendered by The Joint Commission.

There are many requirements that must be met to obtain DSC PSC certification. Data collection for the eight stroke measures is one requirement scored by the reviewer under the Performance Measurement Standard DSPM-2, "The program uses measurement data to evaluate process and outcomes", i.e.,selects measures (8 stroke core measures mandated for PSC), collects data, aggregates data, reports aggregated data to The Joint Commission at defined intervals, analyzes data and uses it to improve processes/outcomes.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK,

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