Performance Measurement Network

Question: Primary Stroke Certification and Transition to Stroke Core Measures

Joint Commission stroke certification requires 10 measures, while the new ORYX core stroke measure set contains only 8 measures. Will hospitals currently collecting stroke data to meet the stroke certification requirements be officially transitioning to the new “Core Stroke” measure set with October 2009 discharges?

Will certified primary stroke centers be required to submit ORYX core stroke data to The Joint Commission electronically, as they do for other core measure sets?

If hospitals are submitting stroke data for certification purposes, will this count as one of their “four” core measure sets or would this be a 5th topic?

Answer:

•Ten standardized stroke performance measures have been used in the Joint Commission’s advanced Disease-Specific Care Primary Stroke Center Certification Program since January 1, 2008.

•Of the original 10 measures, eight have been endorsed by the National Quality Forum (NQF).

•Joint Commission certified Primary Stroke Centers must collect and submit data on all 10 stroke measures through Dec. 31, 2009, to maintain their certification. Measure specifications as detailed in the Stroke Perfromance Measurement Implementation Guide, 2nd Edition, Version 2.a should be used for data abstraction.

•As of January 1, 2010, Joint Commission certified Primary Stroke Centers must collect and submit data only on the eight NQF-endorsed measures to maintain their certification. (In 2010, Stroke-7 and Stroke-9 will be retired.) Measure specifications as detailed in the Specifications Manual for National Hospital Quality Measures, Version 3.0a should be used for data abstraction.

•In addition to the changes outlined above for certified Primary Stroke Centers, on October 1, 2009, the eight NQF-endorsed measures will become a core measure set for the purposes of meeting the performance measure requirements for hospital accreditation. Therefore, accredited hospitals may choose the stroke measure set as one of their required four core measure sets.

•A hospital with a certified Primary Stroke Center that wishes to use the stroke measure set as one of its four required ORYX core measures sets may do so.

•Accredited hospitals may use this core measure set to fulfill their performance measurement requirements for accreditation. ***Certified Primary Stroke Centers must use this measure set for certification purposes, and continue to submit stroke data via the CMIP application available on The Joint Commission Connect secure-extranet.***

•It is important to note that accredited hospitals, whether they have a certified Primary Stroke Center or not, may use this measure set to fulfill their core measure reporting requirements for accreditation. ***ORYX core stroke measure data submission is not mandatory for certified Primary Stroke Centers.***

•The Centers for Medicare & Medicaid Services (CMS) is not requiring collection of any of the stroke measures at this time.

•Organizations planning to make changes to their core measure selections should contact their Joint Commission account representative at (630) 792-3007.

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