Performance Measurement Network

Question: Will certified Primary Stroke Centers be required to report the stroke performance measures as core measures?

With the debut of the new stroke core measure set starting with October 1, 2009 discharges, will this suffice for the reporting of the measures for Disease Specific Certification (DSC) requirements? If so, will the time deadlines for the DSC submissions be adjusted to be the same as the core measure set?

Answer:

Certified primary stroke centers must collect and submit data for all 10 stroke measures through the end of the year (December 31, 2009)to maintain their certification. Reporting includes STK-7 Dysphagia Screening and STK-9 Smoking Cessation. The specifications as detailed in the Stroke Performance Measurement Implementation Guide, 2nd Edition, Version 2.a remain effective during this timeframe: http://www.jointcommission.org/CertificationPrograms/PrimaryStrokeCenters/stroke_pm_edition_2_ver_2a.htm.

Stroke data must be submitted quarterly via the CMIP application available on The Joint Commission Connect secure-extranet no later than 45 days following the end of the calendar quarter.

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: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Future+NHQM+Manuals.htm. In 2010, Stroke-7 and Stroke-9 will be retired. There has been no change in the data submission requirements for stroke. PSCs will continue to submit stroke data via CMIP. ORYX core and CMIP databases do not interface at this time.

A hospital with a certified Primary Stroke Center that wishes to use the stroke measure set as one of its four required ORYX core measure sets may choose to do so. **It is important to note that ORYX core stroke measure data submission is not mandatory for certified Primary Stroke Centers.**

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