| Section | Rationale | Description |
|---|---|---|
| ACHFOP-03 | Previously published guidelines were updated to add new evidence. | Selected References Add:
|
| CCCIP-01 | Previously published guidelines and statistics have been updated with new evidence. | Selected References Add:
|
| CCCIP-02 | Previously published guidelines were updated to add new evidence. | Selected References Add:
|
| CSTK-01 | The rationale for the measure was updated to harmonize with recommendations from the American Heart Association and Get With The Guidelines. | Rationale Change from: 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. To: 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. In addition, scoring by a certified examiner is highly recommended. 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. |
| PAL-01 | Updated selected references and rationale citations to reflect current resources and publications. | Rationale
Change from:
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. To: The National Consensus Project for Quality Palliative Care (2018) guidelines recommend that the interdisciplinary team assesses and manages symptoms including 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. Selected References Change from:
|
| PAL-02 | Updated selected references and rationale citations to reflect current resources and publications. | Rationale
Change from:
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. To: The National Consensus Project for Quality Palliative Care (2018) guidelines recommend that the interdisciplinary team assesses and manages symptoms including 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. Selected References Change from:
|
| PAL-03 | Updated selected references and rationale citations to reflect current resources and publications. | Rationale
Change from:
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 To: National Consensus Project for Quality Palliative Care (2018) guidelines recommend that the interdisciplinary team assesses and manages symptoms including dyspnea 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 Selected References Change from:
|
| PAL-04 | Updated selected references and rationale citations to reflect current resources and publications. | Rationale
Change from:
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. To: The National Consensus Project for Quality Palliative Care (2018) 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. Selected References Change from:
|
| PAL-05 | Updated selected references and rationale citations to reflect current resources and publications. | Rationale
Change from:
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. To: The National Consensus Project for Quality Palliative Care (2018) 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. Selected References Change from:
|
| Section | Rationale | Description |
|---|---|---|
| Mineralocorticoid Receptor Antagonist (MRA) Prescribed for LVSD at Discharge | The data element inclusion terms were updated to align with GWTG. | Inclusion Guidelines for Abstraction Add:
|
| Post-Discharge Appointment Scheduled Within 7 Days | A new note was added to align with a recent update to GWTG-HF. | Notes for Abstraction Add: new last bullet:
|
| Referral for Addictions Treatment | Updated technology used for referrals in the definition. | Definition
Change from:
A referral is defined as an appointment made by the provider either through telephone contact, fax or e-mail. To: A referral is defined as an appointment made by the provider either through telephone contact, use of an electronic referral, fax or e-mail. |
| Referral for Outpatient Tobacco Cessation Counseling | Added updated technology used for referrals to the definition. | Definition
Change from:
For quitline referrals, the healthcare provider or hospital can either fax or e-mail a quitline referral or assist the patient in directly calling the quitline prior to discharge. To: For quitline referrals, the healthcare provider or hospital can either use an electronic referral, fax or e-mail a quitline referral or assist the patient in directly calling the quitline prior to discharge. |
| Regional Anesthesia | Sentence added for clarity in last manual update caused confusion and will be removed. | Definition Remove: This does not include regional anesthesia used for the purpose of postoperative analgesia. |
| Section | Rationale | Description |
|---|---|---|
| Acknowledgement - Acknowledgment and Conditions of Use | Updated copyright year. | CPT® Notice
Change from:
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To: The five character CPT® codes included in the Specifications Manual for Joint Commission National Quality Measures are obtained from Current Procedural Terminology (CPT®), copyright 2026 by the American Medical Association (AMA). |
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