Specifications Manual for Joint Commission National Quality Measures (v2027A)
Posted: 8/7/2026

Release Notes:
Measure Information Form
Version 2027A

Measure Information Form

Measure Set: Stroke Outpatient (STK-OP)

Set Measure ID: STK-OP-1

Set Measure ID Performance Measure Name
STK-OP-1a viewtopic Overall Rate (Not Reported)
STK-OP-1b viewtopic Hemorrhagic Stroke
STK-OP-1c viewtopic Ischemic Stroke; IV Alteplase Prior to Transfer (Drip and Ship) RETIRED 7/1/2021
STK-OP-1d viewtopic Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and MER Eligible
STK-OP-1e viewtopic Ischemic Stroke; No IV Alteplase Prior to Transfer, LVO and NOT MER Eligible
STK-OP-1f viewtopic Ischemic Stroke; No IV Alteplase Prior to Transfer, No LVO
STK-OP-1g viewtopic Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and MER Eligible
STK-OP-1h viewtopic Ischemic Stroke; IV Alteplase Prior to Transfer, LVO and NOT MER Eligible
STK-OP-1i viewtopic Ischemic Stroke; IV Alteplase Prior to Transfer, No LVO

Performance Measure Name: Door to Transfer to Another Hospital

Description: Median time from hospital arrival in the emergency department to transfer of a hemorrhagic stroke patient or an ischemic stroke patient to another hospital.

Rationale: Hemorrhagic stroke is a life-threatening condition caused by a rupture in a weakened blood vessel in the brain. Surgical intervention to repair a ruptured aneurysm may be indicated and necessitate timely transfer of the patient to a stroke center with expertise in aneurysmal subarachnoid hemorrhage (aSAH), if the hospital is unable to provide advanced neurological treatments and services. Transfer delays may result in worse outcomes for aSAH patients (Hoh, B.L., et al., 2023).

The benefits of both IV thrombolytics and mechanical thrombectomy for the treatment of acute ischemic stroke are time dependent. The earlier the treatment within the time window, the greater the benefit to patients. Initiation of IV alteplase or tenecteplase at an acute stroke ready hospital (ASRH) or primary stroke center (PSC) and rapid transport to an advanced center capable of performing endovascular treatment may lead to faster and more complete reperfusion for certain patients eligible for these treatments (Powers, W.J., et al., 2018).

The American Heart Association® Target Stroke Phase III goals include a door-in-door-out time (DIDO) of < 90 minutes for acute ischemic stroke patients eligible for mechanical thrombectomy (AHA, 2018). Rapid patient transfer is often a first step towards meeting target times for thrombolytic and/or endovascular therapy initiation when the hospital is unable to initiate treatment. For hospitals without an on-site mechanical thrombectomy (MT) service, shorter door-in-door-out (DIDO) times should be the goal. Choi and colleagues reported a median DIDO time of 86 minutes (IQR, 65–111) for acute ischemic stroke patients transferred out for potential MT. During working hours (0800–1700 hours), a median DIDO time of 59 minutes (IQR, 51–80) was achieved (Choi, P.M.C., et al., 2019). However, a recent large U.S. study reported a median DIDO of 174 minutes with only 27.3% of stroke patients transferred under 120 minutes. A significant performance improvement gap of a median 132 minutes was reported for EVT-eligible AIS patients (Stamm, B., et al., 2023). Prolonged transfer times may result in worse outcomes for MT-eligible patients with evolving large vessel occlusion (ELVO) who are without successful reperfusion. Higher NIHSS scores have been noted at discharge and 90 days (McTaggert, R.A., et al., 2018).

Reducing the time stroke patients remain in the emergency department (ED) can improve access to a higher-level of stroke care, surgical intervention, or advanced endovascular treatments, and increase quality of care. EMS pre-notification and the bundling of imaging services (e.g., CT/CTA) can reduce DIDO times (Royan, R., et al, 2026). Agreements with local EMS resources and interhospital transfer protocols for patients requiring higher-level stroke care are a top priority for a stroke system of care and can reduce DIDO times (Prabhakaran, S., et al., 2026).

Type Of Measure: Process

Improvement Noted As: Decrease in the median value

Continuous Variable Statement:
STK-OP-1b Time (in minutes) from ED arrival to transfer of a hemorrhagic stroke patient to another hospital

STK-OP-1d Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV alteplase given prior to transfer, LVO and MER eligible) to another hospital

STK-OP-1e Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV alteplase given prior to transfer, LVO and NOT MER eligible) to another hospital

STK-OP-1f Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (no IV alteplase given prior to transfer, no LVO) to another hospital

STK-OP-1g Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (IV alteplase prior to transfer (drip and ship), LVO and MER eligible) to another hospital

STK-OP-1h Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (IV alteplase prior to transfer (drip and ship), LVO and NOT MER eligible) to another hospital

STK-OP-1i Time (in minutes) from ED arrival to transfer of an ischemic stroke patient (IV alteplase prior to transfer (drip and ship), no LVO) to another hospital

Included Populations:
  • Patients with an ICD-10-CM Principal Diagnosis Code for ischemic or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2
AND
  • Patients who are transferred to another hospital
AND
  • An E/M Code for emergency department encounter as defined in Appendix A, Table 1.0

Excluded Populations:
  • Patients less than 18 years of age
  • Patients with Comfort Measures Only documented on day of or day after arrival
  • Patients who expired in the emergency department
  • Discharges to dispositions other than an acute care facility

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10 diagnosis and procedure codes, which require retrospective data entry.

NOTE: Records for patients transferred from one hospital site ED/OP to an acute care hospital within the same health system or another outside hospital are to be counted in the measure population.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: No.

Data Reported As: Aggregate measure of central tendency .

Selected References:
  • American Heart Association. (2018). Phase III Target: Stroke: Higher goals for greater good. https://www.stroke.org/-/media/files/professional/quality-improvement/target-stroke/target-stroke-phase-iii/aha-qi-target-stroke-phase-3-brochure.pdf.
  • Choi, P. M. C., Tsoi, A. H., Pope, A. L., Leung, S., Frost, T., Loh, P. S., Chandra, R. V., Ma, T., Parsons, M., Mitchell, P., & Dewey, H. M. (2019). Door-in-door-out time of 60 minutes for stroke with emergent large vessel occlusion at a primary stroke center. Stroke. Advance online publication.
  • Hoh, B. L., Ko, N. U., Amin-Hanjani, S., Chou, S. H.-Y., Cruz-Flores, S., Dangayach, N. S., Derdeyn, C. P., Du, R., Hänggi, D., Hetts, S. W., Ifejika, N. L., Johnson, R., Keigher, K. M., Leslie-Mazwi, T. M., Lucke-Wold, B., Rabinstein, A. A., Robicsek, S. A., Stapleton, C. J., Suarez, J. I., … Welch, B. G. (2023). 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage: A guideline from[KK3.1] the American Heart Association/American Stroke Association. Stroke, 54, e315, e324-25. https://doi.org/10.1161/STR.000000000000043
  • Lyerly, M. J., Albright, K. C., Boehme, A. K., Shahripour, R. B., Donnelly, J. P., Houston, J. T., Rawal, P. V., Kapoor, N., Alvi, M., Sisson, A., Alexandrov, A. W., & Alexandrov, A. V. (2015). Patient selection for drip and ship thrombolysis in acute ischemic stroke. Southern Medical Journal, 108 (7), 393–398. https://doi.org/10.14423/SMJ.0000000000000306
  • McTaggart, R. A., Moldovan, K., Oliver, L. A., Dibiasio, E. L., Baird, G. L., Hemendinger, M. L., Haas, R. A., Goyal, M., Wang, T. Y., & Jayaraman, M. V. (2018). Door-in-door-out time at primary stroke centers may predict outcome for emergent large vessel occlusion patients. Stroke, 49 (12), 2969–2974. https://doi.org/10.1161/STROKEAHA.118.021936
  • Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e63–e74.
  • Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513
  • Royan, R., Stamm, B., Giurcanu, M., Messe, S. R., Jauch, E. C., Saver, J. L., & Prabhakaran, S. (2026). Door-in-door-out times and outcomes in patients with acute ischaemic stroke transferred for endovascular therapy in the USA: A retrospective cohort study. The Lancet Neurology, 25 (2), 160–169. https://doi.org/10.1016/S1474-4422(25)00478-8
  • Sheth, K. N., Smith, E. E., Grau-Sepulveda, M. V., Kleindorfer, D., Fonarow, G. C., & Schwamm, L. H. (2015). Drip and ship thrombolytic therapy for acute ischemic stroke: Use, temporal trends, and outcomes. Stroke, 46 (3):732-9. https://doi:10.1161/STROKEAHA.114.007506
  • Stamm, B., Royan, R., Giurcanu, M., Messe, S. R., Jauch, E. C., & Prabhakaran, S. (2023). Door-in-door-out times for interhospital transfer of patients with stroke. JAMA, 330 (7), 636–649. https://doi.org/10.1001/jama.2023.12739

Measure Algorithm:
Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step. Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step. Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step. Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step.

STK-OP-1: Algorithm Narrative

STK-OP-1: Door to Transfer to Another Hospital


Continuous Variable Statement: Time (in minutes) from ED arrival to transfer of an ischemic or hemorrhagic stroke patient to another hospital.

Stratification Table:
If Measure ID is STK-OP-1a, then Door To Transfer To Another Hospital Stratified By Overall Rate (Not Reported)
If Measure ID is STK-OP-1b, then Door To Transfer To Another Hospital Stratified By Hemorrhagic Stroke
If Measure ID is STK-OP-1d, then Door To Transfer To Another Hospital Stratified By Ischemic Stroke: No IV Alteplase Prior To Transfer, LVO And MER Eligible
If Measure ID is STK-OP-1e, then Door To Transfer To Another Hospital Stratified By Ischemic Stroke: No IV Alteplase Prior To Transfer, LVO And NOT MER Eligible
If Measure ID is STK-OP-1f, then Door To Transfer To Another Hospital Stratified By Ischemic Stroke: No IV Alteplase Prior To Transfer, No LVO
If Measure ID is STK-OP-1g, then Door To Transfer To Another Hospital Stratified By Ischemic Stroke: IV Alteplase Prior To Transfer, LVO And MER Eligible
If Measure ID is STK-OP-1h, then Door To Transfer To Another Hospital Stratified By Ischemic Stroke: IV Alteplase Prior To Transfer, LVO And NOT MER Eligible
If Measure ID is STK-OP-1i, then Door To Transfer To Another Hospital Stratified By Ischemic Stroke: IV Alteplase Prior To Transfer, No LVO

Variable Key: Measurement Value

1. Start Door to Transfer to Another Hospital logic. Run cases that are included in the Stroke Outpatient Initial Patient Population and pass the edits defined in the Clinical Data Processing Flow, through this measure.

2. Check Discharge Code.
  1. If Discharge Code is missing, the case will proceed to an Overall Rate Category Assignment of X and will be rejected. Proceed to Step 9.
  2. If Discharge Code equals 1, 2, 3, 4b, 4c, 5, 6, 7 or 8, the case will proceed to an Overall Rate Category Assignment of B and will not be In Measure Population. Proceed to Step 9.
  3. If Discharge Code equals 4a or 4d, the case will continue processing and proceed to Check Comfort Measures Only.

3. Check Comfort Measures Only.
  1. If Comfort Measures Only is missing, the case will proceed to an Overall Rate Category Assignment of X and will be rejected. Proceed to Step 9.
  2. If Comfort Measures Only equals 1, the case will proceed to an Overall Rate Category Assignment of B and will not be In Measure Population. Proceed to Step 9.
  3. If Comfort Measures Only equals 2, 3, 4, the case will continue processing and proceed to Check Arrival Time.

4. Check Arrival Time.
  1. If Arrival Time equals UTD, the case will proceed to an Overall Rate Category Assignment of Y and will be In Measure Population. Note: There will be no category assignment E for this measure because it is a continuous variable. Proceed to Step 9.
  2. If Arrival Time is Non-UTD value, the case will continue processing and proceed to Check ED Departure Date.
5. Check ED Departure Date.
  1. If ED Departure Date is missing, the case will proceed to an Overall Rate Category Assignment of X and will be rejected. Proceed to Step 9.
  2. If ED Departure Date equals UTD, the case will proceed to an Overall Rate Category Assignment of Y and will be In Measure Population. Note: There will be no category assignment E for this measure because it is a continuous variable. Proceed to Step 9.
  3. If ED Departure Date equals Non-UTD, the case will continue processing and proceed to Check ED Departure Time.

6. Check ED Departure Time.
  1. If ED Departure Time is missing, the case will proceed to an Overall Rate Category Assignment of X and will be rejected. Proceed to Step 9.
  2. If ED Departure Time equals UTD, the case will proceed to an Overall Rate Category Assignment of Y and will be In Measure Population. Note: There will be no category assignment E for this measure because it is a continuous variable. Proceed to Step 9.
  3. If ED Departure Time equals Non-UTD, the case will continue processing and proceed to Check Measurement Value.
7. Measurement Value equals ED Departure Date and ED Departure Time minus Outpatient Encounter Date and Arrival Time (in minutes).

8. Check Measurement Value.
  1. If Measurement Value is less than 0 minutes, the case will proceed to an Overall Rate Category Assignment of X and will be rejected. Proceed to Step 9.
  2. If Measurement Value is greater than or equal to 0 minutes, the case will proceed to an Overall Rate Category Assignment of D and will be In Measure Population. Proceed to Step 9.

9. Initialize the Measure Category Assignment for measures STK-OP-1b through STK-OP-1i to 'B'.

10. Check Overall Measure Category Assignment for STK-OP-1a.
  1. If Overall Measure Category Assignment for STK-OP-1a equals B, the case will stop processing.
  2. If Overall Measure Category Assignment for STK-OP-1a equals D, X or Y, the case will continue processing and proceed to Check ICD-10-CM Principal Diagnosis Code.

11. Check ICD-10-CM Principal Diagnosis Code.
  1. If ICD-10-CM Principal Diagnosis Code is Not on Table 8.2, the case will continue processing and proceed to Check IV Alteplase Initiation. Proceed to Step 13.
  2. If ICD-10-CM Principal Diagnosis Code is On Table 8.2, the case will continue processing and proceed to Check Overall Measure Category Assignment for STK-OP-1a.

12. Check Overall Measure Category Assignment for STK-OP-1a.
  1. If Overall Measure Category Assignment for STK-OP-1a equals D, Set Measure Category Assignment STK-OP-1b equal to STK-OP-1a. Set Measurement Value for STK-OP-1b equal to Measurement Value for STK-OP-1a. Populate measurement value for Measure STK-OP-1b. Proceed to Stop processing.
  2. If Overall Measure Category Assignment for STK-OP-1a equals X or Y, Set Measure Category Assignment STK-OP-1b equal to STK-OP-1a for Stratified Measure STK-OP-1b. Proceed to Stop processing.

13. Check IV Alteplase Initiation.
  1. If IV Alteplase Initiation is Missing, Set Measure Category Assignment STK-OP-1d through STK-OP-1i equal to 'X' for Stratified Measure STK-OP-1d through STK-OP-1i. Proceed to Stop processing.
  2. If IV Alteplase Initiation equals Y, the case will continue processing and proceed to Check Suspected Large Vessel Occlusion (LVO). Proceed to Step 19.
  3. If IV Alteplase Initiation equals N, the case will continue processing and proceed to Check Suspected LVO.

14. Check Suspected LVO.
  1. If Suspected LVO is Missing, Set Measure Category Assignment STK-OP-1d through STK-OP-1f equal to 'X' for Stratified Measure STK-OP-1d through STK-OP-1f. Proceed to Stop processing.
  2. If Suspected LVO equals Y, the case will continue processing and proceed to Check Mechanical Endovascular Reperfusion (MER) Eligibility. Proceed to Step 16.
  3. If Suspected LVO equals N, the case will continue processing and proceed to Check Overall Measure Category Assignment for STK-OP-1a.

15. Check Overall Measure Category Assignment for STK-OP-1a.
  1. If Overall Measure Category Assignment for STK-OP-1a equals D, Set Measure Category Assignment STK-OP-1f equal to STK-OP-1a. Set Measurement Value for STK-OP-1f equal to Measurement Value for STK-OP-1a. Populate measurement value for Measure STK-OP-1f. Proceed to Stop processing.
  2. If Overall Measure Category Assignment for STK-OP-1a equals X or Y, Set Measure Category Assignment STK-OP-1f equal to STK-OP-1a for Stratified Measure STK-OP-1f. Proceed to Stop processing.

16. Check MER Eligibility.
  1. If MER Eligibility is Missing, Set Measure Category Assignment STK-OP-1d and STK-OP-1e equal to 'X' for Stratified Measure STK-OP-1d through STK-OP-1e. Proceed to Stop processing.
  2. If MER Eligibility equals N, the case will continue processing and proceed to Check Overall Measure Category Assignment for STK-OP-1a. Proceed to Step 18.
  3. If MER Eligibility equals Y, the case will continue processing and proceed to Check Overall Measure Category Assignment for STK-OP-1a.

17. Check Overall Measure Category Assignment for STK-OP-1a.
  1. If Overall Measure Category Assignment for STK-OP-1a equals D, Set Measure Category Assignment STK-OP-1d equal to STK-OP-1a. Set Measurement Value for STK-OP-1d equal to Measurement Value for STK-OP-1a. Populate measurement value for Measure STK-OP-1d. Proceed to Stop processing.
  2. If Overall Measure Category Assignment for STK-OP-1a equals X or Y, Set Measure Category Assignment STK-OP-1d equal to STK-OP-1a for Stratified Measure STK-OP-1d. Proceed to Stop processing.

18. Check Overall Measure Category Assignment for STK-OP-1a.
  1. If Overall Measure Category Assignment for STK-OP-1a equals D, Set Measure Category Assignment STK-OP-1e equal to STK-OP-1a. Set Measurement Value for STK-OP-1e equal to Measurement Value for STK-OP-1a. Populate measurement value for Measure STK-OP-1e. Proceed to Stop processing.
  2. If Overall Measure Category Assignment for STK-OP-1a equals X or Y, Set Measure Category Assignment STK-OP-1e equal to STK-OP-1a for Stratified Measure STK-OP-1e. Proceed to Stop processing.

19. Check Suspected LVO.
  1. If Suspected LVO is Missing, Set Measure Category Assignment STK-OP-1g through STK-OP-1i equal to 'X' for Stratified Measure STK-OP-1g through STK-OP-1i. Proceed to Stop processing.
  2. If Suspected LVO equals Y, the case will continue processing and proceed to Check MER Eligibility. Proceed to Step 21.
  3. If Suspected LVO equals N, the case will continue processing and proceed to Check Overall Measure Category Assignment for STK-OP-1a.
20. Check Overall Measure Category Assignment for STK-OP-1a.

  1. If Overall Measure Category Assignment for STK-OP-1a equals D, Set Measure Category Assignment STK-OP-1i equal to STK-OP-1a. Set Measurement Value for STK-OP-1i equal to Measurement Value for STK-OP-1a. Populate measurement value for Measure STK-OP-1i. Proceed to Stop processing.
  2. If Overall Measure Category Assignment for STK-OP-1a equals X or Y, Set Measure Category Assignment STK-OP-1i equal to STK-OP-1a for Stratified Measure STK-OP-1i. Proceed to Stop processing.

21. Check MER Eligibility.
  1. If MER Eligibility is Missing, Set Measure Category Assignment STK-OP-1g and STK-OP-1h equal to 'X' for Stratified Measure STK-OP-1g through STK-OP-1h. Proceed to Stop processing.
  2. If MER Eligibility equals N, the case will continue processing and proceed to Check Overall Measure Category Assignment for STK-OP-1a. Proceed to Step 23.
  3. If MER Eligibility equals Y, the case will continue processing and proceed to Check Overall Measure Category Assignment for STK-OP-1a.

22. Check Overall Measure Category Assignment for STK-OP-1a.
  1. If Overall Measure Category Assignment for STK-OP-1a equals D, Set Measure Category Assignment STK-OP-1g equal to STK-OP-1a. Set Measurement Value for STK-OP-1g equal to Measurement Value for STK-OP-1a. Populate measurement value for Measure STK-OP-1g. Proceed to Stop processing.
  2. If Overall Measure Category Assignment for STK-OP-1a equals X or Y, Set Measure Category Assignment STK-OP-1g equal to STK-OP-1a for Stratified Measure STK-OP-1g. Proceed to Stop processing.

23. Check Overall Measure Category Assignment for STK-OP-1a.
  1. If Overall Measure Category Assignment for STK-OP-1a equals D, Set Measure Category Assignment STK-OP-1h equal to STK-OP-1a. Set Measurement Value for STK-OP-1h equal to Measurement Value for STK-OP-1a. Populate measurement value for Measure STK-OP-1h. Proceed to Stop processing.
  2. If Overall Measure Category Assignment for STK-OP-1a equals X or Y, Set Measure Category Assignment STK-OP-1h equal to STK-OP-1a. For Stratified Measure STK-OP-1h. Proceed to Stop processing.

Measure Information Form STK-OP-1
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Specifications Manual for Joint Commission National Quality Measures (v2027A)
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