Certification for Acute Stroke Ready Hospitals Performance Measure Pilot Testing | Joint Commission
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Performance Measures for Acute Stroke Ready Hospital Certification

November 17, 2017

The Joint Commission recently completed the process of developing standardized performance measures for its Acute Stroke Ready Hospital Certification Program.  All currently certified acute stroke ready hospitals, as well as those hospitals seeking initial certification, will be required to implement data collection for five standardized measures effective with discharges on and after January 1, 2018.

Stroke is the fifth leading cause of death in the United States and is a major cause of serious disability for adults.  The Joint Commission Acute Stroke Ready Hospital Certification Program was developed in collaboration with the American Heart Association / American Stroke Association (AHA/ASA) and launched in July 2015.  This third stroke certification program completes the series of requirements for “spoke and hub” stroke systems of care.

With the assistance of a Technical Advisory Panel (TAP), that included key stakeholders from the field of neurology and other specialists in stroke care, a set of measures were selected and pilot tested. The Acute Stroke Ready (ASR) measure set is comprised of the following five measures:

  • ASR-IP-1 Thrombolytic Therapy (IV t-PA initiated in the ED followed by inpatient admission to the ASRH)
  • ASR-IP-2 Antithrombotic Therapy Administered By End of Hospital Day 2
  • ASR-IP-3  Discharged on Antithrombotic Therapy
  • ASR-OP-1 Thrombolytic Therapy (Drip and Ship)
  • ASR-OP-2 Door to Transfer to Another Hospital
    • 2b Hemorrhagic Stroke
    • 2c Ischemic Stroke; drip and ship
    • 2d Ischemic Stroke; no IV t-PA prior to transfer

Hospitals are required to collect monthly data points (numerator and denominator values) for all five standardized measures and report data quarterly to The Joint Commission via the extranet Certification Measure Information Process (CMIP).

Measure specifications for the five mandatory ASR measures are detailed in two separate implementation guides for inpatient and outpatient data collection:

Acute Stroke Ready Inpatient Performance Measurement Implementation Guide, Version January 2018

Acute Stroke Ready Outpatient Performance Measurement Implementation Guide, Version January 2018

Questions:

Questions about the Acute Stroke Ready (ASR) measure specifications may be submitted to the

Performance Measurement Network Q&A Forum

For additional information about Acute Stroke Ready Hospital Certification, please submit your question to dscinfo@jointcommission.org
 

 
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