Protocol Development and Quality Improvement
| (e) | Comprehensive stroke - CSTK-08 Thrombolysis in cerebral infarction (TICI) post- |
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treatment reperfusion grade
| (f) | Emergency department - ED-1a - Median time from ED arrival to ED departure for |
|---|
admitted ED patients
| (g) | Emergency department - ED-2a - Admit decision time to ED departure time for admitted |
|---|
patients
| (h) | Stroke - STK-01 Venous thromboembolism (VTE) prophylaxis |
|---|---|
| (i) | Stroke - STK-02 Discharged on antithrombotic therapy |
| (j) | Stroke - STK-03 Anticoagulation therapy for atrial fibrillation/flutter |
| (k) | Stroke - STK-04 thrombolytic therapy |
| (l) | Stroke - STK-05 antithrombotic therapy by end of hospital day 2 |
| (m) | Stroke - STK-06 discharged on statin medication |
| (n) | Stroke - STK-08 stroke education |
Det Norske Veritas (DNV) β Established in 2008:
One of three CMS-approved hospital accreditation organizations.
Over 600 hospitals have converted from TJC to DNV.
DNV does not set any standards for quality, but allows the hospital leadership to develop quality
initiatives (e.g., marking the surgical site is a TJC standard).
| d. | If the institution is accredited by the DNV, the hospital leadership establishes these standards. |
|---|
Healthcare Facilities Accreditation Program (HFAP)
One of three CMS-approved hospital accreditation organizations, the HFAP was originally created
in 1945 to conduct objective review of services provided by osteopathic hospitals.
Provides accreditation to all hospitals, ambulatory care/surgical facilities, mental health facilities,
physical rehabilitation facilities, clinical laboratories and critical access hospitals. HFAP also
provides certification reviews for primary stroke centers.
Standards are written and cross-walk written tied directly to the Medicare requirements.
AHRQ (Agency for Healthcare Research and Quality) β The health services research arm of the U.S.
Department of Health and Human Services. Sponsors the National Quality Measures Clearinghouse β
A βpublic repository for evidence-based quality measures and measure setsβ
Hospital Quality Alliance β Created in 2002
Hospital Compare was created through the efforts of Medicare and the Hospital Quality Alliance
2004 β Hospitals could voluntarily report data on 10 βstarter-setβ quality performance measures
and receive incentive payment.
2005 β Quality-of-care data expanded to 21 measures
| d. | 2008 β Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) β First |
|---|
national, standardized, publicly reported survey of patientsβ perspectives of hospital care
Reporting initiatives sharpens the focus on QI.
Mission β To βensure effective up-to-date health care coverage and to promote quality care for
beneficiariesβ
Quality initiative (established in 2001) empowers consumers with quality-of-care information and
encourages providers to improve the quality of care.
Hospital quality initiative (established in 2003) β Hospitals must submit data measures or accept a
reduction in payment.
Pay-for-performance measures associated with quality measures
ii.
CMS has removed many previously reportable core measures; however, the institution can
choose which previously required measures to report.
iii.
FY 2026 Payment Determination Hospital IQR Program Measures (selected measures)