Crosswalk hospital inventory changes

Attachment 11c_Crosswalk of hospital inventory changes_Clean.xlsx

Paul Coverdell National Acute Stroke Program (PCNASP) Reporting System

Crosswalk hospital inventory changes

OMB: 0920-1108

Document [xlsx]
Download: xlsx | pdf





Green - Required











Blue - Optional






Modified question Deleted question New required question New optional question
Current PCNASP Hospital Inventory Survey (0920-1108; exp. 9/30/2022)
Requested changes

Original Data element Original question Response options
Data element Revised question Response options Change description
1



RUCA What is your hospital’s Rural-Urban Commuting Area (RUCA) code? To determine this, navigate to the Rural Health Information Hub website (https://www.ruralhealthinfo.org/am-i-rural). Enter your hospital’s address in the search bar and click “locate”. Then click on the orange “run report” button in the map. Scroll down to find your hospital’s RUCA Code by census tract (e.g. 1.1) and provide this number for the inventory survey Numeric response
RUCA What is your hospital’s Rural-Urban Commuting Area (RUCA) code? To determine this, navigate to the Rural Health Information Hub website (https://www.ruralhealthinfo.org/am-i-rural). Enter your hospital’s address in the search bar and click “locate”. Then click on “Run Report” button in the map. Scroll down to “Rural Urban Commuting Areas (RUCAs) by census tract” to find your hospital’s RUCA Code (two digit number, e.g. 1.1, 1.0) and provide this number for the inventory survey. Numeric response Modification to add more instructions for clarity and accurate data.

1


AISDsch Total number of acute ischemic stroke discharges in the most recent calendar year Numeric response



Optional question deleted as this is data is not core to the program

1


TIADsch Total number of TIA discharges in the most recent calendar year Numeric response



Optional question deleted as this is data is not core to the program

1


SAHDsch Total number of subarachnoid hemorrhagic stroke discharges in the most recent calendar year Numeric response



Optional question deleted as this is data is not core to the program

1


ICHDsch Total number of intracerebral hemorrhagic stroke discharges in the most recent calendar year Numeric response



Optional question deleted as this is data is not core to the program

1


SNSDsch Total number of stroke (type unspecified) discharges in the most recent calendar year Numeric response



Optional question deleted as this is data is not core to the program


1





SAHAText Text response for We admit or transfer depending on staff availability or other factors (please describe) Text response New required data element for text responses


1





ICHAText Text response for We admit or transfer depending on staff availability or other factors (please describe) Text response New required data element for text responses

1


DysScrn Dysphagia screening Yes
No




Required question deleted to align with program activities and focus under new cooperative agreement.

1


DschProt Discharge planning protocols Yes
No




Required question deleted to align with program activities and focus under new cooperative agreement.

1


PostDscF Post-discharge follow-up care protocols Yes
No




Required question deleted to align with program activities and focus under new cooperative agreement.

1


ContECG Do all stroke patients receive continuous ECG monitoring for at least 24 hours during admission? Yes
No




Required question deleted as information is not core to the program. Other questions have been modified to align with scientific advancements
1



Neur_247 If yes to (5), does your hospital have neurosurgical services available 24/7 (may be on-site or at a remote location)? Always
Sometimes
Never

Neur_247 If yes to (4), does your hospital have neurosurgical services available 24/7 (may be on-site or at a remote location)? Always
Sometimes
Rarely
Never
Modification to add response option for data clarity and response
1



Neur_2hr If never to (5a), does your hospital have neurosurgical services available within 2 hours of patient arrival (may be on-site or at a remote location)? Always
Sometimes
Never

Neur_2hr If never to (4a), does your hospital have neurosurgical services available within 2 hours of patient arrival (may be on-site or at a remote location)? Always
Sometimes
Rarely
Never
Modification to add response option for data clarity and response
1



Neurint Does your hospital have stroke neurointerventional capabilities? Yes
No

Neurint Does your hospital provide neurointerventional treatment/mechanical thrombectomy? Yes
No
Modification to align with stroke care guidelines and provide clarity

1


Neurint1
Neurint2
Does your hospital provide neurointerventional treatment for Intra-arterial alteplase
Catheter-based reperfusion/mechanical thrombectomy




Required question deleted because information is already captured in modified above question.
1



EMSPreN Does pre-notification by EMS regarding a suspected stroke case lead to activation of the stroke team? Always
Sometimes
Never
No pre-notification

EMSPreN How often does pre-notification by EMS regarding a suspected stroke case lead to activation of the stroke team? Always
Sometimes
Rarely
Never
No pre-notification
Modification to provide clarity and add respnse option
1



PreNProt Does pre-notification lead to activation of written stroke care protocols (e.g. notification to pharmacy, “clearing” of CT scanner)? Always
Sometimes
Never
No pre-notification

PreNProt How often does pre-notification lead to activation of written stroke care protocols (e.g. notification to pharmacy, “clearing” of CT scanner)? Always
Sometimes
Rarely
Never
No pre-notification
Modification to provide clarity and add respnse option


1





TranProt Does your hospital have written protocols for stroke patients transferred to and from your hospital? Yes
No
New required question to capture information on stroke patients that are transferred and understand hospital capacity in improving and streamlining care for these patients.
1



EMS_Run Does your hospital enter EMS run sheets into a Coverdell-specific in-hospital data collection tool (e.g., GWTG, state-based system)? Always
Sometimes
Rarely
Never

EMS_Run How often does your hospital upload any EMS data (electronically or manually) into stroke patient’s eHR? Always
Sometimes
Rarely
Never
Modification to align with recent changes to data systems and capture data more relevant to the program.

1


EMSFeed_1
EMSFeed_2
EMSFeed_3
EMSFeed_4
EMSFeed_5
If yes to (5), how is the feedback provided to EMS agencies? Fax
Email
Phone
In-person (for example, at a meeting or during a case review)
Other (please specify):




Required question deleted to reduce burden as data is not core to the program

1


EMSFd_P1
EMSFd_P2
EMSFd_P3
EMSFd_P4
EMSFd_P5
If yes to (5), for what patient population is feedback provided? Patients transported by EMS with a final diagnosis of stroke with pre-notification of possible stroke
Patients transported by EMS with a final diagnosis of stroke without pre-notification of possible stroke
Possible stroke patients for whom EMS pre-notified the hospital, regardless of the final diagnosis
Unknown
Other (please specify):




Required question deleted to reduce burden as data is not core to the program


1





Feed_FRQ How often does your hospital provide feedback to EMS agencies? Always
Sometimes
Rarely
Never
New required question to capture information on EMS feedback to measure improvement and hospital engagement in this area

1


EMSCord Does your hospital have an EMS coordinator? Yes
No




Required question deleted as information in not core to program.

1


EMSInt [Optional] To what extent has the interaction between the ED and EMS providers changed during the past calendar year, compared to the prior calendar year, with respect to the following:
a. Communication
Substantial improvement
Minimal improvements
No improvement
Minimal decline
Substantial decline




Optional question deleted as the evalution of these activites are assessed in other better aligned questions in the survey.

1


EMSint_d b. Data exchange Substantial improvement
Minimal improvements
No improvement
Minimal decline
Substantial decline




Optional question deleted as the evalution of these activites are assessed in other better aligned questions in the survey.





TOC_S Do you utilize a transition of care summary with stroke patients during discharge? (The National Transitions of Care Coalition (NTOCC) defines a transition of care summary as a method of communication between sending and receiving providers and patient/family/caregivers. Use of a transition of care summary has been proven to reduce readmission rates and decrease medical errors.) Always
Sometimes
Rarely
Never

TOC_S How often do you utilize a transition of care summary with stroke patients during discharge? (The National Transitions of Care Coalition (NTOCC) defines a transition of care summary as a method of communication between sending and receiving providers and patient/family/caregivers. Use of a transition of care summary has been proven to reduce readmission rates and decrease medical errors.) Always
Sometimes
Rarely
Never
Modification for clarity

1


TOC_F Does your hospital conduct post-discharge follow-up on patients discharged to home? Yes
No




Required question deleted to align with program activities and focus under new cooperative agreement.

1


TOC_FT If yes to (2), how long after discharge does this follow-up typically take place? 1-7 days
8-14 days
15-21 days
22-30 days
>30 days




Required question deleted to align with program activities and focus under new cooperative agreement.

1


TOC_FL1
TOC_FL2
TOC_FL3
TOC_FL4
TOC_FL5
Do you follow-up with (select all that apply): All patients discharged home
A sample of patients discharged home
Only cases that were treated with IV alteplase
Only cases that were treated with IV alteplase and/or thrombectomy
Other: (text)




Required question deleted to align with program activities and focus under new cooperative agreement.


1





RefTrack Has your hospital implemented a system for tracking referrals provided to stroke patients to support their post hospital transition of care? Yes, fully implemented
Yes, partially implemented
No referral tracking system
New required question to capture data for program evaluation of post stroke hospital transitions
1



TOC_res Does your hospital utilize an inventory of community resources to make referrals for post-stroke needs? Yes
No

TOC_res How often does your hospital utilize an inventory of community resources to make referrals for post-stroke needs, including resources that can meet patients’ medical, social, and functional needs? Always
Sometimes
Rarely
Never
Mofification to response options and the question to align with program focus and provide additional context for this area of stroke care


1





Partnr_1
Partnr_2
Partnr_3
Partnr_4
Partnr_5
Has your hospital established partnerships with any of the following? Please count any that your hospital participates in or provides resources to as a partnership (provide an estimated number next to each): ____ State or local stroke coalition
____ State or local stroke initiatives
____ State or local professional organizations
____ National stroke initiatives or organizations
____ Other (open text – provide number in parenthesis (eg. state coalition (2), national association (2)):
New required question to capture data for program evaluation of stroke partnerships


1





CPACHW Does your hospital have a Collaborative Practice Agreement (CPA) in place that includes community health workers (CHWs)? Yes
No
New required question to capture data for program evaluation of post stroke hospital transitions


1





CPASOP If yes to (5), specific to CHWs, does the CPA include a CHW scope of practice? Yes
No
New required question to capture data for program evaluation of post stroke hospital transitions


1





CPAComm Does the CPA ensure that CHW scope of practice maintains CHWs’ connections to the community? Yes
No
New required question to capture data for program evaluation of post stroke hospital transitions


1





CPARefer How often does your hospital utilize community health workers to refer stroke survivors to resources that can meet their medical, social, and functional needs post-discharge? Always
Sometimes
Rarely
Never
Do not utilize community health workers
New required question to capture data for program evaluation of post stroke hospital transitions
1



NeurRes
Does your hospital have the following residency or fellowship programs?
a. Neurology
Yes
No

NeurRes Does your hospital have a residency or fellowship programs (neurology or other/residency fellowship)? Yes
No
Modified question to consolidate two question that captured similar information

1


OthRes b. Other residency/ fellowship program Yes
No




Required question deleted to align with modified question above
1



JCPSC_1
JCPSC_2
JCPSC_3
JCPSC_4
JCPSC_5
JCPSC_6
JCPSC_7
Is your hospital currently certified as a Joint Commission Acute Stroke Ready Hospital (JC ASRH), Joint Commission Primary Stroke Center (JC PSC), Joint Commission Comprehensive Stroke Center (JC CSC), Joint Commission thrombectomy capable stroke center (TSC) or other similar organization such as Det Norske Veritas (DNV) or Healthcare Facilities Accreditation Program (HFAP)? (select all that apply) JC ASRH
JC PSC
DNV PSC
HFAP PSC 
JC CSC
DNV CSC
JC thrombectomy-capable stroke center (TSC)

StrkCert 2. Is your hospital currently certified as a Joint Commission Acute Stroke Ready Hospital (JC ASRH), Joint Commission Primary Stroke Center (JC PSC), Joint Commission Comprehensive Stroke Center (JC CSC), Joint Commission thrombectomy capable stroke center (TSC) or other similar organization such as Det Norske Veritas (DNV) or Healthcare Facilities Accreditation Program (HFAP)? Yes
No
Modified question to consolidate the individual data captured into yes/no question. Also changed data element name.

1


Desn_Y
Desn_Reg
Desn_No
Does your state/county/region/locality have a stroke designation program? Yes, state stroke designation program
Yes, county/regional/local-level stroke designation
No, there is no state/county/regional/local-level designation program




Required question deleted because question is not core to the program. Relevant question on certification of hospital is capured elsewhere.

1


StDesn1
StDesn2
StDesn3
StDesn4
If yes to (3), is your hospital currently designated by that entity as a stroke center or stroke capable/ready hospital? (select all that apply) Stroke Center (State designation)
Stroke Capable/Ready (State designation)
Stroke Center (County/regional/local designation)
Stroke Capable/Ready (County/regional/local designation)




Required question deleted because question is not core to the program. Relevant question on certification of hospital is capured elsewhere.

1


TeleStk1
TeleStk2
TeleStk3
[Optional] If yes to (4), what mode does the telemedicine consult take place? (select all that apply) Telephone call
Interactive video/videoconference
Other (e.g., teleradiology), please specify:




Optional question deleted because question is not core to the program. Relevant information on telestroke is capured elsewhere.

1


TelCon1
TelCon2
TelCon3
[Optional] If yes to (5), what mode does the telemedicine consult take place? (select all that apply) Telephone call
Interactive video/videoconference
Other (e.g., teleradiology), please specify:




Optional question deleted because question is not core to the program. Relevant information on telestroke is capured elsewhere.

1


CommEdu [Optional] Does your hospital provide community education on stroke signs and symptoms and importance of calling 911?




Optional question deleted because question is no longer core to the program.

1


DataAbs_1
DataAbs_2
DataAbs_3
DataAbs_4
DataAbs_5
DataAbs_6
Who is responsible for data abstraction? Physician
Stroke nursing staff/stroke team member
Medical records staff
QI department staff
Other hospital staff (please specify): _____________
Outsourced




Question no longer needed as this is not core the program and hospital capacity data.

1


Abs_Mtd What process is used for data abstraction? Mostly or completely concurrent with care
Mostly or completely retrospective
Roughly equal-- data collected concurrent with care and retrospective




Question no longer needed as this is not core the program and hospital capacity data.

1


Sample Does your hospital sample cases to abstract for data that is submitted to Coverdell? Yes
No




Question no longer needed as this is not core the program and hospital capacity data. States determine sampling methods so this information is not needed at the CDC level.

1


SampleDes If yes to (4), please briefly describe your sampling method (e.g. following The Joint Commission’s requirements), including the percentage of cases that are sampled Open text



Question no longer needed as this is not core the program and hospital capacity data. States determine sampling methods so this information is not needed at the CDC level.

1


EHR What electronic health record system does your hospital use for stroke cases? Allscripts
Centricity
Cerner
Computer Programs and Systems Inc (CPSI)
eClinicalWorks
Epic Systems
McKesson
Meditech
NextGen Healthcare
Other (please specify):




Question has been removed and replaced with one that will capture data more relevant to the program and stroke data integration.


1





HIE Does your hospital contribute data to a state health information exchange (HIE)? Yes
No
new question to replace previous question to capture relevant state level EHR data integration


1





EHR_Use Does your hospital use the EHR system and standardized clinical quality measures to track differences between populations at highest risk for stroke events compared to all stroke patients for any of the following? Stroke risk factors
Acute stroke care
Referrals for post-stroke care
New question to capture use of patient data to identify at risk groups to reduce rehabilitation and prevent strokes.


1





DataQI_1
DataQI_2
DataQI_3
DataQI_4
DataQI_5
DataQI_6
DataQI_7
DataQI_8
G2. During the past 12 months, did your hospital conduct data-driven quality improvement initiatives (e.g. the Plan-Do-Study-Act model, small tests of change, lean, six-sigma) related to stroke care to address any of the following? Use of Multidisciplinary Teams for Care Management
Electronic Health Record (EHR) and Patient Tracking Systems
Self-Management and Care Management
Clinical Guidelines
Clinical Decision Support and Protocols
Patient Education
Other (please specify)
Did not do any data-driven quality improvement in the past 12 months
New question for program evaluation of quality improvement to better align with scope and focus of program under new cooperative agreement









DataText Text response for G2. DataQI_7 if “Other” option selected Text response Data element to capture text resonse

1


DataRPT1
DataRPT2
DataRPT3
DataRPT4
DataRPT5
DataRPT6
DataRPT7
Who receives data reports on your stroke quality of care? Hospital CEO/ upper management
Hospital Board
Chief Nursing Officer (CNO)
Stroke Team
Physician Stroke Champion
Chief of Medicine
Other (please specify):




Question removed as this is not core to the program and information will not be used in program evaluation.

1


QI_Imp
QI_Text
How many systematic quality improvement interventions were implemented by hospital staff as a result of quality of care data reports? Please briefly describe each one (e.g. if there was one that was particularly successful, and if it addressed a specific problem). Number
Description




Question removed as other questions (new and modified) help to capture the necessary information needed to evaluate program related quality improvement.

1


Analyses [Optional] In the most recent calendar year, have you run additional analyses (beyond what was required for reporting) on your hospital’s own stroke data? Yes
No




Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPart Did you participate in any QI activities (e.g. QI training, networking meetings, learning collaboratives) offered through the State health department Coverdell program? Yes
No




Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPart_N If yes to (1), how many? numeric



Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPart_S [Optional, but can be used for process and outcome performance measure (POPM) data collection] Has your stroke team implemented structured quality improvement strategies (e.g. PDSA (Plan-Do-Study-Act) cycles, small tests of change, lean, six-sigma) to improve
quality of care in the most recent calendar year?
Yes
No




Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPart_P If yes to (2), Describe the problem(s) addressed Text



Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPart_R Briefly describe results Text



Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPart_H Was this a helpful way to address the problem? Yes
No




Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPart_W Why or why not? Text



Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPart_C What challenges did you encounter? Text



Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPrt_PO [Optional, but can be used for process and outcome performance measure (POPM) data collection] As a result of participating in the registry the most recent calendar year, what stroke policies or system changes has your hospital implemented? Text



Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPrt_CH Have you assessed the impact of any of these changes, for example, by examining changes in data/performance measures? Yes
No




Optional question removed because evaluation of quaity improvement activities is captured elsewhere.

1


QIPrt_BU [Optional] To what extent do you have buy-in from upper management (i.e. hospital CEO/board/upper management) to implement stroke QI initiatives? A great deal of support
A fair amount of support
Little support
No support




Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities.

1


QIPrt_OT [Optional] Do you have other QI initiatives that are not directly related to stroke care at your hospital? Yes
No




Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities.

1


QIPrt_IN If yes to (5), are your stroke QI initiatives integrated with other QI initiatives in your hospital? Yes
No




Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities.

1


QIPrt_PR If yes to (5), compared to other QI initiatives, how important/prioritized are QI initiatives around stroke? Much more important
A little more important
Equally important
A little less important
A lot less important




Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities.

1


QIPrt_AF If yes to (5), how do you think other hospital QI initiatives affect your stroke QI initiatives? Complement 
Hinder
Do not affect




Optional question removed as this is not core to the program and data is not used to assess/evalutate program activities.


1





QI_Rslt Did your hospital’s data-driven quality improvement initiatives lead to a change in hospital stroke policies or systems? Yes, please describe.
_________________________________
No
Not applicable
New question for program evaluation of quality improvement to better align with scope and focus of program under new cooperative agreement


1





QI_Imprv Did your hospital’s data-driven quality improvement initiatives lead to an improvement in a performance measure of care (e.g. door-to-needle time, proportion of eligible patients receiving IV tPA)? Yes, please describe the improvement and the measure.
__________________________
No
Not applicable
New question for program evaluation of quality improvement to better align with scope and focus of program under new cooperative agreement
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