CMS Hospital Inpatient Quality Reporting Program Measure Comparison Table Fiscal Year 2017 (Calendar Year 2015)
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1 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name 1 AMI-7a Fibrolytic Therapy Received With 30 Mutes of Arrival 2 Sepsis Severe Sepsis and Septic Shock: Management Bundle 3 CLABSI Central Le-Associated Bloodstream Infection (CLABSI) 4 CAUTI Catheter-Associated Urary Tract Infection (CAUTI) 5 SSI Surgical Site Infections- Colon Surgery (SSI- Colon and SSI- Abdomal Hysterectomy) Repted on not Yes Repted Yes Repted Yes Repted Yes 6 MRSA MRSA Bacteremia Repted Yes 7 CDI Clostridium difficile (C. difficile) Repted Yes Additional Infmation Contue to identify and rept the AMI Initial Patient Population and Sample Size counts Submit either all sample of cases to the warehouse AMI-7a data submitted as will not be cluded HVBP Program Data collection to beg with 4Q 2015
2 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name 8 HCP Influenza Vaccation Coverage Among Healthcare Personnel 9 ED-1 Median Time from ED Arrival to ED Departure f Admitted ED Patients 10 ED-2 Admit Decision Time to ED Departure Time f Admitted Patients Repted on Repted not not Additional Infmation Updated August 2015 Page 2 of 9 11 IMM-2 Influenza Immunization Repted Yes 12 STK-1 Venous Thromboembolism (VTE) Prophylaxis Repted 13 STK-4 Thrombolytic Therapy not 14 STK-6 Discharged on Stat Medication not 15 STK-8 Stroke Education not 16 VTE-1 Venous Thromboembolism Prophylaxis not t required f IQR as a chart-abstracted measure if submittg the rest of STK as s
3 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name 17 VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis 18 VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy 19 VTE-5 Venous Thromboembolism Warfar Therapy Discharge Instructions 20 VTE-6 Acquired Potentially- Preventable Venous Thromboembolism 21 PC-01 Elective Delivery Pri to 39 Completed Weeks Gestation. 22 MORT-30-AMI Acute Myocardial Infarction (AMI) 30-Day Mtality Rate 23 MORT-30-HF Heart Failure (HF) 30-Day Mtality Rate 24 MORT-30-PN Pneumonia (PN) 30-Day Mtality Rate 25 MORT-30- Chronic Obstructive Pulmonary COPD Disease (COPD) 30-Day Mtality Rate Repted on not not not not not Yes Repted Yes Data obtaed Repted Yes Data obtaed Repted Yes Data obtaed Repted Data obtaed Additional Infmation Submit aggregate chartabstracted data through web- based application PC-01 data submitted by will not be cluded HVBP Program. Updated August 2015 Page 3 of 9
4 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name 26 MORT-30-STK Acute Ischemic Stroke (STK) 30- Day Mtality Rate 27 MORT-30- Conary Artery Bypass Graft CABG (CABG) 30-day Mtality Rate 28 READM-30- Acute Myocardial Infarction AMI (AMI) 30-Day Readmission Rate 29 READM-30-HF Heart Failure (HF) 30-Day Readmission Rate 30 READM-30-PN Pneumonia (PN) 30-Day Readmission Rate 31 Hip/Knee -Level 30-Day All-Cause Readmission Risk-Standardized Readmission Rate (RSRR) Followg Elective Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA) 32 HWR -Wide All-Cause 33 READM-30- COPD 34 READM-30- STK 35 READM-30- CABG 36 Hip/Knee Complications Unplanned Readmission (HWR) Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission Rate Repted on Repted Data obtaed Repted Data obtaed Repted Data obtaed Repted Data obtaed Repted Data obtaed Repted Data obtaed Repted Data obtaed Repted Data obtaed Stroke (STK) 30-Day Readmission Repted Data obtaed Rate Conary Artery Bypass Graft Repted Data obtaed (CABG) -Level Risk-Standardized Repted Data obtaed Complication Rate (RSCR) Followg Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) 37 PSI-4 Death Among Surgical Patients with Serious Treatable Complications (Harmonized with Nursg Sensitive Care Measure, Repted Data obtaed Additional Infmation Updated August 2015 Page 4 of 9
5 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name Failure to Rescue) 38 PSI-90 Complication/Patient Safety f Selected Indicats (PSI) (composite) 39 Registry f Nursg Sensitive Care 40 Registry f General Surgery 41 Safe Surgery Checklist Participation a Systematic Clical Database Registry f Nursg Sensitive Care Participation a Systematic Clical Database Registry f General Surgery Repted on Repted Yes Data obtaed Repted Web-based entry Repted Web-based entry Safe Surgery Checklist Use Repted Web-based entry 42 HCAHPS Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) Repted Yes Patient Survey 43 MSPB Medicare Spendg per Beneficiary Repted Yes Data obtaed 44 AMI Payment AMI Payment per Episode of Care Repted Data obtaed 45 HF Payment HF Payment per Episode of Care Repted Data obtaed 46 PN Payment PN Payment per Episode of Care Repted Data obtaed 47 AMI-1 Aspir at Arrival t Repted 48 AMI-3 ACEI ARB f LVSD t Repted 49 AMI-5 Beta-Blocker Prescribed at t Repted Discharge 50 AMI-8a Primary PCI Received With 90 Mutes of Arrival reptg of not Additional Infmation f 4Q 2015 f 4Q 2015 f 4Q 2015 f 4Q 2015 Updated August 2015 Page 5 of 9
6 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name Repted on 52 PN-6 Initial Antibiotic Selection f CAP Immunocompetent Patient 53 SCIP-Inf-1 Prophylactic Antibiotic Received With One Hour Pri to Surgical Incision 54 SCIP-Inf-2 Prophylactic Antibiotic Selection f Surgical Patients 55 SCIP-Inf-3 Prophylactic Antibiotics Discontued With 24 Hours After Surgery End Time 56 SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal 57 SCIP-Inf-9 Urary Catheter Removed on Postoperative Day 1 (POD 1) Postoperative Day 2 (POD 2) with Day of Surgery beg Day Zero 58 SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy Pri to Arrival Who Received a Beta- Blocker Durg the Perioperative Period 59 SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis With 24 Hours Pri to Surgery 51 HF-2 Evaluation of LVS Function t Repted reptg of not reptg of not Additional Infmation f 4Q 2015 f 4Q 2015 Updated August 2015 Page 6 of 9 t Repted reptg of not f 4Q 2015 f 4Q 2015 f 4Q 2015 f 4Q 2015 f 4Q 2015 f 4Q 2015 f 4Q 2015
7 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name Repted on 61 STK-2 Discharged on Antithrombotic Therapy 62 STK-3 Anticoagulation Therapy f Atrial Fibrillation/Flutter 63 STK-5 Antithrombotic Therapy By End of Day 2 reptg of not reptg of not reptg of not 64 STK-10 Assessed f Rehabilitation reptg of not Additional Infmation Updated August 2015 Page 7 of 9 to 24 Hours After Surgery 60 IMM-1 Pneumococcal Immunization t Repted Remove from Specs Manual f 4Q 2015 Will be removed f CMS but will not be removed from manual as it is still collected by TJC Remove from Specs Manual f 4Q 2015 Will be removed f CMS but will not be removed from manual as it is still collected by TJC Remove from Specs Manual f 4Q 2015 Will be removed f CMS but will not be removed from manual as it is still collected by TJC Remove from Specs Manual f 4Q 2015 Will be removed f CMS but will not be removed from manual as it is still collected by
8 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name 65 VTE-4 Venous Thromboembolism Patients Receivg Unfractionated Hepar with Dosages/Platelet Count Monitg by Protocol mogram 66 PC-05 Exclusive Breast Milk Feedg and the subset measure: PC-05a Exclusive Breast Milk Feedgs considerg Mother s Choice 67 EHDI-1a Hearg Screeng Pri to Discharge Repted on reptg of not not not 68 HTN Healthy Term Newbn not 69 CAC-3 Home Management Plan of Care not (HMPC) Document Given to Patient/Caregiver 70 AMI-2 Aspir Prescribed at Discharge Removed reptg of not 71 AMI-10 Stat Prescribed at Discharge Removed reptg of not Additional Infmation TJC f 4Q 2015 Updated August 2015 Page 8 of 9 Removed from Specs ; cannot submit begng with 01/01/2015 Removed from Specs ; cannot submit begng with 01/01/ HF-1 Discharge Instructions Removed Removed from Specs ; cannot submit begng with 01/01/2015
9 CMS Inpatient Quality Reptg Program Measure Comparison Table # ID Measure Name Repted on Additional Infmation 73 HF-3 ACEI ARB f LVSD Removed Removed from Specs ; cannot submit begng with 01/01/ PN-3b Blood Cultures Perfmed the Emergency Department Pri to Initial Antibiotic Received 75 SCIP Inf-10 Surgery Patients with Perioperative Temperature Management 76 SCIP-Inf-4 Cardiac Surgery Patients with Controlled Postoperative Blood Glucose Removed t Repted f 4Q 2015 Removed Removed from Specs ; cannot submit begng with 01/01/2015 Suspended t required f IQR participatg hospitals begng with July 1, 2014 and fward t Repted Suspended not required Cases submitted with SCIP-Inf-4 data elements, specifically Glucose, to be accepted to CMS Clical Warehouse but will not be processed sted If submitted, will not receive feedback on repts Updated August 2015 Page 9 of 9
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