The Centers for Medicare & Medicaid Services (CMS) Acute Care Hospital Fiscal Year (FY) 2018 Quality Improvement Program Measures
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1 ID Me asure Name NQF # - (HRRP) ID Me asure Name NQF # - (HRRP) ID Me asure Name NQF # - (HRRP) CMS Measures Fiscal Year 2018 The Centers for Medicare & Medicaid Services (CMS) Acute Care Fiscal Year (FY) 2018 Improvement Measures IQR IQR VBP VBP - HACRP HACRP (HRRP) HRRP HRRP Chart-Abstracted Measures ED-1 ED-2 Median Time from ED Arrival to ED Departure for Admitted ED Patients Admit Decision Time to ED Departure Time for Admitted Patients No No No No No No No No IMM-2 Influenza Immunization Note : The IMM-2 measure is collected for all 4 quarters; however, only discharges included in 1st and 4th quarters will be included in the measure calculation. The IMM-2 measure is reported by flu season on CMS's Compare site Flu Season: December Flu Season: December 2017 No No No No PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation 0469 December 2017 No No No Sepsis Severe Sepsis and Septic Shock: Management Bundle (Composite Measure) 0500 No No No No STK-04 Thrombolytic Therapy 0437 VTE-5 VTE-6 NHSN Measures Venous Thromboembolism Discharge Instructions Incidence of Potentially Preventable Venous Thromboembolism No No No No No No No No No No No No CLABSI CAUTI Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure December 2017 No December 2017 No December 2017 No December 2017 No Colon and Abdominal Hysterectomy SSI American College of Surgeons Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure Colon Procedures Hysterectomy Procedures 0753 December 2017 No December 2017 No MRSA Bacteremia Facility-wide -onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure 1716 December 2017 No December 2017 No CDI Facility-wide -onset Clostridium difficile Infection (CDI) Outcome Measure 1717 December 2017 No December 2017 No HCP Influenza Vaccination Coverage Among Healthcare Personnel 0431 October 1, March 31, December No No No No Patient Survey HCAHPS Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey + 3 Item Care Transition Measure (CTM-3) December 31, December 2017 No No No January 1
2 ID Me asure Name NQF # - (HRRP) CMS Measures Fiscal Year 2018 IQR IQR VBP VBP - HACRP HACRP (HRRP) HRRP HRRP Claims-Based Measures MORT-30-AMI MORT-30-HF MORT-30-PN 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (AMI) ization 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Heart Failure (HF) ization 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Pneumonia ization October 1, June 30, 2012 October 1, October 1, June 30, 2012 October 1, October 1, June 30, 2012 October 1, December 2017 No No No December 2017 No No No December 2017 No No No MORT-30-COPD 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Chronic Obstructive Pulmonary Disease (COPD) ization 1893 No No No No STK Mortality Stroke 30-day Mortality Rate No No No No CABG Mortality 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery 2558 No No No No READM-30-AMI 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) Following Acute Myocardial Infarction (AMI) ization 0505 No No No READM-30-HF 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Heart Failure (HF) ization 0330 No No No READM-30-PN 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Pneumonia ization 0506 No No No READM-30-THA/TKA READM-30-HWR -Level 30-Day, All-Cause Risk- Standardized Readmission Rate (RSRR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) -Wide All-Cause Unplanned Readmission Measure (HWR) July 1, No No No No No No No COPD READMIT 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Chronic Obstructive Pulmonary Disease (COPD) ization 1891 No No No STK READMIT 30-Day Risk Standardized Readmission Rate Following Stroke ization No No No No CABG READMIT 30-Day, All-Cause, Unplanned, Risk- Standardized Readmission Rate (RSRR) Following Coronary Artery Bypass Graft (CABG) Surgery 2515 No No No Hip/Knee Complications PSI 4 (PSI/NSI) -Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Death among Surgical s with Serious, Treatable Complications April 1, March 31, July 1, No No No No No No No No January 2
3 ID Me asure Name NQF # - (HRRP) ID Me asure Name NQF # - (HRRP) CMS Measures Fiscal Year 2018 PSI-90 MSPB ID Measure Name NQF # Patient Safety for Selected Indicators (Composite Measure) Payment-Standardized Medicare Spending Per Beneficiary (MSPB) IQR July 1, December 31, IQR VBP July 1, June 30, 2012 July 1, VBP - December 2017 No HACRP July 1, HACRP (HRRP) HRRP HRRP December 2017 No December 2017 No No No AMI Payment -Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction (AMI) 2431 No No No No HF Payment PN Payment -Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care For Heart Failure (HF) -Level, Risk-Standardized Payment Associated with a 30-day Episode-of-Care For Pneumonia No No No No No No No No THA/TKA Payment Level, Risk Standardized Payment Associated with an Episode-of-Care for Primary Elective Total Hip Arthroplasty and/or Total Knee Arthroplasty April 1, March 31, No No No No Kidney/UTI Payment Cellulitis Payment GI Payment Kidney/Urinary Tract Infection Clinical Episode- Based Payment Measure Cellulitis Clinical Episode-Based Payment Measure Gastrointestinal Hemorrhage Clinical Episode- Based Payment Measure No No No Dry Run Only Dry Run Only Dry Run Only No No No No No No No No No No No No AMI Excess Days Excess Days in Acute Care after ization for Acute Myocardial Infarction No No No No HF Excess Days Structural Excess Days in Acute Care after ization for Heart Failure Patient Safety Culture Survey on Patient Safety Culture Registry for Nursing Sensitive Care Registry for General Surgery Participation in a Systematic Clinical Database Registry for Nursing Sensitive Participation in a Systematic Clinical Database Registry for General Surgery Safe Surgery Checklist Safe Surgery Check List Use No No No No December 2017 No No No No December 2017 No No No No December 2017 No No No No December 2017 No No No No AMI-2 Aspirin Prescribed at Discharge for AMI 0142 * Submit for 1 Calendar Year (CY) Quarter (Q3 or Q4) AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Arrival 0164 * AMI-8a Primary PCI Received Within 90 Minutes of Arrival 0163 * January 3
4 CMS Measures Fiscal Year 2018 IQR IQR VBP VBP - HACRP HACRP (HRRP) HRRP HRRP AMI-10 Statin Prescribed at Discharge * CAC-3 Home Management Plan of Care Document Given to Patient/Caregiver * ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients 0495 * ED-2 Admit Decision Time to ED Departure Time for Admitted Patients 0497 * ED-3 Median Time from ED Arrival to ED Departure for Discharged ED Patients 0496 No No ** EHDI-1a Hearing Screening Prior to Discharge 1354 * HTN Healthy Term Newborn 0716 * PC-01 Elective Delivery (Collected in aggregate) 0469 * PC-05 Exclusive Breast Milk Feeding and the Subset Measure PC-05a Exclusive Breast Milk Feeding Considering Mother s Choice 0480 * PN-6 Initial Antibiotic Selection for Community- Pneumonia (CAP) in Immunocompetent Patients 0147 * January 4
5 CMS Measures Fiscal Year 2018 IQR IQR VBP VBP - HACRP HACRP (HRRP) HRRP HRRP SCIP-Inf-1a Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 0527 * SCIP-Inf-2a Prophylactic Antibiotic Selection for Surgical Patients 0528 * SCIP-Inf-9 Urinary catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with Day of Surgery Being Day Zero * STK-02 Discharged on Antithrombotic Therapy 0435 * STK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter 0436 * STK-04 Thrombolytic Therapy 0437 * STK-05 Antithrombotic Therapy by the End of Day Two 0438 * STK-06 Discharged on Statin Medication 0439 * STK-08 Stroke Education * STK-10 Assessed for Rehabilitation 0441 * January 5
6 CMS Measures Fiscal Year 2018 IQR IQR VBP VBP - HACRP HACRP (HRRP) HRRP HRRP VTE-1 Venous Thromboembolism Prophylaxis 0371 * VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis 0372 * VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy 0373 * VTE-4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram * VTE-5 Venous Thromboembolism Discharge Instructions * VTE-6 Incidence of Potentially Preventable Venous Thromboembolism * Footnotes (*) A hospital may choose to submit this measure as one of the four ecqms required for the IQR. (**) A hospital may choose to submit this measure as: one of the 16 ecqms required for the for submission through the CMS Registration and Attestation system or one of the four required for the for submission through the Net Secure Portal. Updates to Document Date of Update Summary of Update 01/27/ Updated time of the -Wide All-Cause Unplanned Readmission Measure (HWR) (READM-30-HWR) in the to display July 1, 2015-June 30, in place of. January 6
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