Clinical Process Measures Program Changes for Fiscal Year 2014 Beginning with January 1, 2012 discharges; hospitals will begin data collection and submission for 4 new measures. Hospitals will not be required to submit data for ten (removed or suspended) previously required measures. Added two Immunization measures: IMM-1 - Pneumococcal Immunization IMM-2 - Influenza Immunization Added two Emergency Department (ED) measures: ED-1 - Median Time from Emergency Department Arrival to Time of Departure from the Emergency Room for Patients Admitted to the Facility from the Emergency Department ED-2 - Median Time from Admit Decision Time to Time of Departure from the Emergency Department for Emergency Department Patients Admitted to Inpatient Status Removed measures: AMI-4 - Adult Smoking Cessation Advice/Counseling HF-4 - Adult Smoking Cessation Advice/Counseling PN-2 -Pneumococcal Vaccination Status PN-4 - Adult Smoking Cessation Advice/Counseling PN-5c - Timing of Receipt of Initial Antibiotic Following Hospital Arrival PN-7 - Influenza Vaccination Status Suspended measures (Data collection and submission voluntary): HAI Measures AMI-1 - Aspirin at Arrival AMI-3 - ACEI/ARB for Left Ventricular Systolic Dysfunction AMI-5 - Beta-blocker Prescribed at Discharge SCIP Inf-6 - Appropriate Hair Removal Two new HAI measures are added for data collection beginning with January 2012 events. These are collected by CDC via National Healthcare Safety Network (NHSN) tool: Surgical Site Infection (SSI) SSI Abdominal Hysterectomy SSI- Colon Surgery Catheter-Associated Urinary Tract Infection (CAUTI) 10/2012 Page 1 of 7
Structural Measures Hospital Inpatient Quality Reporting (IQR) Program One measure added: Participation in a Systematic Clinical Database Registry for General Surgery Claims-Based Measures Validation Data entry will be between April 1, 2013 and May 15, 2013 with respect to time period January 1, 2012 through December 31, 2012. One measure added: Medicare Spending per Beneficiary Measure added based on claims data for hospital discharges May 15, 2012 through February 14, 2013. Quarterly sample increased: Sample to include Emergency Department (ED) Immunization (IMM), and Central Line-Associated Bloodstream Infection (CLABSI) measures beginning with 1Q12 record selection. Hospitals submit Validation Blood Culture Template via QualityNet Secure File Exchange to the HAI Validation exchange group. 10/2012 Page 2 of 7
Clinical Process Measures Program Changes for Fiscal Year 2015 Beginning January 1, 2013 discharges, hospitals will begin submitting data for 8 new Stroke measures, 6 new VTE measures, 1 Perinatial Care measure and 3 new HAI measures. They will not be required to submit data for one previously required measure. Added eight Stroke measures: STK-1 - Venous Thromboembolism (VTE) Prophylaxis STK-2 - Discharged on Antithrombotic Therapy STK-3 - Anticoagulation Therapy for Atrial Fibrillation/Flutter STK-4 - Thrombolytic Therapy STK-5 - Antithrombotic Therapy by End of Hospital Day 2 STK-6 - Discharged on Statin Medication STK-8 - Stroke Education STK-10 - Assessed for Rehabilitation Added six VTE measures: VTE-1 - Venous Thromboembolism Prophylaxis VTE-2 - Intensive Care Unit Venous Thromboembolism Prophylaxis VTE-3 - Venous Thromboembolism Patients with Anticoagulation Overlap Therapy 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 - Hospital Acquired Potentially-Preventable Venous Thromboembolism Added one Perinatal Care measure: PC-01 - Elective delivery prior to 39 completed weeks of gestation (Collected in aggregated numerator, denominator, exclusion counts and total population per hospital via a Web-Based Measure Tool). Removed measure: SCIP- VTE-1 - Surgery patients with recommended Venous Thromboembolism (VTE) prophylaxis ordered 10/2012 Page 3 of 7
HAI Measures Hospital Inpatient Quality Reporting (IQR) Program Added three new measures: Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Clostridium difficile (C. diff) Healthcare Personnel Influenza Vaccination (only healthcare personnel physically working in the facility for at least 30 days between October 1 and March 31 should be counted). Notice of Participation Changes Include: Hospitals not participating in the Hospital IQR Program who wish to participate in the Hospital IQR Program for FY2015 payment determination must submit a completed Notice of Participation to CMS on or before December 31, 2012. (New hospitals are still required to complete the Notice of Participation no later than 180 days from the hospital s Medicare Accept Date.) If a hospital chooses to withdraw from the Hospital IQR program, a withdrawal form must be submitted by May 15 prior to the start of the payment year affected. Validation The annual random validation provider sample selection is reduced from 800 to 400 hospitals with a supplemental selection of 200 hospitals based on targeting criteria. In addition, validation results for chart-abstracted clinical process of care and HAI measures will be separated. Changes Include: 15 records selected per quarter for chart-abstracted clinical process of care measures 12 records selected per quarter for HAI measures Quarterly sample will include CLABSI, Catheter-Associated Urinary Tract Infection (CAUTI) and Surgical Site Infection (SSI) measures beginning with 1Q12 record selection. Hospitals submit Validation Blood Culture Template and Validation Urine Culture Template via QualityNet Secure File Exchange to the HAI Validation exchange group. 10/2012 Page 4 of 7
Claims-Based Measures Beginning with FY 2015 payment determination hospitals will have 2 new Hospital Wide Readmission measures and 1 new Surgical Complication measure included. Previously, 8 Patient Safety Indicators, Inpatient Quality Indicators and Composite measures, and 8 Hospital Acquired Condition measures were included. These sixteen will no longer be included. Added Two new measures to Hospital Wide Readmission (HWR) measures: Hospital-Level 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) Following Elective Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) Hospital-Wide All-Cause Unplanned Readmissions (HWR) Added one measure to Hospital-Level Risk Standardized Complications: Hip/Knee Complication: Hospital-level Risk-Standardized Complication Rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) Removed eight measures from Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite measures: PSI 06 - Iatrogenic pneumothorax, adult PSI 11 - Post Operative Respiratory Failure PSI 12 - Post Operative PE or DVT PSI 14 - Postoperative wound dehiscence PSI 15 - Accidental puncture or laceration IQI 11 - Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) IQI 19 - Hip fracture mortality rate IQI 91 - Mortality for selected medical conditions (composite) Removed eight measures from Hospital Acquired Condition (HAC) measures: Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Pressure Ulcer Stages III & IV Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, and Electric Shock) Vascular Catheter-Associated Infection Catheter-Associated Urinary Tract Infection (UTI) Manifestations of Poor Glycemic Control 10/2012 Page 5 of 7
Patients Experience of Care Measures Beginning January 1, 2013 discharges, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is expanding to add five additional questions: Three Item Care Transition measures (CTM-3): 1. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. 2. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. 3. When I left the hospital, I clearly understood the purpose for taking each of my medications. Two About You : 1. During the hospital stay, were you admitted to this hospital through the Emergency Room? 2. In general, how would you rate your overall mental or emotional health? 10/2012 Page 6 of 7
Clinical Process Measures Program Changes for Fiscal Year 2016 Beginning January 1, 2015 discharges, hospitals will be required to submit data for one new Structural Measure. Validation One measure added: Safe Surgery Checklist Use Data entry will be between April 1, 2015 and May 15, 2015 with respect to time period January 1, 2014 through December 31, 2014. Add to the targeting criteria hospitals passing validation in the previous year with a two-tailed confidence interval that included 75 percent. This material was prepared by Telligen, Hospital Inpatient Quality Reporting Program Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. 10SoW-IA-HIQRP-09/12-240 10/2012 Page 7 of 7