National Hospital Inpatient Quality Reporting Measures Specifications Manual

National Hospital Inpatient Quality Reporting Measures Specifications Manual Release Notes Version: 5.0 Release Notes Completed: March 9, 2015 Guidelines for Using Release Notes The Release Notes Version 5.0 provides modifications to the Specifications Manual for National Hospital Inpatient Quality Measures. The information in this document is to be used as a reference and is not intended to be used to program abstraction tools. Please refer to the Specifications Manual for National Hospital Inpatient Quality Measures for the complete and current technical specifications and abstraction information. The notes are organized to follow the order of the Table of Contents. The implementation date is 10-01-2015, unless otherwise specified. The headings are described below: Impacts - used to identify the impacted measures and portion(s) of the Manual Section. (i.e., Alphabetical Data Dictionary, Measure Information Form (MIF) and Flowchart (Algorithm)). Description of Changes - used to identify the section within the document where the change occurs, e.g., Definition, Data Collection Question, Allowable Values, and Denominator Statement - Data Elements. Rationale - provided for the change being made. Data elements that cross multiple measures and contain the same changes will be consolidated.

Table of Contents Note: click on any section title in the Release Notes to return to Table of Contents page Table of Contents... 1 Acknowledgement... 3 Introduction... 3 Using the Specifications Manual for National Hospital Inpatient Quality Measures... 4 SECTION 1 Data Dictionary... 5 Introduction to Data Dictionary... 5 Alphabetical Data Dictionary... 6 SECTION 2 Measurement Information... 36 Subsection 2.1 Acute Myocardial Infarction (AMI)... 37 Subsection 2.2 Severe Sepsis and Septic Shock (SEP)... 40 Subsection 2.3 Surgical Care Improvement Project (SCIP)... 40 Subsection 2.5 Children s Asthma Care (CAC)... 46 Subsection 2.6 Venous Thromboembolism (VTE)... 47 Subsection 2.7 Stroke (STK)... 55 Subsection 2.8 Global Initial Patient Population (ED, IMM, TOB, SUB)... 60 Subsection 2.9 Emergency Department (ED)... 60 Subsection 2.10 Prevention... 61 2.10.1 Immunization (IMM)... 61 2.10.2 bacco Treatment (TOB)... 63 2.10.3 Substance Use (SUB)... 66 SECTION 3 Missing and Invalid Data... 70 SECTION 4 Population and Sampling Specifications... 71 SECTION 9 Data Transmission... 73 Transmission Alphabetical Data Dictionary... 78 Transmission Data Processing Flow: Clinical... 79 Transmission Data Processing Flow: Population and Sampling... 80 Hospital Clinical Data XML File Layout... 80 Hospital Initial Patient Population Data XML File Layout... 92 SECTION 10 CMS Outcome Measures (Claims Based)... 93 Subsection 10.1 Introduction Risk Standardized Mortality Measures... 93 Subsection 10.2 Introduction Risk Standardized Readmission and Complication Measures 93 Subsection 10.3 Agency for Healthcare Research and Quality (AHRQ) Measures... 95 Subsection 10.4 Healthcare Associated Infections (HAI) Measures... 95 Subsection 10.5 CMS Episode-of-Care Payment Measures... 95 Subsection 10.6 Structural Measures... 95 APPENDICES... 96 Appendix A ICD-10 Code Tables... 96 Appendix C Medication Tables... 97 Appendix D Glossary of Terms... 100 Appendix E Overview of Measure Information Form and Flowchart Formats... 103 Appendix F Measure Name Crosswalk... 103 Appendix G Resources... 105 Appendix H Miscellaneous Tables... 106 Appendix P Preview Section... 107 Specifications Manual for Hospital Inpatient Quality Measures Page i

The content below is organized to follow the Table of Contents in the specifications manual. Table of Contents Section 2 Measure Information Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Section 2 Measure Information 2.1 Acute Myocardial Infarction (AMI) Measure Information Form (MIF) and Flowchart (algorithm) Remove: AMI-1, AMI-3, AMI-5, AMI-7, AMI-8, AMI-8a Remove entire section: 2.2 Heart Failure (HF) 2.3 Pneumonia (PN) Surgical Care Improvement Project (SCIP) Change subsection title from: 2.4 Surgical Care Improvement Project (SCIP) 2.3 Surgical Care Improvement Project (SCIP) Measure Information Form (MIF) and Flowchart (Algorithm) SCIP Infection Module Remove: SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-6, SCIP-Inf-9 SCIP Cardiac Module SCIP-Card-2 SCIP VTE Module SCIP-VTE-2 Children s Asthma Care (CAC) Change subsection title from: 2.6 Children s Asthma Care (CAC) 2.5 Children s Asthma Care (CAC) Venous Thromboembolism (VTE) Change subsection title from: 2.7 Venous Thromboembolism (VTE) 2.6 Venous Thromboembolism (VTE) Measure Information Form (MIF) and Flowchart (Algorithm) Remove: VTE-4 Specifications Manual for Hospital Inpatient Quality Measures Page 1

Stroke (STK) Change subsection title from: 2.8 Stroke (STK) 2.7 Stroke (STK) Global Initial Patient Population Change subsection title from: 2.9 Global Initial Patient Population (ED, IMM, TOB, SUB) 2.8 Global Initial Patient Population (ED, IMM, TOB, SUB) Emergency Department (ED) Change subsection title from: 2.10 Emergency Department (ED) 2.9 Emergency Department (ED) Prevention Change subsection title from: Section 2.11 Prevention 2.11.1 Immunization (IMM) 2.11.2 bacco Treatment (TOB) 2.11.3 Substance Use (SUB) Section 2.10 Prevention 2.10.1 Immunization (IMM) 2.10.2 bacco Treatment (TOB) 2.10.3 Substance Use (SUB) Appendices Remove under A.1 : HF, PN Section 2 Measure Information Rationale: A new measure set is being added to align with CY 2015 IPPS Final Rule. Add: 2.2 Severe Sepsis and Septic Shock (SEP) Sepsis National Hospital Inpatient Quality Measures SEP Data Element List SEP Initial Patient Population SEP Initial Patient Population Algorithm SEP Sample Size Requirements Measure Information Form (MIF) and Flowchart (Algorithm) SEP-1 Specifications Manual for Hospital Inpatient Quality Measures Page 2

Appendices Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. ICD-9-CM Code Tables ICD-10 Code Tables Appendices Rationale: A new measure set is being added to align with CY 2015 IPPS Final Rule. A.1 ICD-10 Code Tables Add: SEP Acknowledgement No updates in the Acknowledgement section. Introduction Priority Focus Process Strategic Surveillance System (S3 ) Rationale: Remove references to processes no longer used. Remove following sections: Priority Focus Process The Priority Focus Process (PFP) is a data-driven tool that helps focus survey activity on issues most relevant to patient safety and quality of care at the specific health care organization being surveyed. The survey is directed by a PFP that aggregates organizationspecific information through an automated, rules-based tool. Input information includes ORYX measure data, previous recommendations, demographic data related to clinical service groups and diagnostic-related groups, complaints, sentinel event information, and MedPar data. The process identifies systems and processes that are relevant to patient safety and healthcare quality. Strategic Surveillance System (S3 ) The Strategic Surveillance System is a benefit provided to hospitals accredited by the Joint Commission. S3 is a tool that provides a series of risk assessment and comparative performance measure reports to help hospitals improve their care processes. Specifically S3 uses data the Joint Commission currently has, which includes past survey findings, ORYX core measure data, data from the Office of Quality Monitoring (complaints and non-selfreported sentinel events), data from an organization s electronic application and Med PAR data. Specifications Manual for Hospital Inpatient Quality Measures Page 3

Using the Specifications Manual for National Hospital Inpatient Quality Measures N/A Rationale: These changes are needed to revise outdated language. Change throughout document: QIO Clinical Warehouse CMS Clinical Warehouse N/A Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Appendix A ICD-9-CM Code Tables Change sub-header from: Appendix A ICD-9-CM Code Tables Appendix A ICD-10 Code Tables Change in first sentence in paragraph: ICD-9-CM diagnosis and procedure ICD-10-CM diagnosis and ICD-10-PCS procedure Change in second sentence in paragraph: ICD-9-CM code tables ICD-10 code tables Change in fifth sentence in paragraph: ICD-9-CM codes ICD-10 codes Specifications Manual for Hospital Inpatient Quality Measures Page 4

SECTION 1 Data Dictionary Introduction to Data Dictionary N/A Rationale: Changes related to the conversion of ICD-9 to ICD-10 and removal of measures and/or data elements. Introduction ICD-9-CM Other Diagnosis Codes ICD-9-CM Other Procedure Codes ICD-9-CM Other Procedure Dates ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code ICD-9-CM Principal Procedure Date ICD-10-CM Other Diagnosis Codes ICD-10-PCS Other Procedure Codes ICD-10-PCS Other Procedure Dates ICD-10-CM Principal Diagnosis Code ICD-10-PCS Principal Procedure Code ICD-10-PCS Principal Procedure Date Missing and Invalid Data QIO Clinical Warehouse CMS Clinical Warehouse Interpretation of Data Dictionary Terms Change in third bullet: Infection Prior to Anesthesia ED Departure Date SCIP measures ED measures Medical Record Documentation Change in fifth paragraph, first bullet under Examples : Antibiotic Administration Time ED Departure Time Change in fifth paragraph, second bullet under Examples : Antibiotic Administration Date ICU Admission or Transfer Date Specifications Manual for Hospital Inpatient Quality Measures Page 5

Alphabetical Data Dictionary Index Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Remove in their entirety: ACEI Prescribed at Discharge Anesthesia End Date Anesthesia End Time Anesthesia Start Time Another Source of Infection Antibiotic Administration Date Antibiotic Administration Route Antibiotic Administration Time Antibiotic Allergy Antibiotic Name Antibiotic Received ARB Prescribed at Discharge Aspirin Received Within 24 Hours Before or After Hospital Arrival Beta-Blocker Current Medication Beta-Blocker During Pregnancy Beta-Blocker Perioperative Beta-Blocker Prescribed at Discharge Catheter Removed Chest X-Ray First PCI Date First PCI Time LVF Assessment LVSD Monitoring Documentation Non-Primary PCI Oral Antibiotics Other Surgeries Perioperative Death Pneumonia Diagnosis: ED/Direct Admit Preadmission Oral Anticoagulation Therapy Preoperative Hair Removal Pseudomonas Risk Reason for Alternative Empiric Antibiotic Therapy Reason for Delay in PCI Reason for No ACEI and No ARB at Discharge Reason for No Aspirin on Arrival Reason for No Beta-Blocker at Discharge Reason for Not Administering Beta-Blocker Perioperative Reason for Not Administering VTE Prophylaxis Specifications Manual for Hospital Inpatient Quality Measures Page 6

Reasons for Continuing Urinary Catheterization Reasons to Extend Antibiotics Surgical Incision Date Surgical Incision Time UFH Therapy Administration Urinary Catheter Vancomycin VTE Timely Anesthesia Start Date Remove under Collected For column: SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP- Inf-6, SCIP-Inf-9, SCIP-Card-2, SCIP-VTE-2 Arrival Date Remove under Collected For column: AMI-1, AMI-7, AMI-8, AMI-8a, PN-6 Arrival Time Remove under Collected For column: AMI-7, AMI-8, AMI-8a, PN-6 Clinical Trial Change Collected For column to: AMI-7a, CAC-3, SCIP-Inf-4, All STK Measures, VTE-1, VTE-2, VTE-3, VTE-5, VTE-6 Comfort Measures Only Remove under Collected For column: AMI-1, AMI-3, AMI-5, HF-2, PN-6, VTE-4 Discharge Disposition Remove under Collected For column: AMI-1, AMI-3, AMI-5, HF-2, VTE-4 Fibrinolytic Administration Initial ECG Interpretation Remove under Collected For column: AMI-7, AMI-8, AMI-8a Fibrinolytic Administration Date Fibrinolytic Administration Time Reason for Delay in Fibrinolytic Therapy Remove under Collected For column: AMI-7 ICU Admission or Transfer Remove under Collected For column: PN-6 Infection Prior to Anesthesia Remove under Collected For column: SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Specifications Manual for Hospital Inpatient Quality Measures Page 7

VTE Confirmed VTE Diagnostic Test Remove under Collected For column: VTE-4 VTE Prophylaxis Remove under Collected For column: SCIP-VTE-2 Index Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Change ICD-9-CM Other Diagnosis Codes to: ICD-10-CM Other Diagnosis Codes Change ICD-9-CM Other Procedure Codes to: ICD-10-PCS Other Procedure Codes Change ICD-9-CM Other Procedure Dates to: ICD-10-PCS Other Procedure Dates Change ICD-9-CM Principal Diagnosis Code to: ICD-10-CM Principal Diagnosis Code Change ICD-9-CM Principal Procedure Code to: ICD-10-PCS Principal Procedure Code Change ICD-9-CM Principal Procedure Date to: ICD-10-PCS Principal Procedure Date Index Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Measurement Value Remove under Collected For column: AMI-7, AMI-8 New Data Elements Rationale: A new measure set is being added to align with CY 2015 IPPS Final Rule. Add new data element names to Index and data element pages: Administrative Contraindication to Care Bedside Cardiovascular Ultrasound Date Bedside Cardiovascular Ultrasound Performed Specifications Manual for Hospital Inpatient Quality Measures Page 8

Bedside Cardiovascular Ultrasound Time Blood Culture Collection Blood Culture Collection Date Blood Culture Collection Time Broad Spectrum or Other Antibiotic Administration Broad Spectrum or Other Antibiotic Administration Date Broad Spectrum or Other Antibiotic Administration Selection Broad Spectrum or Other Antibiotic Administration Time Capillary Refill Examination Date Capillary Refill Examination Performed Capillary Refill Examination Time Cardiopulmonary Evaluation Date Cardiopulmonary Evaluation Performed Cardiopulmonary Evaluation Time Central Venous Oxygen Measurement Central Venous Oxygen Measurement Date Central Venous Oxygen Measurement Time Central Venous Pressure Measurement Central Venous Pressure Measurement Date Central Venous Pressure Measurement Time Crystalloid Fluid Administration Crystalloid Fluid Administration Date Crystalloid Fluid Administration Time Directive for Comfort Care, Septic Shock Directive for Comfort Care, Severe Sepsis Discharge Time Fluid Challenge Date Fluid Challenge Performed Fluid Challenge Time Hypotension Initial Lactate Level Collection Initial Lactate Level Date Initial Lactate Level Result Initial Lactate Level Time Passive Leg Raise Exam Date Passive Leg Raise Exam Performed Passive Leg Raise Exam Time Peripheral Pulse Evaluation Date Peripheral Pulse Evaluation Performed Peripheral Pulse Evaluation Time Repeat Lactate Level Collection Repeat Lactate Level Date Repeat Lactate Level Time Septic Shock Present Septic Shock Presentation Date Septic Shock Presentation Time Severe Sepsis Present Severe Sepsis Presentation Date Specifications Manual for Hospital Inpatient Quality Measures Page 9

Severe Sepsis Presentation Time Skin Examination Date Skin Examination Performed Skin Examination Time Vasopressor Administration Vasopressor Administration Date Vasopressor Administration Time Vital Signs Review Date Vital Signs Review Performed Vital Signs Review Time Alcohol or Drug Disorder Rationale: The data element is duplicative of Tables 13.2 and 13.3 which are already used to identify patients with alcohol or drug disorders via ICD-9-CM diagnosis codes. Removal of this data element will greatly reduce the burden of data abstraction. Index Remove row: Alcohol or Drug Disorder Data Elements Remove in its entirety: Alcohol or Drug Disorder Alcohol or Drug Use Status Post Discharge - Counseling Alcohol or Drug Use Status Post Discharge - Medication Alcohol Use Status Post Discharge - Quit Status Drug Use Status Post Discharge - Quit Status Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Collected For Change to: The Joint Commission: SUB-4 data collection suspended Alcohol Use Status Rationale: Allowable values have been updated to include high risk patients. The list of single item screeners was updated based on current evidence and clarifications have been added throughout the notes for abstraction to better reflect the intent of the data element. Definition Change in first sentence the word unhealthy to bold font Specifications Manual for Hospital Inpatient Quality Measures Page 10

Allowable Values Change 2 from: 2 The patient was screened with a validated tool within the first three days of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate risk) benefiting from brief intervention. 2 The patient was screened with a validated tool within the first three days of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate or high risk) benefiting from brief intervention. Change 4 from: 4 The patient was screened with a non-validated tool within the first three days of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate risk) benefiting from brief intervention. 4 The patient was screened with a non-validated tool within the first three days of admission and the score on the alcohol screen indicates unhealthy alcohol use (moderate or high risk) benefiting from brief intervention. Notes for Abstraction Change first bullet to: If patient has a blood alcohol test with a result of.08 or greater or the clinician documents the patient was acutely intoxicated per blood alcohol test results select Value 2. Change second bullet to: Screening may be done with a Single-item Validated Questionnaire (SASQ) in order to identify those patients with no risk or low risk or who do not drink. Further screening should be done with a validated tool for those patients with a positive result to determine if there is need for a brief intervention. Examples of SASQs include: o On any single occasion during the past 3 months, have you had more than 5 drinks containing alcohol? (Yes response is considered positive.) o "When was the last time you had more than X drinks in 1 day?" (X = 4 for women and 5 for men) (Within the last 3 months is considered positive.) o How many times in the past year have you had X or more drinks in a day?" (X = 5 men and 4 women) (Response of >1 is considered positive.) o How often have you had 6 or more drinks on one occasion in the past year? (Ever in the past year considered positive.) o How often do you have X or more drinks on one occasion? (X = 4 for women and 5 for men) (Ever in the past year considered positive.) Remove under seventh bullet: Examples of cognitive impairment include: o Altered Level of Consciousness (LOC) o Altered Mental Status o Cognitive impairment o Cognitively impaired o Confused Specifications Manual for Hospital Inpatient Quality Measures Page 11

o o o Memory loss Mentally retarded Obtunded Add new eighth and ninth bullet: If there is documentation that the patient was psychotic with documented symptoms e.g., hallucinating, non-communicative, catatonic, etc. which prevented them from answering questions reliably, they would be considered cognitively impaired. If there is documentation that the patient is not a reliable historian, a relative or guardian if available, may answer the screening questions on behalf of the patient. Examples of cognitive impairment include: o Altered Level of Consciousness (LOC) o Altered Mental Status o Cognitive impairment o Cognitively impaired o Confused o Memory loss o Mentally retarded o Obtunded Inclusion Guidelines for Abstraction Change sentence to: Validated Screening ols for Unhealthy Alcohol Use: This list is not ALL Inclusive. Exclusion Guidelines for Abstraction Change to: Any tool which specifically screens for alcohol use disorder, alcohol dependency or alcohol abuse. Examples include, but are not limited to: CAGE SASSI S2BI Alcohol Use Status Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Collected For Remove: CMS Informational Only: All SUB Measures Specifications Manual for Hospital Inpatient Quality Measures Page 12

Anesthesia Start Date Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Remove under Collected For : CMS Voluntary Only: SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-6, SCIP-Inf-9, SCIP-Card- 2, SCIP-VTE-2 Anesthesia Start Date Clinical Trial Glucose Infection Prior to Anesthesia Rationale: The Centers for Medicare & Medicaid Services (CMS) and The Joint Commission made the decision to suspend SCIP-Inf-4 beginning with discharges effective July 1, 2014. Change under Collected For : SCIP-Inf-4 SCIP-Inf-4 suspended Antithrombotic Therapy Administered by End of Hospital Day 2 IV OR IA Thrombolytic (t-pa) Therapy Administered at This Hospital or Within 24 Hours Prior to Arrival Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2 Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-5 as an electronic clinical quality measure, as stated in the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: STK-5 Anticoagulation Therapy Prescribed at Discharge Atrial Fibrillation/Flutter Reason for Not Prescribing Anticoagulation Therapy at Discharge Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-3 as an electronic clinical quality measure, as stated in the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: STK-3 Specifications Manual for Hospital Inpatient Quality Measures Page 13

Antithrombotic Therapy Prescribed at Discharge Reason for Not Prescribing Antithrombotic Therapy at Discharge Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: STK-2 Arrival Date Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-5 measure as an electronic clinical quality measure, as stated in the CY 2015 IPPS Final Rule. The STK-5 measure will now be collected for The Joint Commission Only. Collected For Remove under CMS Voluntary Only : STK-5 Arrival Date Arrival Time Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: AMI-1, AMI-7, AMI-8, AMI-8a, PN-6 Assessed for Rehabilitation Services Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-10 as an electronic clinical quality measure, as stated in the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: STK-10 Atrial Fibrillation/Flutter Rationale: The change provides clarification for cases discharged from the hospital with telemetry monitoring. Specifications Manual for Hospital Inpatient Quality Measures Page 14

Notes for Abstraction Add new fifth bullet: If there is documentation to monitor the patient for atrial fibrillation/flutter after discharge and no other documentation of a confirmed diagnosis or history of atrial fibrillation/flutter in the medical record, select No. Example: Possible cardioembolic origin. Telemetry monitoring for 30 days to exclude PAF. Brief Intervention Rationale: Additional notes for abstraction were added to clarify the use of a trained peer support person to perform the intervention. Definition Change first sentence to: A single interaction conducted by a qualified healthcare professional or trained peer support person with the patient, following a positive screening result for unhealthy alcohol use or alcohol use disorder (abuse or dependence). Notes for Abstraction Add new second bullet: A peer support person who has received specialized training in brief intervention may perform the brief intervention in lieu of a qualified healthcare professional. Brief Intervention Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Collected For Remove: CMS Informational Only: SUB-2 Clinical Trial Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, STK-3, STK-5, and STK-10 as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule. Collected For Remove under CMS Voluntary Only : STK-2, STK-3, STK-5, STK-10 Specifications Manual for Hospital Inpatient Quality Measures Page 15

Clinical Trial Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: AMI-1, AMI-3, AMI-5, AMI-7, AMI-8, AMI-8a, HF-2, PN-6, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-6, SCIP-Inf-9, SCIP-Card-2, SCIP-VTE-2,VTE-4 Definition Remove: HF, PN Allowable Values Remove in Yes and in No : HF, PN Notes for Abstraction Remove under first bullet in 2 : HF, PN Remove: HF: Only capture patients enrolled in clinical trials studying patients with heart failure (HF). PN: Only capture patients enrolled in clinical trials studying patients with pneumonia. Comfort Measures Only Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Remove under CMS Voluntary Only : AMI-1, AMI-3, AMI-5, HF-2, PN-6, VTE-4 Comfort Measures Only Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Collected For Remove: CMS Informational Only: All SUB Measures, All TOB Measures Specifications Manual for Hospital Inpatient Quality Measures Page 16

Comfort Measures Only Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, STK-3, STK-5, and STK-10 as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: STK-2, STK-3, STK-5, STK-10 Discharge Disposition Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Remove under CMS Voluntary Only : AMI-1, AMI-3, AMI-5, HF-2, VTE-4 Discharge Disposition Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, STK-3, and STK-10 as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule. Remove under CMS Voluntary Only : STK-2, STK-3, STK-10 Discharge Disposition Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Collected For Change SUB-4 under The Joint Commission Only to: SUB-4 data collection suspended Change TOB-4 under The Joint Commission Only to: TOB-4 data collection suspended Remove: CMS Informational Only: SUB-3, SUB-4, TOB-3, TOB-4 Discharge Disposition Transfer From Another Hospital or ASC Rationale: A new measure set is being added to align with CY 2015 IPPS Final Rule. Specifications Manual for Hospital Inpatient Quality Measures Page 17

Index and Data Elements Add under Collected For : CMS Only: SEP-1 Elective Carotid Intervention Rationale: The Centers for Medicare & Medicaid Services (CMS) will retain STK-2, STK-3, STK-5, and STK-10 as electronic clinical quality measures, as stated in the CY 2015 IPPS Final Rule. Remove under Collected For : CMS Voluntary Only: STK-2, STK-3, STK-5, STK-10 Elective Carotid Intervention Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Inclusion Guidelines for Abstraction Change in paragraph: ICD-9-CM ICD-10-PCS Exclusion Guidelines for Abstraction Change in paragraph: ICD-9-CM ICD-10-PCS Fibrinolytic Administration Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: AMI-7, AMI-8, AMI-8a Fibrinolytic Administration Date Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Specifications Manual for Hospital Inpatient Quality Measures Page 18

Collected For Remove: CMS Voluntary Only: AMI-7 Fibrinolytic Administration Time Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: AMI-7 Follow-Up Contact Follow-Up Contact Date Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Collected For Change under The Joint Commission Only to: SUB-4 data collection suspended, TOB-4 data collection suspended Remove: CMS Informational Only: SUB-4, TOB-4 Glucose Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Allowable Values Change in fifth bullet in 5 : ICD-9-CM ICD-10-PCS ICD-9-CM Other Diagnosis Codes Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Specifications Manual for Hospital Inpatient Quality Measures Page 19

Change data element name from: ICD-9-CM Other Diagnosis Codes ICD-10-CM Other Diagnosis Codes Definition ICD-9-CM ICD-10-CM Suggested Data Collection Question ICD-9-CM ICD-10-CM Format: Change to: Length: 3-7 (without decimal point or dot) Type: Character (upper or lower case) Occurs: 24 Allowable Values: Change to: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2015 Code Descriptions in Tabular Order): http://www.cms.gov/medicare/coding/icd10/2015-icd-10-cm-and-gems.html ICD-9-CM Other Procedure Codes Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Change data element name from: ICD-9-CM Other Procedure Codes ICD-10-PCS Other Procedure Codes Definition ICD-9-CM ICD-10-PCS Suggested Data Collection Question ICD-9-CM ICD-10-PCS Specifications Manual for Hospital Inpatient Quality Measures Page 20

Format: Change to: Length: 3-7 (without decimal point or dot) Type: Character (upper or lower case) Occurs: 24 Allowable Values: Change to: Any valid procedure code as per the CMS ICD-10-PCS master code table (2015 PCS Long and Abbreviated Titles): http://www.cms.gov/medicare/coding/icd10/2015-icd-10-pcs-and-gems.html ICD-9-CM Other Procedure Dates Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Change data element name from: ICD-9-CM Other Procedure Dates ICD-10-PCS Other Procedure Dates Notes for Abstraction Change under second bullet: ICD-9-CM ICD-10-PCS Change in Note, first sentence: QIO Clinical Warehouse CMS Clinical Warehouse Change in Note, second sentence: ICD-9-CM ICD-10-PCS ICD-9-CM Principal Diagnosis Code Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Change data element name from: ICD-9-CM Principal Diagnosis Code ICD-10-CM Principal Diagnosis Code Specifications Manual for Hospital Inpatient Quality Measures Page 21

Definition ICD-9-CM ICD-10-CM Suggested Data Collection Question ICD-9-CM ICD-10-CM Format Change to: Length: 3-7 (without decimal point or dot) Type: Character (upper or lower case) Occurs: 1 Allowable Values Change to: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2015 Code Descriptions in Tabular Order): http://www.cms.gov/medicare/coding/icd10/2015-icd-10-cm-and-gems.html ICD-9-CM Principal Procedure Code Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Change data element name from: ICD-9-CM Principal Procedure Code ICD-10-PCS Principal Procedure Code Suggested Data Collection Question ICD-9-CM ICD-10-PCS Format Change to: Length: 3-7 (without decimal point or dot) Type: Character (upper or lower case) Occurs: 1 Allowable Values Change to: Any valid procedure code as per the CMS ICD-10-PCS master code table (2015 PCS Long and Abbreviated Titles): http://www.cms.gov/medicare/coding/icd10/2015-icd-10-pcs-and-gems.html Specifications Manual for Hospital Inpatient Quality Measures Page 22

ICD-9-CM Principal Procedure Date Rationale: The ICD-9 codes used to report medical diagnoses and inpatient procedures are being replaced by ICD-10 codes per legislation. Change throughout, data element name from: ICD-9-CM Principal Procedure Date ICD-10-PCS Principal Procedure Date Notes for Abstraction Change in Note, first sentence: QIO Clinical Warehouse CMS Clinical Warehouse Change in Note, second sentence: ICD-9-CM ICD-10-PCS ICU Admission or Transfer Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Allowable Values Remove in 1 (Yes), 2 (No), and 3 (UTD) : (at this hospital within the first 24 hours following arrival at this hospital for PN). ICU Admission or Transfer Rationale: Additional acceptable data sources were added to assist the field in abstraction. Collected For Remove: CMS Voluntary Only: PN-6 Notes for Abstraction Add new first and second bullets: In order to select Value 1 for this data element there must be a Physician/APN/PA order for admission or transfer to an ICU. Documentation of ICU admit or transfer can be found in the physician orders or in the secondary data sources. When the physician orders do not have a clear admission or transfer to the ICU, additional information listed in the secondary data sources, such as protocol to transfer to ICU, can be used to support the order to admit or transfer to the ICU. Specifications Manual for Hospital Inpatient Quality Measures Page 23

Example: Patient has a code blue on medical floor. The code blue sheet notes transfer from medical bed to ICU bed when stabilized. The code blue sheet is signed and dated. Hospital protocol indicates that all code blue patients are transferred to ICU. Select Yes. Add new seventh and eighth bullets: For patients who are admitted to Observation status and then transferred to full admission to ICU, a physician order must be present to select Yes. Example: Medical record documentation reflects that the patient was admitted to observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to ICU. Select Yes. The patient was admitted or transferred with a physician/apn/pa order to the ICU anytime during this hospitalization regardless of the patient location select Value 1. Remove PN and VTE sections: PN: The patient was admitted or transferred to the intensive care unit (ICU) at this hospital within the first 24 hours following arrival at this hospital. In order to select value 1 (yes) for this data element there must be a physician order for admission or transfer to an ICU AND documentation that the patient was transferred or admitted to the ICU within 24 hours following hospital arrival. The 24-hour timeframe relates to the time from hospital arrival to arrival in the ICU unit, not the time of the physician order to admit or transfer to the ICU. If documentation reflects ICU graphic sheets or ICU nursing notes and there is no physician order for ICU, select value 2 (No). If other pneumonia related reasons for transfer or admission, such as septic shock, respiratory distress or failure, hypotension, tachypnea, hypoxemia or the need for a ventilator are documented, select value 1. If the patient was transferred or admitted to the ICU at this hospital within the first 24 hours after arrival to the hospital for reasons other than complications due to pneumonia, select value 2 to this question (i.e., a patient presents to the ED with pneumonia and shortly after arrival has a GI bleed or cardiac arrhythmia or the ICU may be the only place with monitored beds). If there is no other documented reason why the patient was transferred/admitted to the ICU at this hospital, assume it was for complications due to pneumonia. VTE: The patient was admitted or transferred to the ICU anytime during this hospitalization regardless of the patient location select value 1 (yes). Suggested Data Sources Change to: Priority Data Source (required) Physician/APN/PA orders Specifications Manual for Hospital Inpatient Quality Measures Page 24

Add: Secondary Data Souces for the Physician/APN/PA order: Ambulance record Code Blue/RRT Sheet Emergency Department record Helicopter record Order to transfer Protocol to transfer to ICU Remove: PN ONLY Suggested data sources to support admission or transfer to ICU Emergency Department record ICU Nursing admission assessment ICU Nursing notes ICU Admission or Transfer Date Rationale: Additional acceptable data sources were added to assist the field in abstraction. Notes for Abstraction Change to: The intent of this data element is to determine the date that the patient was actually admitted to ICU. In order to find the ICU admission date for this data element, there must be a Physician/APN/PA order for ICU admission or transfer to an ICU. Documentation of the date a patient was admitted or transferred to the ICU can be found in the physician orders in the secondary data sources. When the physician orders for ICU admission or transfer date are not clear, documentation in the secondary data sources, such as the date of a protocol to transfer to ICU, can be used. Example: Patient has a code blue on the medical floor. The code blue sheet is signed and dated 1/1/XX, and notes the patient is transfer from medical bed to ICU bed. Hospital protocol indicates that all code blue patients are transferred to ICU, use the date noted on the code blue sheet. For patients who are admitted to Observation status and subsequently admitted to ICU, abstract the date the order was written to admit to ICU. Do not abstract the date that the patient was admitted to Observation. Example: Medical record documentation reflects that the patient was admitted to observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to ICU. The ICU Admission or Transfer Date would be abstracted as 04-06-20xx; the date the determination was made to admit to acute inpatient care and the order was written. If a patient has more than one admission to the ICU for more than one day, subsequent transfers back to an ICU during the same hospitalization will NOT be abstracted. Specifications Manual for Hospital Inpatient Quality Measures Page 25

If a patient is admitted to ICU on 10/19/xx and discharged to a medical floor on 10/20/xx, that is equal to one day, regardless of the number of hours. More than a day in ICU is when a patient is admitted to ICU on 10/19/xx and discharged on 10/21/xx, regardless of the number of hours. Abstract the date that the admission/transfer was ordered regardless of whether the patient is physically placed into the ICU on the same date. The medical record must be abstracted as documented (taken at face value ). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select UTD. Example: Documentation indicates the ICU Admission or Transfer Date was 03-42-20xx. No other physician order in the medical record provides a valid date. Since the ICU Admission or Transfer Date is outside of the range listed in the Allowable Values for Day, it is not a valid date and the abstractor should select UTD. Note: Transmission of a case with an invalid date as described above will be rejected from the CMS Clinical Warehouse and the Joint Commission s Data Warehouse. Use of UTD allows the case to be accepted into the warehouses. Suggested Data Sources Change to: Primary Data Source: Physician/APN/PA orders Secondary Data Source to support Admission or Transfer Date Admit Discharge Transfer (ADT) record Ambulance record Code Blue/ RRT Sheet Emergency Department record Helicopter record Medication Reconciliation Nursing admission assessment/admitting note Observation record Order to transfer Physician H& P Physician Progress Notes Protocol to transfer to ICU Infection Prior to Anesthesia Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Remove under Collected For : CMS Voluntary Only: SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Specifications Manual for Hospital Inpatient Quality Measures Page 26

Initial ECG Interpretation Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Collected For Remove: CMS Voluntary Only: AMI-7, AMI-8, AMI-8a LDL-c Greater Than or Equal to 100 mg/dl LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival Pre-Arrival Lipid-Lowering Agent Rationale: This change is to update measure information to align with 2013 guideline recommendations on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease in adults. Remove in Index and Data Dictionary in their entirety: LDL-c Greater Than or Equal to 100 mg/dl LDL-c Measured Within the First 48 Hours or 30 Days Prior to Hospital Arrival Pre-Arrival Lipid-Lowering Agent Measurement Value Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Remove under Collected For : AMI-7, AMI-8 Prescription for Alcohol or Drug Disorder Medication Referral for Addictions Treatment Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Collected For Remove: CMS Informational Only: SUB-3 Prescription for bacco Cessation Medication Referral for Outpatient bacco Cessation Counseling Rationale: The Joint Commission SUB and TOB Technical Advisory Panels have recommended that SUB-4 and TOB-4 be inactivated due to burden of data abstraction. In addition, there are no future plans to adopt these measures by CMS for the IQR program. Specifications Manual for Hospital Inpatient Quality Measures Page 27

Collected For Change TOB-4 under The Joint Commission Only to: TOB-4 data collection suspended Remove: CMS Informational Only: TOB-3, TOB-4 Reason for Delay in Fibrinolytic Therapy Rationale: These measures are being removed at the direction of CMS due to consistently high performance rates as per the CY 2015 IPPS Final Rule. Remove under Collected For : CMS Voluntary Only: AMI-7 Reason for Discontinuation of Parenteral Anticoagulation Therapy Rationale: This change is to correct the measure so that the FDA approval of Pradaxa for VTE treatment can pass the measure. IVC Filter is not an acceptable reason for the discontinuation of the parenteral therapy. Inclusion Guidelines for Abstraction Change bullets to: Administration of Oral Factor Xa Inhibitors o Xarelto or rivaroxaban o Eliquis or apixaban Administration of Direct Thrombin Inhibitor o Pradaxa or dabigatran Documentation of active bleeding Documentation of a plan for surgery Documentation of a plan for blood transfusion Documentation that patient is not a candidate for anticoagulation therapy Documentation of thrombocytopenia Refer to Appendix H, Table 2.3 VTE Parenteral Therapy Table and Appendix C, Table 1.4 Warfarin Therapy. Exclusion Guidelines for Abstraction Add new bullet: IVC filter is not an acceptable reason for discontinuing parenteral therapy prior to five days of treatment unless physician/apn/pa indicates a reason. Reason for No Administration of VTE Prophylaxis Rationale: This change is to correct the measure so that the FDA approval of Pradaxa for VTE treatment can pass the measure. Specifications Manual for Hospital Inpatient Quality Measures Page 28

Notes for Abstraction EXCEPTIONS Add new bullet: For patients receiving anticoagulant therapy other than warfarin for atrial fibrillation or other conditions the day of or the day after hospital admission, select Yes. Inclusion Guidelines for Abstraction Add: Refer to Appendix H, Table 2.7 Anticoagulation Therapy for Atrial Fibrillation and Other Conditions. Reason for No Overlap Therapy Rationale: This change is to correct the measure so that the FDA approval of Pradaxa for VTE treatment can pass the measure. Inclusion Guidelines for Abstraction Change bullets to: Administration of Oral Factor Xa Inhibitors o Xarelto or rivaroxaban o Eliquis or apixaban Administration of Direct Thrombin Inhibitor o Pradaxa or dabigatran Documentation of active bleeding Documentation of a plan for surgery Documentation of a plan for blood transfusion Documentation that patient is not a candidate for anticoagulation therapy Reason for No bacco Cessation Medication at Discharge Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Collected For Remove: CMS Informational Only: TOB-3 Reason for No bacco Cessation Medication During the Hospital Stay bacco Use Treatment FDA - Approved Cessation Medication bacco Use Treatment Practical Counseling Rationale: There are no future plans to adopt these measures by CMS for the IQR program. Collected For Remove: CMS Informational Only: TOB-2 Specifications Manual for Hospital Inpatient Quality Measures Page 29

Reason for No bacco Cessation Medication During the Hospital Stay Rationale: This change corrects a typo in the data element Reason for No bacco Cessation Medication During the Hospital Stay. Notes for Abstraction Change first bullet to: Reasons for not administering FDA-approved tobacco cessation medications must be documented by a physician/apn/pa or pharmacist. Reason for No bacco Cessation Medication During the Hospital Stay Rationale: Due to confusion related to data abstraction, change in terminology to reflect that tobacco treatment should be provided during the hospital stay within the 3 rd day of admission. Definition Change sentence to: Reasons for not administering an FDA-approved tobacco cessation medication documented during the hospital stay within the first three days of admission include: Suggested Data Collection Question Change to: Is there documentation of a reason for not administering one of the FDA-approved tobacco cessation medications during the hospital stay within the first three days of admission? Allowable Values Change from: Y (Yes) There is documentation of a reason for not administering an FDA-approved cessation medication during the first three days of admission. N (No) There is no documentation of a reason for not administering an FDA-approved cessation medication during the first three days of admission or unable to determine from medical record documentation. Y (Yes) N (No) There is documentation of a reason for not administering an FDA-approved cessation medication during the hospital stay within the first three days of admission. There is no documentation of a reason for not administering an FDA-approved cessation medication during the hospital stay within the first three days of admission or unable to determine from medical record documentation. Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2 Rationale: This change is needed to reinforce that reason documentation must be within the timeframe of arrival to end of hospital day 2. Specifications Manual for Hospital Inpatient Quality Measures Page 30

Exclusion Guidelines for Abstraction Change to: Delay in stroke diagnosis Reason for Not Prescribing Statin Medication at Discharge Rationale: This change is to update measure information to align with 2013 guideline recommendations on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease in adults. Definition Add new bullet: LDL-c less than 70 mg/dl Notes for Abstraction Add new third bullet: Documentation of a LDL-c less than 70 mg/dl anytime during the hospital stay is an acceptable stand-alone reason for not prescribing statin medication at discharge Linkage with statin is not needed. Direct or calculated, fasting or non-fasting values are both acceptable. LDL values obtained within 30 days prior to hospital arrival are acceptable to select Yes. Reason for Oral Factor Xa Inhibitor Rationale: This change is being made to remove ICD-9 codes that were used to determine if a record has evidence of atrial fibrillation/flutter or history of total hip or total knee surgery. Inclusion Guidelines for Abstraction Remove: ICD-9-CM Principal/Other Diagnosis Code of 427.31 or 427.32 ICD-9-CM Other Procedure Codes of 81.51, 81.52, 81.53, 81.54, 81.55. Reason for Oral Factor Xa Inhibitor - ICU Admission Rationale: This change is being made to remove ICD-9 codes that were used to determine if a record has evidence of atrial fibrillation/flutter or history of total hip or total knee surgery. Inclusion Guidelines for Abstraction Remove: ICD-9-CM Other Procedure Code of 81.51, 81.52, 81.53, 81.54 or 81.55 ICD-9-CM Principal/Other Diagnosis Code of 427.31 or 427.32 Specifications Manual for Hospital Inpatient Quality Measures Page 31