SPC Measure definitions

Key measures

Within the SPC section, measures are displayed as the average or rate for the encounters discharged each week. These measure values are risk- and volume-adjusted within the control charts of the SPC section.

Measure name Measure definition
LOS (Length of Stay) Average length of stay
1 to 30 Day Readmission Forward Rate The percentage of encounters discharged that were readmitted within 30 days, excluding same-day readmissions
Total Charge Amount Sum of all charges for the encounter
Charge Amount - Principal Procedure

Sum of all operating room charges on the date of the principal procedure
Charge Amount - Cardiology Sum of all cardiology charges for the encounter
Mortality Rate Percentage of encounters discharged with discharge disposition 20 (expired)

Adverse events

These measures flag the encounter if the criteria are met. The adverse events are aggregated and labeled in the Adverse Event bar chart. Note that these adverse events are presented as flags and, as such, are not risk- or volume-adjusted.

Adverse event Definition

AMI within 7 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

  • A secondary diagnosis code for AMI, not POA

  • A principal diagnosis code for AMI on a subsequent encounter with the admit date within 7 days of the admit date of the initial encounter

Pneumonia within 7 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

  • A secondary diagnosis code for Pneumonia, not POA

  • A principal diagnosis code for Pneumonia on a subsequent encounter with the admit date within 7 days of the admit date of the initial encounter

Sepsis within 7 Days of index admission

The encounter is flagged for this event if either of the following conditions are present:

  • A diagnosis code for sepsis, septicemia, or septic shock, not POA

  • A diagnosis code for sepsis, septicemia, or septic shock on a subsequent encounter with an admit date within 7 days of the admit date of the initial encounter

Surgical site bleeding within 30 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

  • A diagnosis code for Surgical Site Bleeding, not POA

  • A diagnosis code for Surgical Site Bleeding on a subsequent encounter with an admit date within 30 days of the admit date of the initial encounter

Pulmonary embolism within 30 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

  • A diagnosis code for Pulmonary Embolism, not POA

  • A diagnosis code for Pulmonary Embolism on a subsequent encounter with an admit date within 30 days of the admit date of the initial encounter.

Mortality within 30 days of admission

The encounter is flagged for this event if either of the following conditions are present:

  • The discharge disposition indicates the patient expired

  • The discharge disposition indicates expired on a subsequent encounter with a discharge date within 30 days of the admit date of the initial encounter

Mechanical complications within 90 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

  • A diagnosis code for Mechanical Complications, not POA

  • A diagnosis code for Mechanical Complications on a subsequent encounter with an admit date within 90 days of the admit date of the initial encounter

Periprosthetic joint/wound infection within 90 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

  • A diagnosis code for Periprosthetic Joint or Wound Infection, not POA

  • A diagnosis code for Periprosthetic Joint or Wound Infection on a subsequent encounter with an admit date within 90 days of the admit date of the initial encounter

Unexplained cardiac arrest

Encounter has a diagnosis code of I462, I468 or I469, not POA

Dysglycemia

 Encounter has a diagnosis code of E15, not POA

Postoperative atrial fibrillation

Encounter has a major procedure (HCUP Procedure Class of 3 or 4) and a diagnosis code of I48.0, I48.1, I48.2, I48.91, I49.91, or I49.01, not POA

Postoperative respiratory failure

Encounter has a major procedure (HCUP Procedure Class of 3 or 4) and a diagnosis code of J95.821, J96.00, or J96.01, not POA

Myocardial rupture

Encounter has a diagnosis code of I23.3, not POA

Pleural effusion Encounter has a diagnosis code of J90, J918, J940, or J942, not POA

Congestive heart failure

Encounter has a diagnosis code of I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, or I50.43, not POA

Stroke/cerebrovascular accident

Encounter has a diagnosis code of I6300, I63011, I63012, I63019, I6302, I63031, I63032, I63039, I6309, I6310, I63111, I63112, I63119, I6312, I63131, I63132, I63139, I6319, I6320, I63211, I63212, I63219, I6322, I63231, I63232, I63239, I6329, I6330, I63311, I63312, I63319, I63321, I63322, I63329, I63331, I63332, I63339, I63341, I63342, I63349, I6339, I6340, I63411, I63412, I63419, I63421, I63422, I63429, I63431, I63432, I63439, I63441, I63442, I63449, I6349, I6350, I63511, I63512, I63519, I63521, I63522, I63529, I63531, I63532, I63539, I63541, I63542, I63549, I6359, I636, I638, I639, or I6789, not POA

Surgical re-exploration

This measure only applies to encounters in the CABG cohort

Encounter has any non-CABG procedure codes (with an HCUP Procedure Class of 3 or 4) on or after the date of principal procedure

Postoperative renal failure

Encounter has a diagnosis code of E883, I120, I129, I1311, N170, N171, N172, N178, N179, N181, N182, N183, N184, N185, N186, N189, N19, R34, or T795xxA, not POA

Prolonged intubation

Encounter has a procedure code of 5A1945Z (Respiratory Ventilation 24-96 Consecutive Hours) or 5A1955Z (Respiratory Ventilation, Greater than 96 Consecutive Hours)

Reaction to Anesthesia

Encounter has a diagnosis code of T8859 (Other Complications of Anesthesia), not POA

Medical PE/DVT

Encounter has a medical MDC and a diagnosis code for Pulmonary Embolism or Deep Vein Thrombosis (one of: I2602, I2609, I2692, I2699, I82401, I82402, I82403, I82409, I82411, I82412, I82413, I82419, I82421, I82422, I82423, I82429, I82431, I82432, I82433, I82439, I82441, I82442, I82443, I82449, I82491, I82492, I82493, I82499, I824Y1, I824Y2, I824Y3, I824Y9, I824Z1, I824Z2, I824Z3, or I824Z9), not POA

This measure extends beyond HAC 10 (DVT/PE with Total Knee or Hip Replacement), which only targets THA/TKA patients, and PSI 12 (Perioperative PE/DVT Rate), which only targets surgical patients. This measure focuses on medical (non-surgical) encounters.

Eclampsia, postpartum

Encounter has a diagnosis code of O152, not POA

Major Puerperal Infection, Postpartum

Encounter has a diagnosis code of O85 or O8669, not POA

Failed Forceps Delivery

Encounter has a diagnosis code of O665, not POA

Complications of Obstetrical Surgical Wound, Postpartum

Encounter has a diagnosis code of O860, not POA

Any PSI

Flag indicating the encounter had at least one PSI event

Any HAC

Flag indicating the encounter had at least one HAC event

ICU Usage

 Flag indicating the encounter had charges associated with time in the ICU (Revenue code of 0200, 0201, 0202, 0203, 0204, 0206, 0207, 0208, or 0209)

Blood Usage

 Flag indicating the encounter had charges associated with blood products (Revenue code of 0380, 0381, 0382, 0383, 0384, 0385, 0386, 0387, 0389, 0390, 0391, or 0399)

NOTE: For more information about how these measures are displayed in Clinical Analytics, see About the Statistical Process Control section. See Cohort definitions for lists of which measures are included in the SPC section for each cohort.

HCAHPS measures

When there is sufficient volume of surveys received for the cohort, the XmR charts for the following HCAHPS measures appear at the bottom of the section:

  • Hospital rating of 9 or 10 (Adjusted)
  • Patient's pain was well controlled (Adjusted Composite)
    • This composite only applies to surveys from patients discharged prior to January 1, 2018.

Because of the relatively small percentage of patients that receive and return HCAHPS surveys, we often see low volume in the HCAHPS measure control charts. Rather than display the yellow low volume banner in these instances, the HCAHPS charts do not display.

Also, because these HCAHPS measure values are already adjusted according to CMS specifications, Clinical Analytics does not perform additional severity- or volume-adjustments to these control chart values.