Inpatient and Observation measures

Alcohol abuse

Patient had a comorbidity of "Alcohol abuse" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Blood loss anemia

Patient had a comorbidity of "Blood loss anemia" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Chronic Peptic Ulcer Disease (includes bleeding only if obstruction is also present)

Patient had a comorbidity of "Chronic Peptic Ulcer Disease (includes bleeding only if obstruction is also present)" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Chronic pulmonary disease

Patient had a comorbidity of "Chronic pulmonary disease" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Coagulation deficiency

Patient had a comorbidity of "Coagulation deficiency" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Congestive Heart Failure

Patient had a comorbidity of "Congestive Heart Failure" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Deficiency anemia

Patient had a comorbidity of "Deficiency anemia" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Depression

Patient had a comorbidity of "Depression" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Diabetes with chronic complications

Patient had a comorbidity of "Diabetes with chronic complications" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Diabetes without chronic complications

Patient had a comorbidity of "Diabetes without chronic complications" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Drug abuse

Patient had a comorbidity of "Drug abuse" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Fluid and electrolyte disorders

Patient had a comorbidity of "Fluid and electrolyte disorders" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Heart Attack Case

Number of cases with at least one secondary diagnosis for a heart attack

N/A

No

No

Heart Failure Case

Number of cases with at least one secondary diagnosis for heart failure

N/A

No

No

HIV and AIDS

Patient had a comorbidity of "HIV and AIDS (Acquired immune deficiency syndrome)" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Hypertension (combine uncomplicated and complicated)

Patient had a comorbidity of "Hypertension (combined uncomplicated and complicated)" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Hypothyroidism

Patient had a comorbidity of "Hypothyroidism" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Liver disease

Patient had a comorbidity of "Liver disease" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Lymphoma

Patient had a comorbidity of "Lymphoma" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Metastatic cancer

Patient had a comorbidity of "Metastatic cancer" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Obesity

Patient had a comorbidity of "Obesity" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Other neurological disorders

Patient had a comorbidity of "Other neurological disorders" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Paralysis

Patient had a comorbidity of "Paralysis" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Peripheral vascular disease

Patient had a comorbidity of "Peripheral vascular disease" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Pneumonia Case

Number of cases with at least one Secondary Diagnosis for pneumonia

N/A

No

No

Psychoses

Patient had a comorbidity of "Psychoses" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Pulmonary Circulation disorders

Patient had a comorbidity of "Pulmonary Circulation disorders" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Renal failure

Patient had a comorbidity of "Renal failure" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Rheumatoid arthritis/collagen vascular diseases

Patient had a comorbidity of "Rheumatoid arthritis/collagen vascular diseases" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Septicemia Case

Number of cases with at least one secondary diagnosis for septicemia

N/A

No

No

Solid tumor without metastasis

Patient had a comorbidity of "Solid tumor without metastasis" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

Stroke Case

Number of cases with at least one secondary diagnosis for stroke

N/A

No

No

Valvular disease

Patient had a comorbidity of "Valvular disease" unrelated to the principal diagnosis for the given encounter

N/A

Yes

Yes

VTE Case

Number of cases with at least one diagnosis in the following list: acute pulmonary heart disease, phlebitis and thrombophlebitis, and other venous embolism and thrombosis

N/A

No

No

Usage - Blood Administration

Percent of patients with at least one revenue code for Blood Administration

Revenue codes: 0390-0392, 0399

Low

Yes

Yes

Usage - Blood Use

Percent of patients with at least one revenue code for Blood Use

Revenue codes: 0380-0387, 0389

Low

Yes

Yes

Usage - Coronary Care

Percent of patients with a revenue code for at least one coronary care day

Revenue codes: 0210-0214, 0219

Low

Yes

Yes

Usage - Critical Care / Intermediate ICU

Percent of patients with at least one revenue code for Critical Care (ICU or CCU) days

ICU Use revenue codes: 0200-0204, 0206-0209

CCU Use revenue codes: 0210-0214, 0219

Low

Yes

Yes

Usage - CT Scan

Percent of patients with at least one revenue code for a CT Scan

Revenue codes: 0350-0352, 0359

Low

No

Yes

Usage - ICU

Percent of patients with at least one revenue code for ICU days

Revenue codes: 0200-0204, 0206-0209

Low

Yes

Yes

Usage - MRI Use

Percent of patients with at least one revenue code for an MRI

Revenue codes: 0610-0612, 0614-0616, 0618, 0619

Low

No

Yes

Usage - Occupational Therapy

Percent of patients with at least one revenue code for Occupational Therapy

Revenue codes: 0430-0434, 0439

Usage - Palliative Care Consultation

Percent of discharges receiving a palliative care consult

Based on additional data provided by your facility; see Palliative Care measures for more information.

N/A

No

No

Usage - Physical Therapy

Percent of patients with at least one revenue code for Physical Therapy

Revenue codes: 0420-0424, 0429

Usage - Radiology and CT Scan

Percent of patients with at least one revenue code for Radiology or a CT Scan

Revenue codes: 0320-0324, 0329, 0330, 0339-0342, 0349-0352, 0359, 0400-0404, 0409

Low

Yes

Yes

Usage - Respiratory Therapy

Percent of patients with at least one revenue code for Respiratory Therapy

Revenue codes: 0410, 0412, 0413, 0419

Socioeconomic Factors Influencing Health

Percent of patients with at least one revenue code for Socioeconomic Factors Influencing Health

Revenue codes: Z586, Z5982, Z5986, Z5987, Z5989, Z59819, Z59812, Z59811, Z5948, Z5941, Z5902, Z5901, Z5900, Z555, Z62813, Z659, Z658, Z655, Z654, Z653, Z652, Z651, Z650, Z644, Z641, Z640, Z639, Z638, Z6379, Z6372, Z6371, Z636, Z635, Z634, Z6332, Z6331, Z631, Z630, Z629, Z62898, Z62891, Z62890, Z62822, Z62821, Z62820, Z62819, Z62812, Z62811, Z62810, Z626, Z623, Z6229, Z6222, Z6221, Z621, Z620, Z609, Z608, Z605, Z604, Z603, Z602, Z600, Z599, Z598, Z597, Z596, Z595, Z594, Z593, Z592, Z591, Z590, Z579, Z578, Z577, Z576, Z575, Z574, Z5739, Z5731, Z572, Z571, Z570, Z569, Z5689, Z5682, Z5681, Z566, Z565, Z564, Z563, Z562, Z561, Z560, Z559, Z558, Z554, Z553, Z552, Z551, Z550

Usage - Speech Therapy

Percent of patients with at least one revenue code for Speech Therapy

Revenue codes: 0440-0444, 0449, 0470-0472, 0479

CMS Data - Air Embolism

Count of Hospital-Acquired Condition - Medical Events: Air Embolism

Diagnosis Code 9991 not present on admission (not POA)

Low

No

No

CMS Data - Blood Incompatibility

Count of Hospital-Acquired Condition - Medical Events: Blood Incompatibility

Diagnosis Codes 99960, 99961, 99962, 99963, or 99969 not present on admission (not POA)

Low

No

No

CMS Data - Catheter-Associated UTI

Count of Hospital-Acquired Condition - Medical Events: Catheter-Associated UTI

Diagnosis Code 99664 not present on admission (not POA); excludes the following from acting as a CC/MCC: 1122, 59010, 59011, 5902, 5903, 59080, 59081, 5950, 5970, 5990.

Low

No

No

CMS Data - Falls and Trauma

Count of Hospital-Acquired Condition - Medical Events: Falls and Trauma

Diagnosis Codes within these ranges: 800-829, 830-839, 850-854, 925-929, 940-949, or 991-994 not present on admission (not POA)

Low

No

No

CMS Data - Foreign Object Retained after Surgery

Count of Hospital-Acquired Condition - Surgical Events: - Foreign Object Retained after Surgery

Diagnosis Codes 9984 or 9987 not present on admission (not POA)

Low

No

No

CMS Data - Manifestations of Poor Glycemic Control

Count of Hospital-Acquired Condition - Medical Events: Poor Glycemic Control

Diagnosis Codes 25010-25013, 25020-25023, 2510, 24910-24911, or 24920-24921 not present on admission (not POA)

Low

No

No

CMS Data - Pressure Ulcer Stages III and IV

Count of Hospital-Acquired Condition - Medical Events: Pressure Ulcer- Stage III and IV

Diagnosis Codes 70723 or 70724 not present on admission (not POA)

Low

No

No

CMS Data - Total Number of HACs

Low

No

No

CMS Data - Vascular Catheter-Associated Infection

Count of Hospital-Acquired Condition - Medical Events: - Vascular Catheter-Associated Infection

Diagnosis Code 99931 not present on admission (not POA)

Low

No

No

HAC - Air Embolism

(HAC 02) Count of Hospital-Acquired Condition - Medical Events: Air Embolism.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 999.1 and T800XXA

Low

No

No

HAC - Air Embolism - Rate

Low

Yes

Yes

HAC - Blood Incompatibility

(HAC 03) Count of Hospital-Acquired Condition - Medical Events: Blood Incompatibility.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 999.60, 999.61, 999.62, 999.63, 999.69, T8030XA, T80310A, T80311A, T80319A, and T8039XA

Low

No

No

HAC - Blood Incompatibility - Rate

Low

Yes

Yes

HAC - Catheter-associated UTI

(HAC 06) Count of Hospital-Acquired Condition - Medical Events: Catheter-associated Urinary Tract Infection.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 996.64, T83511A, and T83518A

Low

No

No

HAC - Catheter-associated UTI - Rate

Low

Yes

Yes

HAC - DVT/PE After Knee or Hip Replacement

(HAC 10) Count of Hospital-Acquired Condition - Surgical Events: - Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) After Knee or Hip Replacement.

For encounters with a hip or knee replacement procedure code (see Patient Safety measures for a complete list), includes Secondary Diagnosis Codes not present on admission (POA = N or U): 415.11, 415.1, 415.19, 453.40-453.42, 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, and I824Z9

Low

No

No

HAC - DVT/PE After Knee or Hip Replacement - Rate

Low

Yes

Yes

HAC - DVT/PE after THR

Count of Hospital-Acquired Condition - Surgical Events: - DVT/PE after THR (a subset of HAC 10)

For encounters with a hip replacement procedure code (see Patient Safety measures for a complete list), includes Secondary Diagnosis Codes not present on admission (POA = N or U): 415.11, 415.1, 415.19, 453.40-453.42, 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, and I824Z9

Low

No

No

HAC - DVT/PE after THR - Rate

Low

Yes

Yes

HAC - DVT/PE after TKR

Count of Hospital-Acquired Condition - Surgical Events: - DVT/PE after TKR (a subset of HAC 10)

For encounters with a knee replacement procedure code (see Patient Safety measures for a complete list), includes Secondary Diagnosis Codes not present on admission (POA = N or U): 415.11, 415.1, 415.19, 453.40-453.42, 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, and I824Z9

Low

No

No

HAC - DVT/PE after TKR - Rate

Low

Yes

Yes

HAC - Falls and Trauma

(HAC 05) Count of Hospital-Acquired Condition - Medical Events: Falls and Trauma.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 800-829, 830-839, 850-854, 925-929, 940-949, 991-994 and 3,726 ICD-10 Diagnosis Codes

Low

No

No

HAC - Falls and Trauma - Rate

Low

Yes

Yes

HAC - Foreign Object Retained after Surgery

(HAC 01) Count of Hospital-Acquired Condition - Surgical Events: Foreign Object Retained after Surgery.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 998.4, 998.7, T81500A, T81501A, T81502A, T81503A, T81504A, T81505A, T81506A, T81507A, T81508A, T81509A, T81510A, T81511A, T81512A, T81513A, T81514A, T81515A, T81516A, T81517A, T81518A, T81519A, T81520A, T81521A, T81522A, T81523A, T81524A, T81525A, T81526A, T81527A, T81528A, T81529A, T81530A, T81531A, T81532A, T81533A, T81534A, T81535A, T81536A, T81537A, T81538A, T81539A, T81590A, T81591A, T81592A, T81593A, T81594A, T81595A, T81596A, T81597A, T81598A, T81599A, T8160XA, T8161XA, and T8169XA

Low

No

No

HAC - Foreign Object Retained after Surgery - Rate

Low

Yes

Yes

(HAC 14) Count of Hospital-Acquired Condition - Iatrogenic Pneumothorax with Venous Catheterization.

For encounters with a venous catherization procedure code (see Patient Safety measures for a complete list), includes Secondary Diagnosis Code not present on admission (POA = N or U): J95811

Low

No

No

Low

Yes

Yes

(HAC 08) Count of Hospital-Acquired Condition - Surgical Events: - Mediastinitis after CABG.

For encounters with a CABG procedure code (see Patient Safety measures for a complete list), includes Secondary Diagnosis Codes not present on admission (POA = N or U): 519.2, J9851, and J9859

Low

No

No

Low

Yes

Yes

(HAC 09) Hospital-Acquired Condition - Medical Events: Poor Glycemic Control.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0800, E0801, E0810, E0900, E0901, E0910, E1010, E1100, E1101, E1300, E1301, E1310, and E15

Low

No

No

Low

Yes

Yes

HAC - Poor Glycemic Control - Diabetic Ketoacidosis

Count of Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Diabetic Ketoacidosis (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0910, E1010, and E1310

Low

No

No

HAC - Poor Glycemic Control - Diabetic Ketoacidosis - Rate

Low

Yes

Yes

HAC - Poor Glycemic Control - Hypoglycemic Coma

Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Hypoglycemic Coma (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0801, E0901, E1101, E1301, and E15

Low

No

No

HAC - Poor Glycemic Control - Hypoglycemic Coma - Rate

Low

Yes

Yes

HAC - Poor Glycemic Control - Nonketotic Hyperosmolar Coma

Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Nonketotic Hyperosmolar Coma (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0801, E0901, E1101, and E1301

Low

No

No

HAC - Poor Glycemic Control - Nonketotic Hyperosmolar Coma - Rate

Low

Yes

Yes

HAC - Poor Glycemic Control - Secondary Diabetes with Hyperosmolarity

Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Secondary Diabetes with Hyperosmolarity (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0800, E0801, E0900, E0901, E1100, E1101, E1300, and E1301

Low

No

No

HAC - Poor Glycemic Control - Secondary Diabetes with Hyperosmolarity - Rate

Low

Yes

Yes

HAC - Poor Glycemic Control - Secondary Diabetes with Ketoacidosis

Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Secondary Diabetes with Ketoacidosis (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0810, E0910, E1010, and E1310

Low

No

No

HAC - Poor Glycemic Control - Secondary Diabetes with Ketoacidosis - Rate

Low

Yes

Yes

HAC - Pressure Ulcer- Stage III and IV

(HAC 04) Count of Hospital-Acquired Condition - Medical Events: Pressure Ulcer- Stage III and IV.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 707.23, 707.24, L89003, L89004, L89013, L89014, L89023, L89024, L89103, L89104, L89113, L89114, L89123, L89124, L89133, L89134, L89143, L89144, L89153, L89154, L89203, L89204, L89213, L89214, L89223, L89224, L89303, L89304, L89313, L89314, L89323, L89324, L8943, L8944, L89503, L89504, L89513, L89514, L89523, L89524, L89603, L89604, L89613, L89614, L89623, L89624, L89813, L89814, L89893, L89894, L8993, and L8994

Low

No

No

HAC - Pressure Ulcer- Stage III and IV - Rate

Low

Yes

Yes

HAC - Surgical Site Infection - After Bariatric Surgery for Obesity

(HAC 11) Hospital-Acquired Condition - Surgical Events: - Surgical Site Infection - After Bariatric Surgery for Obesity

For encounters with a Principal Diagnosis Code of E6601 and a bariatric procedure code (see Patient Safety measures for a complete list), includes Secondary Diagnosis Codes not present on admission (POA = N or U): K6811, K9501, K9581, and T814XXA

Low

No

No

HAC - Surgical Site Infection - After Bariatric Surgery for Obesity - Rate

(HAC 11) Count of "Hospital-Acquired Condition - Surgical Events: - Surgical Site Infection - After Bariatric Surgery for Obesity divided by the volume of inpatient cases with a bariatric surgery for obesity.

Low

Yes

Yes

HAC - Surgical Site Infection - After Certain Orthopedic Surgeries

(HAC 12) Hospital-Acquired Condition - Surgical Events: - Surgical Site Infection - After Certain Orthopedic Surgeries

For encounters with a procedure code for a certain orthopedic procedure of the spine, shoulder, or elbow (see Patient Safety measures for a complete list), includes Secondary Diagnosis Codes not present on admission (POA = N or U): K6811, T814XXA, T8460XA, T84610A, T84611A, T84612A, T84613A, T84614A, T84615A, T84619A, T8463XA, T8469XA, or T847XXA

Low

No

No

HAC - Surgical Site Infection - After Certain Orthopedic Surgeries - Rate

(HAC 12) Count of "Hospital-Acquired Condition - Surgical Events: - Surgical Site Infection - After Certain Orthopedic Surgeries" divided by the volume of After Certain Orthopedic Surgeries inpatient cases.

Low

Yes

Yes

(HAC 13) Hospital-Acquired Condition - Surgical Events: Surgical Site Infection - After Cardiac Implantable Electronic Device (CIED)

For encounters with a CIED procedure code (see Patient Safety measures for a complete list), includes Secondary Diagnosis Codes not present on admission (POA = N or U): K6811, T814XXA, T826XXA, and T827XXA

Low

No

No

(HAC 13) Count of "Hospital-Acquired Condition - Surgical Events: Surgical Site Infection - After Cardiac Implantable Electronic Device (CIED)" divided by the volume of inpatient encounters with one of the CIED procedure codes listed above.

Low

Yes

Yes

HAC - Vascular Catheter-Associated Infection

(HAC 07) Count of Hospital-Acquired Condition - Medical Events: - Vascular Catheter-Associated Infection.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 999.31, T80211A, T80212A, T80218A, and T80219A

Low

No

No

HAC - Vascular Catheter-Associated Infection - Rate

(HAC 07) Count of "Hospital-Acquired Condition - Medical Events: - Vascular Catheter-Associated Infection" divided by the volume of inpatient cases.

Low

Yes

Yes

Any HAC

Flag indicating the encounter had at least one HAC event

Low

No

No

Total HACs

Total Hospital-Acquired Conditions (HAC) is the number of Total Surgical HAC and Total Medical HAC: Mediastinitis after CABG, Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) After Knee or Hip Replacement, Foreign Object Retained after Surgery, Surgical Site Infection - After Bariatric Surgery for Obesity, Surgical Site Infection - After Certain Orthopedic Surgeries, Air Embolism, Blood Incompatibility, Catheter-associated UTI, Falls and Trauma, Poor Glycemic Control, Pressure Ulcer- Stage III and IV, Vascular Catheter-Associated Infection

Low

No

No

Total HACs - Rate

Total number of Hospital-Acquired Conditions

Low

Yes

Yes

Total Medical HACs

Total Medical Hospital-Acquired Conditions (HAC) is the total count of the following medical HACs: Air Embolism, Blood Incompatibility, Catheter-associated UTI, Falls and Trauma, Iatrogenic Pneumothorax with Venous Catheterization, Poor Glycemic Control, Pressure Ulcer- Stage III and IV, Vascular Catheter-Associated Infection

Low

No

No

Total Medical HACs - Rate

Total Medical Hospital-Acquired Conditions

Low

Yes

Yes

Total Surgical HACs

Total Surgical Hospital-Acquired Conditions (HAC) is the number of surgical HAC: Mediastinitis after CABG, Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) After Knee or Hip Replacement, Foreign Object Retained after Surgery, Surgical Site Infection - After Bariatric Surgery for Obesity, Surgical Site Infection - After Certain Orthopedic Surgeries

Low

No

No

Total Surgical HACs - Rate

Total Surgical Hospital-Acquired Conditions

Low

Yes

Yes

PDI-1 - Accidental Puncture/Laceration Count

Based on AHRQ software: Accidental punctures or lacerations (secondary diagnosis) during procedure for patients ages 17 years and younger. Includes metrics for discharges grouped by risk category. Excludes obstetric discharges, spinal surgery discharges, discharges with accidental puncture or laceration as a principal diagnosis, discharges with accidental puncture or laceration as a secondary diagnosis that is present on admission, normal newborns, and neonates with birth weight less than 500 grams.

Low

No

No

PDI-1 - Accidental Puncture/Laceration O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PDI-2 - Pressure Ulcer Count

Based on AHRQ software: Stage III, IV, or unstageable pressure ulcers (secondary diagnosis) among surgical or medical patients 17 years of age and younger. Discharges are grouped by risk category. Includes metrics for discharges grouped by risk category. Excludes neonates; stays less than three (3) days; obstetric discharges; discharges with diseases of the skin; and discharges with principal diagnosis or secondary diagnosis present on admission for Stage III, IV or unstageable pressure ulcer.

Low

No

No

PDI-2 - Pressure Ulcer O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

AHRQ has discontinued this measure as of V2019, so there is no longer count or O/E measure data being calculated for this PDI.

Low

No

No

PDI-3 - Foreign Body Count

Based on AHRQ software: The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 17 years and younger. Excludes normal newborns, newborns with birth weight less than 500 grams, cases with principal diagnosis of retained surgical item or unretrieved device fragment, cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission, and obstetric cases.

AHRQ has discontinued this measure as of V2019, so there is no longer count measure data being calculated for this PDI.

Low

No

No

PDI-5 - Iatrogenic Pneumothorax Count

Based on AHRQ software: Iatrogenic pneumothorax cases (secondary diagnosis) among surgical or medical discharges for patients ages 17 years and younger. Excludes normal newborns; neonates with a birth weight less than 500 grams; cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic surgery repair or cardiac surgery; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.

Low

No

No

PDI-5 - Iatrogenic Pneumothorax O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PDI-6 - RACHS-1 Pediatric Heart Surgery Mortality Count

Based on AHRQ software: In-hospital deaths among pediatric heart surgery admissions for patients with congenital heart disease ages 17 years and younger. Excludes obstetric discharges; cases with transcatheter interventions as a single cardiac procedure, performed without bypass but with catheterization; cases with septal defect repairs as single cardiac procedures without bypass but with catheterization; cases with heart transplants; premature infants with patent ductus arteriosus (PDA) closure as the only cardiac procedure; age less than 30 days with PDA closure as only cardiac procedure; transfers to another hospital; cases with an unknown disposition; and neonates with birth weight less than 500 grams.

NOTE: This measure accounts for ICD-9 coding only; it is not available for ICD-10 coding until AHRQ updates their software accordingly.

Low

No

No

PDI-6 - RACHS-1 Pediatric Heart Surgery Mortality Rate

Based on AHRQ software: In-hospital deaths among pediatric heart surgery admissions for patients with congenital heart disease ages 17 years and younger, divided by the volume of such surgeries.

AHRQ has discontinued this measure as of V2019, so there is no longer rate or count measure data being calculated for this PDI.

NOTE: This measure accounts for ICD-9 coding only; it is not available for ICD-10 coding until AHRQ updates their software accordingly.

Low

No

No

PDI-7 - RACHS-1 Pediatric Heart Surgery Volume

Based on AHRQ software: The number of hospital discharges with a pediatric heart surgery procedure for patients with congenital heart disease ages 17 years and younger.

AHRQ has discontinued this measure as of V2019, so there is no longer volume measure data being calculated for this PDI.

NOTE: This measure accounts for ICD-9 coding only; it is not available for ICD-10 coding until AHRQ updates their software accordingly.

High

No

No

PDI-8 - Perioperative Hemorrhage or Hematoma Count

Based on AHRQ software: Perioperative hemorrhage or hematoma cases with control of perioperative hemorrhage or drainage of hematoma following surgery among elective surgical discharges for patients ages 17 years and younger. Includes metrics for discharges grouped by high and low risk. Excludes cases with a diagnosis of coagulation disorder; cases with a principal diagnosis of perioperative hemorrhage or hematoma; cases with a secondary diagnosis of perioperative hemorrhage or hematoma present on admission; cases where the only operating room procedure is control of perioperative hemorrhage, drainage of hematoma, or a miscellaneous hemorrhage- or hematoma-related procedure; obstetric cases; and neonates with birth weight less than 500 grams.

Low

No

No

PDI-8 - Perioperative Hemorrhage or Hematoma O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PDI-9 - Post-Op Resp. Failure Count

Based on AHRQ software: Postoperative respiratory failure (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases among elective surgical discharges for patients ages 17 and younger. Excludes cases with principal diagnosis for acute respiratory failure; cases with secondary diagnosis for acute respiratory failure present on admission; cases in which tracheostomy is the only operating room procedure or in which tracheostomy occurs before the first operating room procedure; cases with neuromuscular disorders or degenerative neurological disorders; cases with laryngeal, pharyngeal or craniofacial surgery; cases with craniofacial anomalies; cases with esophageal resection, lung cancer, lung transplant cases; cases with respiratory or circulatory diseases; and obstetric discharges.

Low

No

No

PDI-9 - Post-Op Resp. Failure O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PDI-10 - Post-Op Sepsis Count

Based on AHRQ software: Postoperative sepsis cases (secondary diagnosis) among surgery discharges for patients ages 17 years and younger. Includes metrics for discharges grouped by risk category. Excludes cases with a principal diagnosis of sepsis, cases with a secondary diagnosis of sepsis present on admission, cases with a principal diagnosis of infection (only if they also have a secondary diagnosis of sepsis), cases in which the procedure belongs to surgical class 4, neonates and obstetric discharges.

Low

No

No

PDI-10 - Post-Op Sepsis O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PDI-11 - Post-Op Wound Dehiscence Count

Based on AHRQ software: Postoperative reclosures of the abdominal wall among abdominopelvic surgery discharges for patients ages 17 years and younger. Excludes cases in which the abdominal wall reclosure occurs on or before the day of the first abdominopelvic surgery, newborn cases with gastroschisis or umbilical hernia repair occurring before the day of the abdominal wall reclosure, cases with a high- or intermediate-risk immunocompromised state, cases with cirrhosis and hepatic failure with a diagnosis of coma or hepatorenal syndrome, cases with transplants, cases with stays less than two (2) days, neonates with birth weight less than 500 grams, and obstetric cases.

Low

No

No

PDI-11 - Post-Op Wound Dehiscence O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

AHRQ has discontinued this measure as of V2019, so there are no longer count or O/E measure data being calculated for this PDI.

Low

No

No

PDI-12 - CR-BSIs Count

Based on AHRQ software: Central venous catheter-related bloodstream infections (secondary diagnosis) among medical and surgical discharges for patients ages 17 years and younger. Excludes cases with a principal diagnosis of a central venous catheter-related bloodstream infection, cases with a secondary diagnosis of a central venous catheter-related bloodstream infection present on admission, normal newborns, neonates with a birth weight of less than 500 grams, cases with stays less than two (2) days, and obstetric cases.

Low

No

No

PDI-12 - CR-BSIs O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PDI-13 - Transfusion Reaction Count

Based on AHRQ software: The number of medical and surgical discharges with a secondary diagnosis of transfusion reaction for patients ages 17 years and younger. Excludes cases with a principal diagnosis of transfusion reaction, cases with a secondary diagnosis of transfusion reaction that is present on admission, neonates, and obstetric cases.

AHRQ has discontinued this measure as of V2019, so there is no longer count measure data being calculated for this PDI.

Low

No

No

Low

Yes

Yes

Low

Yes

Yes

Low

Yes

Yes

Low

Yes

Yes

Low

Yes

Yes

Low

Yes

Yes

Low

Yes

Yes

Risk Adjusted Pediatric Patient Safety Index

Sum of Numerators / (Sum of Expected Rate * Number of Cases for Each Measure for AHRQ Pediatric PSI Measures).

PSI Measures Include: Accidental Puncture or Laceration (PDI-1), Pressure Ulcer (PDI-2), Iatrogenic Pneumothorax (PDI-5), Pediatric Heart Surgery Mortality (PDI-6 - RACHS-1), Postoperative Hemorrhage or Hematoma (PDI-8), Postoperative Respiratory Failure (PDI-9), Postoperative Sepsis (PDI-10), Postoperative Wound Dehiscence (PDI-11), Central Line-Associated Bloodstream Infection (PDI-12), Iatrogenic Pneumothorax in Neonates (NQI-1)

Low

No

No

PSI-2 - Death in Low-Mortality DRGs Count

Based on AHRQ software: In-hospital deaths among discharges for low mortality (< 0.5%) Diagnosis Related Groups (DRGs) among patients ages 18 years and older or obstetric patients. Excludes cases with trauma, cases with cancer, cases with an immunocompromised state, and transfers to an acute care facility.

Low

No

No

PSI-2 - Death in Low-Mortality DRGs Rate

Based on AHRQ software: Count of in-hospital deaths divided by total discharges for low mortality (< 0.5%) Diagnosis Related Groups (DRGs) among patients ages 18 years and older or obstetric patients. Excludes cases with trauma, cases with cancer, cases with an immunocompromised state, and transfers to an acute care facility.

Low

Yes

Yes

PSI-2 - Death in Low-Mortality DRGs O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-3 - Pressure Ulcer Count

Based on AHRQ software: Stage III or IV pressure ulcers or unstageable (secondary diagnosis) among surgical or medical discharges ages 18 years and older. Excludes stays less than 3 days; cases with a principal stage III or IV (or unstageable) pressure ulcer diagnosis; cases with a secondary diagnosis of stage III or IV pressure ulcer (or unstageable) that is present on admission; obstetric cases; severe burns; exfoliative skin disorders.

Low

No

No

PSI-3 - Pressure Ulcer Rate

Based on AHRQ software: Count of stage III or IV pressure ulcers or unstageable (secondary diagnosis) divided by total surgical or medical discharges ages 18 years and older. Excludes stays less than 3 days; cases with a principal stage III or IV (or unstageable) pressure ulcer diagnosis; cases with a secondary diagnosis of stage III or IV pressure ulcer (or unstageable) that is present on admission; obstetric cases; severe burns; exfoliative skin disorders.

Low

Yes

Yes

PSI-3 - Pressure Ulcer O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-4 - Death Among Surgical Inpatients Count

Based on AHRQ software: In-hospital deaths among elective surgical discharges for patients ages 18 through 89 years or obstetric patients, with serious treatable complications (deep vein thrombosis / pulmonary embolism, pneumonia, sepsis, shock/cardiac arrest, or gastrointestinal hemorrhage/acute ulcer). Includes metrics for the number of discharges for each type of complication. Excludes cases transferred to an acute care facility and cases in hospice care at admission.

Low

No

No

PSI-4 - Death Among Surgical Inpatients Rate

Based on AHRQ software: Count of in-hospital deaths divided by total elective surgical discharges for patients ages 18 through 89 years or obstetric patients, with serious treatable complications (deep vein thrombosis / pulmonary embolism, pneumonia, sepsis, shock/cardiac arrest, or gastrointestinal hemorrhage/acute ulcer). Includes metrics for the number of discharges for each type of complication. Excludes cases transferred to an acute care facility and cases in hospice care at admission.

Low

Yes

Yes

PSI-4 - Death Among Surgical Inpatients O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-5 - Foreign Body Count

Based on AHRQ software: The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) among surgical and medical patients ages 18 years and older or obstetric patients. Excludes cases with principal diagnosis of retained surgical item or unretrieved device fragment and cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

Low

No

No

PSI-5 -Retained Surgical Item or Unretrieved Device Fragment Rate

Based on AHRQ software: The number of hospital discharges with a retained surgical item or unretrieved device fragment (secondary diagnosis) divided by the number of surgical and medical patients ages 18 years and older or obstetric patients. Excludes cases with principal diagnosis of retained surgical item or unretrieved device fragment and cases with a secondary diagnosis of retained surgical item or unretrieved device fragment present on admission.

Low

Yes

Yes

PSI-6 - Iatrogenic Pneumothorax Count

Based on AHRQ software: Iatrogenic pneumothorax cases (secondary diagnosis) among surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.

Low

No

No

PSI-6 - Iatrogenic Pneumothorax Rate

Based on AHRQ software: Count of iatrogenic pneumothorax cases (secondary diagnosis) divided by total surgical and medical discharges for patients ages 18 years and older. Excludes cases with chest trauma, pleural effusion, thoracic surgery, lung or pleural biopsy, diaphragmatic repair, or cardiac procedures; cases with a principal diagnosis of iatrogenic pneumothorax; cases with a secondary diagnosis of iatrogenic pneumothorax present on admission; and obstetric cases.

Low

Yes

Yes

PSI-6 - Iatrogenic Pneumothorax O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-7 - CR-BSIs Count

Based on AHRQ software: Central venous catheter-related bloodstream infections (secondary diagnosis) among medical and surgical discharges for patients ages 18 years and older or obstetric cases. Excludes cases with a principal diagnosis of a central venous catheter-related bloodstream infection, cases with a secondary diagnosis of a central venous catheter-related bloodstream infection present on admission, cases with stays less than 2 days, cases with an immunocompromised state, and cases with cancer.

Low

No

No

PSI-7 - CR-BSIs Rate

Based on AHRQ software: Count of central venous catheter-related bloodstream infections (secondary diagnosis) divided by total medical and surgical discharges for patients ages 18 years and older or obstetric cases. Excludes cases with a principal diagnosis of a central venous catheter-related bloodstream infection, cases with a secondary diagnosis of a central venous catheter-related bloodstream infection present on admission, cases with stays less than 2 days, cases with an immunocompromised state, and cases with cancer.

Low

Yes

Yes

PSI-7 - CR-BSIs O/E

Based on AHRQ software: Observed count of Central Catheter-Related Blood Stream Infections divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-8 - Postoperative Hip Fracture Count

Based on AHRQ software: In-hospital fall with hip fracture (secondary diagnosis) among discharges for patients ages 18 years and older. Excludes discharges with principal diagnosis of a condition with high susceptibility to falls (seizure disorder, syncope, stroke, occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium or other psychoses, anoxic brain injury), diagnoses associated with fragile bone (metastatic cancer, lymphoid malignancy, bone malignancy), a principal diagnosis of hip fracture, a secondary diagnosis of hip fracture present on admission, and obstetric cases.

Low

No

No

PSI-8 - Postoperative Hip Fracture Rate

Based on AHRQ software: Count of in-hospital fall with hip fracture (secondary diagnosis) divided by total discharges for patients ages 18 years and older. Excludes discharges with principal diagnosis of a condition with high susceptibility to falls (seizure disorder, syncope, stroke, occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium or other psychoses, anoxic brain injury), diagnoses associated with fragile bone (metastatic cancer, lymphoid malignancy, bone malignancy), a principal diagnosis of hip fracture, a secondary diagnosis of hip fracture present on admission, and obstetric cases.

Low

Yes

Yes

PSI-8 - Postoperative Hip Fracture O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-9 - Perioperative Hemorrhage or Hematoma Count

Based on AHRQ software: Perioperative hemorrhage or hematoma cases involving a procedure to treat the hemorrhage or hematoma, following surgery among surgical discharges for patients ages 18 years and older. Excludes cases with a diagnosis of coagulation disorder; cases with a principal diagnosis of perioperative hemorrhage or hematoma; cases with a secondary diagnosis of perioperative hemorrhage or hematoma present on admission; cases where the only operating room procedure is for treatment of perioperative hemorrhage or hematoma; obstetric cases.

Low

No

No

PSI-9 - Perioperative Hemorrhage or Hematoma Rate

Based on AHRQ software: Count of perioperative hemorrhage or hematoma cases involving a procedure to treat the hemorrhage or hematoma, following surgery divided by total surgical discharges for patients ages 18 years and older. Excludes cases with a diagnosis of coagulation disorder; cases with a principal diagnosis of perioperative hemorrhage or hematoma; cases with a secondary diagnosis of perioperative hemorrhage or hematoma present on admission; cases where the only operating room procedure is for treatment of perioperative hemorrhage or hematoma; obstetric cases.

Low

Yes

Yes

PSI-9 - Perioperative Hemorrhage or Hematoma O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-10 - Post-Op Kidney Injury Requiring Dialysis Count

Based on AHRQ software: Postoperative acute kidney failure requiring dialysis among elective surgical discharges for patients ages 18 years and older. Excludes cases with principal diagnosis of acute kidney failure; cases with secondary diagnosis of acute kidney failure present on admission; cases with secondary diagnosis of acute kidney failure and dialysis procedure before or on the same day as the first operating room procedure; cases with acute kidney failure, cardiac arrest, severe cardiac dysrhythmia, cardiac shock, chronic kidney failure; a principal diagnosis of urinary tract obstruction and obstetric cases.

Low

No

No

PSI-10 - Post-Op Kidney Injury Requiring Dialysis Rate

Based on AHRQ software: Count of postoperative acute kidney failure requiring dialysis divided by total elective surgical discharges for patients ages 18 years and older. Excludes cases with principal diagnosis of acute kidney failure; cases with secondary diagnosis of acute kidney failure present on admission; cases with secondary diagnosis of acute kidney failure and dialysis procedure before or on the same day as the first operating room procedure; cases with acute kidney failure, cardiac arrest, severe cardiac dysrhythmia, cardiac shock, chronic kidney failure; a principal diagnosis of urinary tract obstruction and obstetric cases.

Low

Yes

Yes

PSI-10 - Post-Op Kidney Injury Requiring Dialysis O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-11 - Post-Op Respiratory Failure Count

Based on AHRQ software: Postoperative respiratory failure (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases among elective surgical discharges for patients ages 18 years and older. Excludes cases with principal diagnosis for acute respiratory failure; cases with secondary diagnosis for acute respiratory failure present on admission; cases in which tracheostomy is the only operating room procedure or in which tracheostomy occurs before the first operating room procedure; cases with neuromuscular disorders; cases with laryngeal, oropharyngeal or craniofacial surgery involving significant risk of airway compromise; esophageal resection, lung cancer, lung transplant or degenerative neurological disorders; cases with respiratory or circulatory diseases; and obstetric discharges.

Low

No

No

PSI-11 - Post-Op Respiratory Failure Rate

Based on AHRQ software: Count of postoperative respiratory failure (secondary diagnosis), prolonged mechanical ventilation, or reintubation cases divided by total elective surgical discharges for patients ages 18 years and older. Excludes cases with principal diagnosis for acute respiratory failure; cases with secondary diagnosis for acute respiratory failure present on admission; cases in which tracheostomy is the only operating room procedure or in which tracheostomy occurs before the first operating room procedure; cases with neuromuscular disorders; cases with laryngeal, oropharyngeal or craniofacial surgery involving significant risk of airway compromise; esophageal resection, lung cancer, lung transplant or degenerative neurological disorders; cases with respiratory or circulatory diseases; and obstetric discharges.

Low

Yes

Yes

PSI-11 - Post-Op Respiratory Failure O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-12 - Perioperative PE/DVT Count

Based on AHRQ software: Perioperative pulmonary embolism or proximal deep vein thrombosis (secondary diagnosis) among surgical discharges for patients ages 18 years and older. Excludes discharges with a principal diagnosis of pulmonary embolism or proximal deep vein thrombosis; with a secondary diagnosis of pulmonary embolism or proximal deep vein thrombosis present on admission; in which interruption of the vena cava or a pulmonary arterial thromboectomy occurs before or on the same day as the first operating room procedure; with extracorporeal membrane oxygenation; with acute brain or spinal injury present on admission; and obstetric cases.

Low

No

No

PSI-12 - Perioperative PE/DVT Rate

Based on AHRQ software: Count of perioperative pulmonary embolism or proximal deep vein thrombosis (secondary diagnosis) divided by total surgical discharges for patients ages 18 years and older. Excludes discharges with a principal diagnosis of pulmonary embolism or proximal deep vein thrombosis; with a secondary diagnosis of pulmonary embolism or proximal deep vein thrombosis present on admission; in which interruption of the vena cava or a pulmonary arterial thromboectomy occurs before or on the same day as the first operating room procedure; with extracorporeal membrane oxygenation; with acute brain or spinal injury present on admission; and obstetric cases.

Low

Yes

Yes

PSI-12 - Perioperative PE/DVT O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-13 - Post-Op Sepsis Count

Based on AHRQ software: Postoperative sepsis cases (secondary diagnosis) among elective surgical discharges for patients ages 18 years and older. Excludes cases with a principal diagnosis of sepsis, cases with a secondary diagnosis of sepsis present on admission, cases with a principal diagnosis of infection, cases with a secondary diagnosis of infection present on admission (only if they also have a secondary diagnosis of sepsis), obstetric discharges.

Low

No

No

PSI-13 - Post-Op Sepsis Rate

Based on AHRQ software: Count of postoperative sepsis cases (secondary diagnosis) divided by total elective surgical discharges for patients ages 18 years and older. Excludes cases with a principal diagnosis of sepsis, cases with a secondary diagnosis of sepsis present on admission, cases with a principal diagnosis of infection, cases with a secondary diagnosis of infection present on admission (only if they also have a secondary diagnosis of sepsis), obstetric discharges.

Low

Yes

Yes

PSI-13 - Post-Op Sepsis O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-14 - Post-Op Wound Dehiscence Count

Based on AHRQ software: Postoperative reclosures of the abdominal wall with a diagnosis of disruption of internal operational wound among abdominopelvic surgery discharges for patients ages 18 years and older. Excludes cases in which the abdominal wall reclosure occurs on or before the day of the first abdominopelvic surgery, cases with an immunocompromised state, cases with stays less than two (2) days, and obstetric cases.

Low

No

No

PSI-14 - Post-Op Wound Dehiscence Rate

Based on AHRQ software: Count of postoperative reclosures of the abdominal wall with a diagnosis of disruption of internal operational wound divided by total abdominopelvic surgery discharges for patients ages 18 years and older. Excludes cases in which the abdominal wall reclosure occurs on or before the day of the first abdominopelvic surgery, cases with an immunocompromised state, cases with stays less than two (2) days, and obstetric cases.

Low

Yes

Yes

PSI-14 - Post-Op Wound Dehiscence O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-15 - Accidental Puncture/Laceration Count

Based on AHRQ software: Accidental punctures or lacerations (secondary diagnosis) among discharges for patients ages 18 years and older who have undergone an abdominopelvic procedure; in which a second abdominopelvic procedure follows one or more days after an index abdominopelvic procedure. Excludes cases with accidental puncture or laceration as a principal diagnosis, cases with accidental puncture or laceration as a secondary diagnosis that is present on admission, and obstetric cases.

Low

No

No

PSI-15 - Accidental Puncture/Laceration Rate

Based on AHRQ software: Count of accidental punctures or lacerations (secondary diagnosis) divided by total discharges for patients ages 18 years and older who have undergone an abdominopelvic procedure; in which a second abdominopelvic procedure follows one or more days after an index abdominopelvic procedure. Excludes cases with accidental puncture or laceration as a principal diagnosis, cases with accidental puncture or laceration as a secondary diagnosis that is present on admission, and obstetric cases.

Low

Yes

Yes

PSI-15 - Accidental Puncture/Laceration O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

Low

No

No

PSI-16 - Transfusion Reaction Count

Based on AHRQ software: The number of medical and surgical discharges with a secondary diagnosis of transfusion reaction for patients ages 18 years and older or obstetric patients. Excludes cases with a principal diagnosis of transfusion reaction or cases with a secondary diagnosis of transfusion reaction that is present on admission.

Low

No

No

PSI-16 - Transfusion Reaction Rate

Based on AHRQ software: Count of medical and surgical discharges with a secondary diagnosis of transfusion reaction for patients ages 18 years and older or obstetric patients divided by the number of such discharges. Excludes cases with a principal diagnosis of transfusion reaction or cases with a secondary diagnosis of transfusion reaction that is present on admission.

Low

Yes

Yes

PSI-17 - Injury to Neonate Count

Based on AHRQ software: Birth trauma injuries among newborns. Excludes preterm infants with a birth weight less than 2,000 grams, and cases with osteogenesis imperfecta.

Low

No

No

PSI-17 - Injury to Neonate Rate

Based on AHRQ software: Count of birth trauma injuries divided by total newborn discharges. Excludes preterm infants with a birth weight less than 2,000 grams, and cases with osteogenesis imperfecta.

Low

Yes

Yes

PSI-18 - Vaginal Obstetric Trauma w/Inst. Count

Based on AHRQ software: Third and fourth degree obstetric traumas among instrument-assisted vaginal deliveries.

Low

No

No

PSI-18 - Vaginal Obstetric Trauma w/Inst. Rate

Based on AHRQ software: Count of third and fourth degree obstetric traumas divided by total instrument-assisted vaginal delivery discharges.

Low

Yes

Yes

PSI-19 - Vaginal Obstetric Trauma w/o Inst. Count

Based on AHRQ software: Third and fourth degree obstetric traumas among vaginal deliveries. Excludes cases without instrument-assisted delivery.

Low

No

No

PSI-19 - Vaginal Obstetric Trauma w/o Inst. Rate

Based on AHRQ software: Count of third and fourth degree obstetric traumas divided by total vaginal delivery discharges. Excludes cases without instrument-assisted delivery.

Low

Yes

Yes

PSI-90 Count

Count of all instances of PSIs 3, 6, 8, 9, 10, 11, 12, 13, 14, and 15. These are all of the PSIs included in the PSI-90 composite.

Low

No

No

Any PSI

Count of patients with at least one PSI event

Low

No

No

Risk Adjusted Obstetric Patient Safety Index

Sum of Numerators / (Sum of Expected Rate * Number of Cases for Each Measure for AHRQ Obstetrics PSI Measures).

PSI Measures Include: Vaginal Obstetric Trauma w/Inst. Rate (PSI-18) and Vaginal Obstetric Trauma w/o Inst. (PSI 19)

Low

No

No

Risk Adjusted Patient Safety Index

Sum of Numerators / (Sum of Expected Rate * Number of Cases for Each Measure for AHRQ PSI Measures).

PSI Measures Include: Death in Low Mortality DRGs (PSI 2), Pressure Ulcer (PSI 3), Death Among Surgical Inpatients (PSI 4), Iatrogenic Pneumothorax (PSI 6), CR-BSIs (PSI 7), Postoperative Hip Fracture (PSI 8), Perioperative Hemorrhage or Hematoma (PSI 9), Post-Op Acute Kidney Injury(PSI 10), Postoperative Respiratory Failure (PSI 11), Postoperative PE or DVT (PSI 12), Postoperative Sepsis (PSI 13), Postoperative Wound Dehiscence (PSI 14), Accidental Puncture or Laceration (PSI 15)

Low

No

No

CAUTI Infection Count

Count of CAUTI (Catheter-Associated Urinary Tract Infection) incidents, based on your NHSN list file

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

CAUTI Infection Rate

Count of CAUTI (Catheter-Associated Urinary Tract Infection) incidents divided by Device Days, as provided in your NHSN files

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

Count of CAUTI (Catheter-Associated Urinary Tract Infection) incidents divided by Device Days, as provided in your NHSN files, then multiplied by 1000

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

CLABSI Infection Count

Count of CLABSI (Central Line-Associated Blood Stream Infection) incidents, based on your NHSN list file

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

CLABSI Infection Rate

Count of CLABSI (Central Line-Associated Blood Stream Infection) incidents divided by Device Days, as provided in your NHSN files

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

Count of CLABSI (Central Line-Associated Blood Stream Infection) incidents divided by Device Days, as provided in your NHSN files, then multiplied by 1000

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

MRSA Infection Count

Count of MRSA (Methicillin-Resistant Staphylococcus Aureus) incidents, based on your NHSN list file

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

MRSA Infection Rate

Count of MRSA (Methicillin-Resistant Staphylococcus Aureus) incidents divided by the number of nursing unit days, as provided in your NHSN files

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

Count of MRSA (Methicillin-Resistant Staphylococcus Aureus) incidents divided by the number of nursing unit days, as provided in your NHSN files, then multiplied by 1000

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

CDI Infection Count

Count of CDI (C. Diff: Clostridium Difficile) incidents, based on your NHSN list file

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

CDI Infection Rate

Count of CDI (C. Diff: Clostridium Difficile) incidents divided by the number of nursing unit days, as provided in your NHSN files

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

Count of CDI (C. Diff: Clostridium Difficile) incidents divided by the number of nursing unit days, as provided in your NHSN files, then multiplied by 1000

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

SSI-COLO Infection Count

Count of SSI-COLO (Surgical Site Infection after a colon procedure) incidents, based on your NHSN list file

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

SSI-COLO Infection Rate

Count of SSI-COLO (Surgical Site Infection after a colon procedure) incidents divided by the number of procedures, as provided in your NHSN files

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

Count of SSI-COLO (Surgical Site Infection after a colon procedure) incidents divided by the number of procedures, as provided in your NHSN files, then multiplied by 1000

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

SSI-HYST Infection Count

Count of SSI-HYST (Surgical Site Infection after a hysterectomy procedure) incidents, based on your NHSN list file

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

SSI-HYST Infection Rate

Count of SSI-HYST (Surgical Site Infection after a hysterectomy procedure)) incidents divided by the number of procedures, as provided in your NHSN files

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

Count of SSI-HYST (Surgical Site Infection after a hysterectomy procedure) incidents divided by the number of procedures, as provided in your NHSN files, then multiplied by 1000

NOTE: There are 15 nursing-unit-based versions of this measure: All Units, ED (Adult), ED (Pediatric), ICU, Medical, Medical/Surgical, Mixed Acuity, NICU, Observation (Adult), Observation (Pediatric), Oncology, Orthopedics, Pediatric ICU, Surgical, Telemetry. This assignment is according to your NHSN file.

Low

No

No

Patient had one of 1,710 diagnosis codes in any position, not Present on Admission (POA).

See Patient Safety measures for a complete list of included codes.

Harm Rate

The Harm Rate is the rate at which certain CMS Hospital Acquired Conditions and AHRQ Patient Safety Indicators occur among all patients.

The measured events include Post-op DVT/PE (AHRQ PSI 12), Post-op sepsis (AHRQ PSI 13), Pressure Ulcer (stage 3-4) (CMS HAC-04), Central line infection (CMS HAC-07), Falls and Trauma (CMS HAC-05). A patient experiencing any one of the events listed is flagged as having experienced a harmful event. The rate is calculated as the sum of patients experiencing a harmful event divided by the total number of patients.

Low

Yes

Yes

Post-Operative Infection - Rate

Number of Cases with a diagnosis code for a post-operative infection divided by the number of Surgical Cases

Post-operative infection diagnosis codes: 99660-99669, 9985, 9993, T8579XA, T826XXA, T827XXA, T8351XA, T8359XA, T836XXA, T8450XA, T8460XA, T847XXA, T8571XA, K6811, T814XXA, T80219A, T8029XA, T880XXA

Low

Yes

Yes

Post-Operative Infection - O/E Ratio

Observed number of cases with a post-operative infection, divided by the benchmark (expected) value.

Post-operative infection diagnosis codes: 99660-99669, 9985, 9993, T8579XA, T826XXA, T827XXA, T8351XA, T8359XA, T836XXA, T8450XA, T8460XA, T847XXA, T8571XA, K6811, T814XXA, T80219A, T8029XA, T880XXA

Low

No

No

Survival Rate

Total live discharges divided by total discharges

High

Yes

Yes

Survival without Palliative Rate

Total live discharges divided by total discharges of patients without a diagnosis code for palliative care

High

Yes

Yes

Survival Rate (with exclusions)

Total live discharges divided by total discharges, excluding encounter transferred in (4, A), transferred out (2, 5, 43, 82), or discharged Against Medical Advice (AMA: 7).

High

Yes

Yes

Survival Rate without Palliative (with exclusions)

Total live discharges divided by total discharges of patients without a diagnosis code for palliative care, excluding encounter transferred in (4, A), transferred out (2, 5, 43, 82), or discharged Against Medical Advice (AMA: 7).

High

Yes

Yes

Respiratory Complications

Rate of respiratory complications (based on flag in client data)

Low

No

No

AMI within 7 days of index admission

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

Low

No

No

Pneumonia within 7 days of index admission

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

Low

No

No

Sepsis within 7 days of index admission

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

Low

No

No

Surgical site bleed within 30 days of index admission

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

Low

No

No

Pulmonary embolism within 30 days of index admission

The encounter is flagged for this event if either of the following conditions is 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.

Low

No

No

Mortality within 30 days of admission

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

Low

No

No

Mechanical complications within 90 days of index admission

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

Low

No

No

Periprosthetic joint/wound infection within 90 days of index admission

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

Low

No

No

Number of cases with a complication divided by the number of Total Hip Arthroplasty (hip replacement) or Total Knee Arthroplasty (knee replacement) patients. This measure applies to patients in the THA or TKA cohorts only.

Complications include: AMI within 7 days of index admission, Pneumonia within 7 days of index admission, Sepsis within 7 days of index admission, Pulmonary embolism within 30 days of index admission, Periprosthetic joint/wound infection within 90 days of index admission, Mortality within 30 days of index admission, Mechanical complications within 90 days of index admission.

Unexplained Cardiac Arrest

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

Low

No

No

Dysglycemia

Encounter has a diagnosis code of E15, not POA

Low

No

No

Postoperative Atrial Fibrillation

Encounter has a major procedure (HCUP Procedure Class of 3 or 4) and a diagnosis code of I480, I481, I482, I4891, I4991, or I4901, not POA

Low

No

No

Postoperative Respiratory Failure

Encounter has a major procedure (HCUP Procedure Class of 3 or 4) and a diagnosis code of J95821, J9600, or J9601, not POA

Low

No

No

Myocardial Rupture

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

Low

No

No

Pleural effusion

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

Low

No

No

Congestive Heart Failure

Encounter has a diagnosis code of I5020, I5021, I5022, I5023, I5030, I5031, I5032, I5033, I5040, I5041, I5042, or I5043, not POA

Low

No

No

Stroke/Cerebrovascular Incident

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

Low

No

No

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

Low

No

No

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

Low

No

No

Prolonged Intubation

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

Low

No

No

Reaction to Anesthesia

Encounter has a diagnosis code of T8859XA, T8859XD, or T8859XS, not POA

Low

No

No

Low

No

No

Medical PE/DVT

Encounter has a medical MDC and a diagnosis code 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.

Low

No

No

Postpartum Eclampsia

Encounter has a diagnosis code of O152, not POA

Low

No

No

Postpartum Major Puerperal Infection

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

Low

No

No

Failed Forceps Delivery

Encounter has a diagnosis code of O665, not POA

Low

No

No

HCAHPS Total Volume

Total number of HCAHPS surveys received

N/A

No

No

HCAHPS Completed Volume

Total number of HCAHPS surveys received and not excluded

N/A

No

No

Nurses explain things in a way the patient can understand- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q3. During this hospital stay, how often did nurses explain things in a way you could understand?

High

No

No

Nurses listen carefully to the patient- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q2. During this hospital stay, how often did nurses listen carefully to you?

High

No

No

Nurses treat the patient with courtesy and respect- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q1. During this hospital stay, how often did nurses treat you with courtesy and respect?

High

No

No

Nurses communicated well (Bundle)

Percentage of patients that answered 'always' to all of the following HCAHPS questions: Q1. During this hospital stay, how often did nurses treat you with courtesy and respect? Q2. During this hospital stay, how often did nurses listen carefully to you? Q3. During this hospital stay, how often did nurses explain things in a way you could understand?

This is a Clinical Analytics-specific measure not mandated by CMS.

High

No

No

Nurses communicated well (Composite)

Percentage of patients that answered 'always' to the following HCAHPS questions: Q1. During this hospital stay, how often did nurses treat you with courtesy and respect? Q2. During this hospital stay, how often did nurses listen carefully to you? Q3. During this hospital stay, how often did nurses explain things in a way you could understand? The percentage of "top box" answers is calculated for each question in the composite and then averaged among all questions to obtain an overall "top box" composite value.

High

Yes

Yes

Nurses communicated well (Adjusted Composite)

This adjusted composite measure applies the CMS-specified adjustments to the (unadjusted) Composite specified above.

High

Yes

Yes

Doctors listen carefully to the patient- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q6. During this hospital stay, how often did doctors listen carefully to you?

High

No

No

Doctors explain things in a way the patient can understand- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q7. During this hospital stay, how often did doctors explain things in a way you could understand?

High

No

No

Doctors treat the patient with courtesy and respect- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q5. During this hospital stay, how often did doctors treat you with courtesy and respect?

High

No

No

Doctors communicated well (Bundle)

Percentage of patients that answered 'always' to all of the following HCAHPS questions: Q5. During this hospital stay, how often did doctors treat you with courtesy and respect? Q6. During this hospital stay, how often did doctors listen carefully to you? Q7. During this hospital stay, how often did doctors explain things in a way you could understand?

This is a Clinical Analytics-specific measure not mandated by CMS.

High

No

No

Doctors communicated well (Composite)

Percentage of patients that answered 'always' to the following HCAHPS questions: Q5. During this hospital stay, how often did doctors treat you with courtesy and respect? Q6. During this hospital stay, how often did doctors listen carefully to you? Q7. During this hospital stay, how often did doctors explain things in a way you could understand? The percentage of "top box" answers is calculated for each question in the composite and then averaged among all questions to obtain an overall "top box" composite value.

High

Yes

Yes

Doctors communicated well (Adjusted Composite)

This adjusted composite measure applies the CMS-specified adjustments to the (unadjusted) Composite specified above.

High

Yes

Yes

Patient's room and bathroom is kept clean- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q8. During this hospital stay, how often were your room and bathroom kept clean?

High

Yes

Yes

Patient's room and bathroom is kept clean- Always (Adjusted)

This adjusted measure applies the CMS-specified adjustments to the (unadjusted) measure specified above.

High

Yes

Yes

Patient's room is quiet at night- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q9. During this hospital stay, how often was the area around your room quiet at night?

High

Yes

Yes

Patient's room is quiet at night- Always (Adjusted)

This adjusted measure applies the CMS-specified adjustments to the (unadjusted) measure specified above.

High

Yes

Yes

Hospital environment clean and quiet (Bundle)

Percentage of patients that answered 'always' to both of the following HCAHPS questions: Q8. During this hospital stay, how often were your room and bathroom kept clean? Q9. During this hospital stay, how often was the area around your room quiet at night?

This is a Clinical Analytics-specific measure not mandated by CMS.

High

No

No

Hospital environment clean and quiet (Composite)

Percentage of patients that answered 'always' to the following HCAHPS questions: Q8. During this hospital stay, how often were your room and bathroom kept clean? Q9. During this hospital stay, how often was the area around your room quiet at night? The percentage of "top box" answers is calculated for each question in the composite and then averaged among all questions to obtain an overall "top box" composite value.

High

No

No

Patient got help as soon as wanted- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

High

No

No

Patient receives help with bathroom or bedpan as soon as wanted- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q11. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

High

No

No

Patients received help as soon as they wanted (Bundle)

Percentage of patients that answered 'always' to both of the following HCAHPS questions: Q4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? Q11. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

This is a Clinical Analytics-specific measure not mandated by CMS.

High

No

No

Patients received help as soon as they wanted (Composite)

Percentage of patients that answered 'always' to the following HCAHPS questions: Q4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? Q11. During this hospital stay, how often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? The percentage of "top box" answers is calculated for each question in the composite and then averaged among all questions to obtain an overall "top box" composite value.

High

Yes

Yes

Patients received help as soon as they wanted (Adjusted Composite)

This adjusted composite measure applies the CMS-specified adjustments to the (unadjusted) Composite specified above.

High

Yes

Yes

Patient's pain is well controlled- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q13. During this hospital stay, how often was your pain well controlled?

This question only applies to discharges prior to January 1, 2018.

High

No

No

Hospital staff does everything they can to help with the patient's pain- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

This question only applies to discharges prior to January 1, 2018.

High

No

No

Patient's pain was well controlled (Bundle)

Percentage of patients that answered 'always' to both of the following HCAHPS questions: Q13. During this hospital stay, how often was your pain well controlled? Q14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

This is a Clinical Analytics-specific measure not mandated by CMS.

This bundle only applies to discharges prior to January 1, 2018.

High

No

No

Patients pain was well controlled (Composite)

Percentage of patients that answered 'always' to the following HCAHPS questions: Q13. During this hospital stay, how often was your pain well controlled? Q14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? The percentage of "top box" answers is calculated for each question in the composite and then averaged among all questions to obtain an overall "top box" composite value.

This composite only applies to discharges prior to January 1, 2018.

High

Yes

Yes

Patients pain was well controlled (Adjusted Composite)

This adjusted composite measure applies the CMS-specified adjustments to the (unadjusted) Composite specified above.

This adjusted composite only applies to discharges prior to January 1, 2018.

High

Yes

Yes

Hospital staff talks with you about how much pain you had? Always

Percentage of patients that answered 'always' to the HCAHPS question: Q13. During this hospital stay, how often did hospital staff talk with out about how much pain you had?

This question only applies to discharges on or after January 1, 2018.

High

No

No

Hospital staff talks with you about how to treat your pain? Always

Percentage of patients that answered 'always' to the HCAHPS question: Q14. During this hospital stay, how often did hospital staff talk with out about how to treat your pain?

This question only applies to discharges on or after January 1, 2018.

High

No

No

Communication about Pain (Bundle)

Percentage of patients that answered 'always' to both of the following HCAHPS questions: Q13. During this hospital stay, how often did hospital staff talk with out about how much pain you had? Q14. During this hospital stay, how often did hospital staff talk with out about how to treat your pain?

This is a Clinical Analytics-specific measure not mandated by CMS.

This bundle only applies to discharges on or after January 1, 2018.

High

No

No

Communication about Pain (Composite)

Percentage of patients that answered 'always' to the following HCAHPS questions: Q13. During this hospital stay, how often did hospital staff talk with out about how much pain you had? Q14. During this hospital stay, how often did hospital staff talk with out about how to treat your pain?

The percentage of "top box" answers is calculated for each question in the composite and then averaged among all questions to obtain an overall "top box" composite value.

This composite only applies to discharges on or after January 1, 2018.

High

Yes

Yes

Communication about Pain (Adjusted Composite)

This adjusted composite measure applies the CMS-specified adjustments to the (unadjusted) Composite specified above.

This adjusted composite only applies to discharges on or after January 1, 2018.

High

Yes

Yes

Hospital staff tells the patient what a new medicine is for before giving it- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

High

No

No

Hospital staff describes possible side effects before giving new medicine- Always

Percentage of patients that answered 'always' to the HCAHPS question: Q17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

High

No

No

Staff explained medicines before giving them to the patient (Bundle)

Percentage of patients that answered 'always' to both of the following HCAHPS questions: Q16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Q17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

This is a Clinical Analytics-specific measure not mandated by CMS.

High

No

No

Staff explained medicines before giving them to the patient (Composite)

Percentage of patients that answered 'always' to the following HCAHPS questions: Q16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Q17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? The percentage of "top box" answers is calculated for each question in the composite and then averaged among all questions to obtain an overall "top box" composite value.

High

Yes

Yes

Staff explained medicines before giving them to the patient (Adjusted Composite)

This adjusted composite measure applies the CMS-specified adjustments to the (unadjusted) Composite specified above.

High

Yes

Yes

Hospital staff talks to the patient about whether they will have the help needed when they leave hospital- Yes

Percentage of patients that answered 'yes' to the HCAHPS question: Q19. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

High

No

No

Patient receives information about symptoms or health problems to look out for when they leave the hospital- Yes

Percentage of patients that answered 'yes' to the HCAHPS question: Q20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

High

No

No

Patients given information about what to do during their recovery at home (Bundle)

Percentage of patients that answered 'yes' to both of the following HCAHPS questions: Q19. During this hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital? Q20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

This is a Clinical Analytics-specific measure not mandated by CMS.

High

No

No

Patients given information about what to do during their recovery at home (Composite)

Percentage of patients that answered 'yes' to the following HCAHPS questions: Q19. During this hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital? Q20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? The percentage of "top box" answers is calculated for each question in the composite and then averaged among all questions to obtain an overall "top box" composite value.

High

Yes

Yes

Patients given information about what to do during their recovery at home (Adjusted Composite)

This adjusted composite measure applies the CMS-specified adjustments to the (unadjusted) Composite specified above.

High

Yes

Yes

Hospital rating of 9 or 10

Percentage of patients that answered '9 or 10' to the HCAHPS question: Q21. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

High

Yes

Yes

Hospital rating of 9 or 10 (Adjusted)

This adjusted measure applies the CMS-specified adjustments to the (unadjusted) measure specified above.

High

Yes

Yes

Patients would definitely recommend the hospital

Percentage of patients that answered 'definitely yes' to the HCAHPS question: Q22. Would you recommend this hospital to your friends and family?

High

Yes

Yes

Patients would definitely recommend the hospital (Adjusted)

This adjusted measure applies the CMS-specified adjustments to the (unadjusted) measure specified above.

High

Yes

Yes

Preferences about health care needs? Strongly Agree

Percentage of patients that answered 'Strongly Agree' to the HCAHPS question: Q23. 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.

High

No

No

Understanding for managing my health? Strongly Agree

Percentage of patients that answered 'Strongly Agree' to the HCAHPS question: Q24. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.

High

No

No

Understanding the purpose for taking each medication? Strongly Agree

Percentage of patients that answered 'Strongly Agree' to the HCAHPS question: Q25. When I left the hospital, I clearly understood the purpose for taking each of my medications.

High

No

No

IRF-CAHPS - Overall Rating (9 or 10)

Percent of patients who rated the facility a 9 or 10 (out of 10) for IRF-CAHPS question 40: Using any number from 0 to 10, where 0 is the worst rehabilitation hospital/unit possible and 10 is the best rehabilitation hospital/unit possible, what number would you use to rate this rehabilitation hospital/unit?

High

No

No

IRF-CAHPS - Recommendation (Definitely yes)

Percent of patients who indicated "definitely yes" for IRF-CAHPS survey question 41: Would you recommend this rehabilitation hospital/unit to your friends and family?

High

No

No

High

No

No

High

No

No

OAS-CAHPS - Doctor or staff provided information before procedure (Yes, definitely)

Percent of patients who indicated "yes, definitely" for OAS-CAHPS survey question 1: Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure?

High

No

No

OAS-CAHPS - Doctor or staff provided preparation instructions (Yes, definitely)

Percent of patients who indicated "yes, definitely" for OAS-CAHPS survey question 2: Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?

High

No

No

High

No

No

High

No

No

High

No

No

High

No

No

High

No

No

High

No

No

High

No

No

High

No

No

High

No

No

High

No

No

High

No

No

Use of Contrast Material - Abdomen CT

Similar to OP-10: Percent of abdominal CT scans both with and without contrast. Calculated as the number of encounters receiving a abdomen or abdomen/pelvis Computed Tomography (CT) scan both with and without contrast divided by number of encounters receiving an abdomen or andomen/pelvis CT scan. Encounters with diagnosis codes from the following categories are excluded: adrenal mass, blunt abdominal trauma, hematuria, infections of kidney, jaundice, liver lesion (mass or cancer), malignant cancer of pancreas, diseases of urinary system, pancreatic disorders, non-traumatic aortic disease, and unspecified disorder of kidney or ureter.

Low

No

No

Mortality Rate

Number of deaths in-house divided by number of patients

Low

Yes

Yes

Mortality - O/E Ratio

Mortality observed/expected ratio, where expected rate is the encounter-level (not facility-level) Nationwide All Payer mortality rate for a given DRG group (APR-DRG/ROM or MS-DRG). Mortality is defined as number of in-house deaths.

Low

Yes

Yes

Mortality without Palliative Rate

Number of in-house deaths (excluding deaths of patients with palliative care) divided by number of patients

Low

Yes

Yes

Mortality without Palliative - O/E Ratio

Mortality without palliative observed/expected ratio, where expected rate is the encounter-level (not facility-level) Nationwide Medicare mortality rate for a given DRG group (APR-DRG/ROM or MS-DRG). Mortality is defined as number of in-house deaths (among patients without palliative care).

Low

Yes

Yes

Low

Yes

Yes

Number of in-house deaths (excluding deaths of patients with palliative care) divided by number of patients; numerator and denominator also exclude patients transferred in (4, A), transferred out (2, 5, 43, 82), or discharged Against Medical Advice (AMA: 7).

Low

Yes

Yes

% Mortality with Palliative Care

Percent of mortalities with a palliative care consult; the number of mortalities with a palliative care consult during that encounter divided by the number of mortalities.

Based on additional data provided by your facility; see Palliative Care Measures for more information.

High

No

No

No

No

No

No

No

No

Days to Readmission

This measure calculates the number of days between an encounter discharge and the following admit for that patient. MRN (Medical Record Number) is required for this calculation to identify multiple encounters for a single patient. This supports forward-looking readmission measures.

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

No

No

This measure uses date math calculations to determine the number of days between an encounter admission and the previous discharge for that patient. MRN (Medical Record Number) is required for this calculation to identify multiple encounters for a single patient. This supports backward-looking readmission measures.

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

No

No

Same Day Readmission Rate*

Number of patients admitted to the facility on the same day as the previous discharge divided by the total number of discharges. This is one way to identify transfers, as defined by CMS. Days to Readmission=0

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

No

No

3 Day Readmission Rate*

Number of patients readmitted within 3 days of the previous discharge divided by the total number of discharges. There are not Same Hospital versions of this measure. Days to Readmission ≤ 3

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

Yes (NRD)

No

7 Day Readmission Rate*

Number of patients readmitted within 7 days of the previous discharge divided by the total number of discharges. Days to Readmission ≤ 7

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

Yes (NRD)

No

10 Day Readmission Rate*

Number of patients readmitted within 10 days of the previous discharge divided by the total number of discharges. Days to Readmission ≤ 10

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

Yes (NRD)

No

14 Day Readmission Rate*

Number of patients readmitted within 14 days of the previous discharge divided by the total number of discharges. Days to Readmission ≤ 14

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

Yes (NRD)

No

30 Day Readmission Rate*

Number of patients readmitted within 30 days of the previous discharge divided by the total number of discharges. Days to Readmission ≤ 30

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

Yes (NRD)

No

1 to 30 Day Readmission Rate*

Number of patients readmitted within 30 days of the previous discharge, excluding Same Day readmissions, divided by the total number of discharges. CMS defines transfers as same-day readmissions, so this is one way to look at readmissions excluding transfers. Days to Readmission ≤ 30 AND Days to Readmission ≠ 0

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

Yes (NRD)

No

90 Day Readmission Rate*

Number of patients readmitted within 90 days of the previous discharge divided by the total number of discharges. Days to Readmission ≤ 90

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

Yes (NRD)

No

180 Day Readmission Rate*

Number of patients readmitted within 180 days of the previous discharge divided by the total number of discharges. Days to Readmission ≤ 180

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

Yes (NRD)

No

1 Year Readmission Rate*

Number of patients readmitted within 365 days of the previous discharge divided by the total number of discharges. Days to Readmission ≤ 365

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

No

No

30 Day Readmission Forward - O/E Ratio

Observed (numerator) value is the number of 30-day (forward) readmissions. Expected (denominator) value is based on the median Nationwide NRD 30-day readmission benchmark rate for each encounter's APR-DRG/SOI. Ratio values less than (or equal to) 1 are preferred.

If your facility does not provide Patient Class, only patient encounters discharged to a short-term inpatient facility are not included as an index admission for later further readmission calculations.

Low

No

No

30 Day All Cause Readmission Rate - Cardio-Respiratory Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS All Cause Hospital-Wide Cardio-Respiratory Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day All Cause Readmission Rate - Cardiovascular Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS All Cause Hospital-Wide Cardiovascular Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day All Cause Readmission Rate - Medical Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS All Cause Hospital-Wide Medical Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day All Cause Readmission Rate - Neurology Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS All Cause Hospital-Wide Neurology Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day All Cause Readmission Rate - Surgical Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS All Cause Hospital-Wide Surgical Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day All Cause Readmission Rate - Roll Up All Cohorts

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS All Cause Hospital-Wide Readmissions measure (includes all 5 Hospital-Wide All Cause Readmissions Cohorts). All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day Readmission Rate - CABG Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS CABG (Coronary Artery Bypass Graft) Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day Readmission Rate - THA/TKA Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS THA/TKA (Total Hip Arthroplasty/Total Knee Arthroplasty) Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day Readmission Rate - AMI Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS AMI (Acute Myocardial Infarction) Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day Readmission Rate - COPD Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS COPD (Chronic Obstructive Pulmonary Disease) Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day Readmission Rate - Heart Failure Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS Heart Failure (HF) Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day Readmission Rate - Pneumonia Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS Pneumonia (PN) Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

30 Day Readmission Rate - Stroke Cohort

30-day forward unplanned readmission rate for encounters in the selected Profile also included in the CMS Ischemic Stroke (STK) Cohort Readmissions measure. All CMS inclusions and exclusions are accounted for except for the age and payer restrictions.

See the Readmission measures page for more details.

Low

Yes (NRD)

No

Hours to Return (Any Patient Type)

Average number of hours from patient discharge date/time to subsequent admit date/time.

NOTE: The return encounter can be for any patient type.

High

No

No

Patient returns within 24 hours (Any Patient Type)

Percent of patients who were re-admitted as any patient type within 24 hours of discharge.

Low

No

No

Patient returns within 48 hours (Any Patient Type)

Percent of patients who were re-admitted as any patient type within 48 hours of discharge.

Low

No

No

Days to Return (Any Patient Type) - Decimal

Average number of days from patient discharge date/time to subsequent admit date/time.

NOTE: The return encounter can be for any patient type.

High

No

No

Patient returns within 7 days (Any Patient Type)

Percent of patients who were re-admitted as any patient type within 7 days of discharge.

Low

No

No

Patient returns within 14 days (Any Patient Type)

Percent of patients who were re-admitted as any patient type within 14 days of discharge.

Low

No

No

Patient returns within 30 days (Any Patient Type)

Percent of patients who were re-admitted as any patient type within 30 days of discharge.

Low

No

No

Hours to Return to ED

Average number of hours from patient discharge date/time to subsequent Emergency Department admit date/time.

High

No

No

Patient returns to ED within 24 hours

Percent of patients who were re-admitted to the Emergency Department within 24 hours of discharge.

Low

No

No

Patient returns to ED within 48 hours

Percent of patients who were re-admitted to the Emergency Department within 48 hours of discharge.

Low

No

No

Days to Return to ED - Decimal

Average number of days from patient discharge date/time to subsequent Emergency Department admit date/time.

High

No

No

Patient returns to ED within 7 days

Percent of patients who were re-admitted to the Emergency Department within 7 days of discharge.

Low

No

No

Patient returns to ED within 14 days

Percent of patients who were re-admitted to the Emergency Department within 14 days of discharge.

Low

No

No

Patient returns to ED within 30 days

Percent of patients who were re-admitted to the Emergency Department within 30 days of discharge.

Low

No

No

Hours to Return to Surgery

Average number of hours from patient discharge date/time to subsequent surgery encounter admit date/time.

NOTE: The returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters.

High

No

No

Patient returns to Surgery within 24 hours

Percent of patients who were re-admitted as a surgical patient within 24 hours of discharge.

NOTE: The returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters.

Low

No

No

Patient returns to Surgery within 48 hours

Percent of patients who were re-admitted as a surgical patient within 48 hours of discharge.

NOTE: The returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters.

Low

No

No

Days to Return to Surgery - Decimal

Average number of days from patient discharge date/time to subsequent surgery encounter admit date/time.

NOTE: The returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters.

High

No

No

Patient returns to Surgery within 7 days

Percent of patients who were re-admitted as a surgical patient within 7 days of discharge.

NOTE: The returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters.

Low

No

No

Patient returns to Surgery within 14 days

Percent of patients who were re-admitted as a surgical patient within 14 days of discharge.

NOTE: The returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters.

Low

No

No

Patient returns to Surgery within 30 days

Percent of patients who were re-admitted as a surgical patient within 30 days of discharge.

NOTE: The returns include inpatient encounters with a surgical MS-DRG and ASC (outpatient ambulatory surgery) encounters.

Low

No

No

IQI-1 - Esophageal Resection Volume

Esophageal Resection Volume (IQI 1). Esophageal surgery is a rare procedure that requires technical proficiency; and errors in surgical technique or management may lead to clinically significant complications, such as sepsis, pneumonia, anastomotic breakdown, and death.

AHRQ has discontinued this measure as of V2019, so there is no longer volume measure data being calculated for this IQI.

High

No

No

IQI-2 - Pancreatic Resection Volume

Pancreatic Resection Volume (IQI 2). Pancreatic resection is a rare procedure that requires technical proficiency; and errors in surgical technique or management may lead to clinically significant complications, such as sepsis, anastomotic breakdown, and death.

AHRQ has discontinued this measure as of V2019, so there is no longer volume measure data being calculated for this IQI.

High

No

No

IQI-4 - AAA Repair Volume

Abdominal Aortic Aneurysm (AAA) Repair Volume (IQI 4). AAA repair is a rare procedure that requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as arrhythmias, acute myocardial infarction, colonic ischemia, and death.

AHRQ has discontinued this measure as of V2019, so there is no longer volume measure data being calculated for this IQI.

High

No

No

IQI-5 - CABG Volume

Coronary Artery Bypass Graft Volume (IQI 5). Coronary artery bypass graft (CABG) requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as myocardial infarction, stroke, and death.

AHRQ has discontinued this measure as of V2019, so there is no longer volume measure data being calculated for this IQI.

High

No

No

IQI-6 - PTCA Volume

Percutaneous Transluminal Coronary Angioplasty (PTCA) Volume (IQI 6). PTCA is a common procedure that requires proficiency with the use of complex equipment, and technical errors may lead to clinically significant complications. The definition for PTCA mortality rate (IQI 30) is also noted below. The QI software calculates mortality for PTCA, so that the volumes for this procedure can be examined in conjunction with mortality. However, the mortality measure should not be examined independently, because it did not meet the literature review and empirical evaluation criteria to stand alone as its own measure.

AHRQ has discontinued this measure as of V2019, so there is no longer volume measure data being calculated for this IQI.

High

No

No

IQI-7 - CEA Volume

Carotid Endarterectomy (CEA) Volume (IQI 7). CEA is a common procedure that requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as abrupt carotid occlusion with or without stroke, myocardial infarction, and death. The definition for CEA mortality rate (IQI 31) is also noted below. The QI software calculates mortality for CEA, so that the volumes for this procedure can be examined in conjunction with mortality. However, the mortality measure should not be examined independently, because it did not meet the literature review and empirical evaluation criteria to stand alone as its own measure.

AHRQ has discontinued this measure as of V2019, so there is no longer volume measure data being calculated for this IQI.

High

No

No

IQI-8 - Esophageal Resection Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with a procedure for esophogeal resection or total gastrectomy and a diagnosis of esophageal cancer; or with a procedure for esophogeal resection and a diagnosis of gastrointestinal cancer, ages 18 years and older.

Esophageal cancer surgery is a rare procedure that requires technical proficiency; and errors in surgical technique or management may lead to clinically significant complications, such as sepsis, pneumonia, anastomotic breakdown, and death.

Low

No

No

IQI-8 - Esophageal Resection Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-9 - Pancreatic Resection Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with pancreatic resection, ages 18 years and older. Includes metrics to stratify discharges grouped by presence or absence of a diagnosis of pancreatic cancer. Excludes acute pancreatitis discharges, obstetric discharges, and transfers to another hospital.

Pancreatic resection is a rare procedure that requires technical proficiency; and errors in surgical technique or management may lead to clinically significant complications, such as sepsis, anastomotic breakdown, and death.

Low

No

No

IQI-9 - Pancreatic Resection Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-11 - AAA Repair Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with abdominal aortic aneurysm (AAA) repair, ages 18 years and older. Excludes obstetric discharges and transfers to another hospital.

Abdominal aortic aneurysm (AAA) repair is a relatively rare procedure that requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as arrhythmias, acute myocardial infarction, colonic ischemia, and death.

Low

No

No

IQI-11 - AAA Repair Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-12 - CABG Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with coronary artery bypass graft (CABG), ages 40 years and older. Excludes obstetric discharges and transfers to another hospital.

CABG is a common procedure that requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications such as myocardial infarction, stroke, and death.

Low

No

No

IQI-12 - CABG Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-13 - Craniotomy Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with craniotomy, ages 18 years and older. Excludes patients with a principal diagnosis of head trauma and transfers to another short-term hospital.

Craniotomy for the treatment of subarachnoid hemorrhage or cerebral aneurysm entails high post-operative mortality rates.

Low

No

No

IQI-13 - Craniotomy Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

AHRQ has discontinued this measure as of V2019, so there are no longer rate or O/E measure data being calculated for this IQI.

Low

No

No

IQI-14 - Hip Replacement Mortality Rate

Based on AHRQ software: In-hospital deaths among pelvic and thigh osteoarthrosis discharges with partial or full hip replacement, ages 18 years and older. Excludes hip fracture discharges, obstetric discharges, and transfers to another hospital.

Total hip arthroplasty (without hip fracture) is an elective procedure performed to improve function and relieve pain among patients with chronic osteoarthritis, rheumatoid arthritis, or other degenerative processes involving the hip joint.

Low

No

No

IQI-14 - Hip Replacement Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

AHRQ has discontinued this measure as of V2019, so there are no longer rate or O/E measure data being calculated for this IQI.

Low

No

No

IQI-15 - AMI Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with acute myocardial infarction (AMI) as a principal diagnosis for patients ages 18 years and older. Excludes cases in hospice care at admission, obstetric discharges, and transfers to another hospital.

Timely and effective treatments for acute myocardial infarction (AMI), which are essential for patient survival, include appropriate use of thrombolytic therapy and revascularization.

Low

No

No

IQI-15 - AMI Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-16 - HF Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with heart failure as a principal diagnosis for patients ages 18 years and older. Excludes cases in hospice care at admission, obstetric discharges, and transfers to another hospital.

Congestive heart failure (CHF) is a progressive, chronic disease with substantial short-term mortality.

Low

No

No

IQI-16 - HF Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-17 - Acute Stroke Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with acute stroke as a principal diagnosis for patients ages 18 years and older. Includes metrics for discharges grouped by type of stroke. Excludes obstetric discharges, cases in hospice care at admission, and transfers to another hospital.

Quality treatment for acute stroke must be timely and efficient to prevent potentially fatal brain tissue death, and patients may not present until after the fragile window of time has passed.

Low

No

No

IQI-17 - Acute Stroke Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-18 - GI Hemorrhage Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with a principal diagnosis of gastrointestinal hemorrhage; or a secondary diagnosis of esophageal varices with bleeding along with a qualifying associated principal diagnosis, for patients age 18 years and older. Excludes obstetric discharges, cases in hospice care at admission, discharges with a procedure for liver transplant, and transfers to another hospital.

Gastrointestinal (GI) hemorrhage may lead to death when uncontrolled, and the ability to manage severely ill patients with comorbidities may influence the mortality rate.

Low

No

No

IQI-18 - GI Hemorrhage Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-19 - Hip Fracture Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with hip fracture as a principal diagnosis for patients ages 65 years and older. Excludes periprosthetic fracture discharges, obstetric discharges, cases in hospice care at admission, and transfers to another hospital.

Hip fractures, which are a common cause of morbidity and functional decline among elderly persons, are associated with a significant increase in the subsequent risk of mortality.

Low

No

No

IQI-19 - Hip Fracture Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-20 - Pneumonia Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with pneumonia as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges, cases in hospice care at admission, and transfers to another hospital.

Treatment with appropriate antibiotics may reduce mortality, which is a leading cause of death in the United States.

Low

No

No

IQI-20 - Pneumonia Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-21 - Cesarean Delivery Rate, Uncomplicated

Based on AHRQ software: Cesarean deliveries among all deliveries without a hysterotomy procedure. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure).

Cesarean delivery is the most common operative procedure performed in the United States and is associated with higher costs than vaginal delivery. Many organizations have aimed to monitor and reduce the rate.

N/A

No

No

IQI-21 - Cesarean Delivery, Uncomplicated O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

N/A

No

No

IQI-22 - VBAC, Uncomplicated Rate

Based on AHRQ software: Vaginal births among all deliveries by patients with previous Cesarean deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure).

The policy of recommending vaginal birth after Cesarean delivery (VBAC) represents to some degree a matter of opinion on the relative risks and benefits of a trial of labor in patients with previous Cesarean delivery.

N/A

No

No

IQI-22 - VBAC, Uncomplicated O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

N/A

No

No

IQI-23 - Laparoscopic Cholecystectomy Rate

Based on AHRQ software: Laparoscopic cholecystectomy discharges per 1,000 cholecystectomy discharges for patients with cholecystitis and/or cholelithiasis ages 18 years and older. Excludes obstetric discharges.

AHRQ has discontinued this measure as of V7.0, so there is no longer rate or O/E measure data available for this IQI.

N/A

No

No

IQI-24 - Incidental Appendectomy in the Elderly Rate

Based on AHRQ software: Incidental appendectomy discharges per 1,000 hospital discharges with abdominal or pelvic surgery for patients ages 65 years and older. Excludes surgical removal of the colon (colectomy) or pelvic evisceration discharges, appendiceal cancer discharges, and obstetric discharges.

AHRQ has discontinued this measure as of V7.0, so there is no longer rate or O/E measure data available for this IQI.

N/A

No

No

IQI-25 - Bilateral Cardiac Catheterization Rate

Based on AHRQ software: Bilateral cardiac catheterization discharges per 1,000 heart catheterizations discharges for coronary artery disease for patients ages 18 years and older. Excludes valid indications for right-side catheterization discharges and obstetric discharges.

AHRQ has discontinued this measure as of V7.0, so there is no longer rate or O/E measure data available for this IQI.

N/A

No

No

IQI-30 - Percutaneous Coronary Intervention (PCI) Rate

Based on AHRQ software: In-hospital deaths among all discharges with a procedure for percutaneous coronary intervention (PCI), for patients 40 years of age and older.

N/A

No

No

IQI-30 - Percutaneous Coronary Intervention (PCI) O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

N/A

No

No

IQI-31 - Carotid Endarterectomy Mortality Rate

Based on AHRQ software: In-hospital deaths among all discharges with a procedure for endarterectomy (CEA), for patients 18 years of age and older. Excludes obstetric discharges and transfers to another hospital.

CEA is a common procedure that requires proficiency with the use of complex equipment; and technical errors may lead to clinically significant complications, such as abrupt carotid occlusion with or without stroke, myocardial infarction, and death.

Low

No

No

IQI-31 - Carotid Endarterectomy Mortality O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-32 - Acute Myocardial Infarction (AMI) Mortality Rate, Without Transfer Cases

Based on AHRQ software: In-hospital deaths among all discharges with acute myocardial infarction (AMI) as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges, transfers to another hospital, cases in hospice care at admission, and transfers in from another acute care hospital.

Timely and effective treatments for acute myocardial infarction (AMI), which are essential for patient survival, include appropriate use of thrombolytic therapy and revascularization.

Low

No

No

IQI-32 - Acute Myocardial Infarction (AMI) Mortality, Without Transfer Cases O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

Low

No

No

IQI-33 - Primary Cesarean Delivery Rate, Uncomplicated

Based on AHRQ software: First-time Cesarean deliveries without a hysterotomy procedure divided by total deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure).

Cesarean delivery is the most common operative procedure performed in the United States and is associated with higher costs than vaginal delivery. Many organizations have aimed to monitor and reduce the rate.

N/A

No

No

IQI-33 - Primary Cesarean Delivery, Uncomplicated O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

N/A

No

No

IQI-34 - VBAC "All" Rate

Based on AHRQ software: Vaginal births divided by total deliveries by patients with previous Cesarean deliveries.

The policy of recommending vaginal birth after Cesarean delivery (VBAC) represents to some degree a matter of opinion on the relative risks and benefits of a trial of labor in patients with previous Cesarean delivery.

N/A

No

No

IQI-34 - VBAC "All" O/E

Based on AHRQ software: Observed count divided by the Expected number of incidents, where the Expected value is provided by the AHRQ software.

The Expected values are not currently available from the AHRQ software, but are anticipated in early 2019, so AHRQ O/E measures are not available in Clinical Analytics for now.

N/A

No

No

AMI Core Measure Bundle

Acute myocardial infarction (AMI) patients which received all appropriate quality of care measures, including AMI-1 - Aspirin within 24 Hours, AMI-2 - Aspirin at Discharge, AMI-3 - ACE or ARB at Discharge, AMI-4 - Smoking Cessation, AMI-5 - Beta-Blocker at Discharge, AMI -10 - Statin Prescribed at Discharge

High

No

No

AMI Overall

Sum of Numerators for all AMI measures / Sum of Denominators for all AMI measures

High

No

No

AMI-1 - Aspirin within 24 Hours

Acute myocardial infarction (AMI) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival.

High

No

No

AMI-2 - Aspirin at Discharge

AMI patients without aspirin contraindications who were prescribed aspirin at hospital discharge.

High

No

No

AMI-3 - ACE or ARB at Discharge

AMI patients with left ventricular systolic dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACE inhibitor) contraindications or angiotensin receptor blocker (ARB) contraindications who are prescribed an ACE inhibitor or an ARB at hospital discharge.

High

No

No

AMI-4 - Smoking Cessation

AMI patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during a hospital stay.

High

No

No

AMI-5 - Beta-Blocker at Discharge

AMI patients without beta-blocker contraindications who were prescribed a beta-blocker at hospital discharge.

High

No

No

AMI-7a - Fibrinolytic Therapy within 30 Minutes

AMI patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less

High

No

No

AMI-8a - PCI within 90 Minutes

AMI patients receiving Percutaneous Coronary Intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less.

High

No

No

AMI -10 - Statin Prescribed at Discharge

Acute myocardial infarction (AMI) patients, without statin contraindications, who are prescribed a statin at hospital discharge. For patients who had a heart attack and have high cholesterol, taking statins can lower the chance that they have another heart attack or die.

High

No

No

CAC Overall

Sum of Numerators for all CAC measures/ Sum of Denominators for all CAC measures

High

No

No

CAC-1a - Relievers for Inpatient Asthma

National guidelines recommend using reliever medication in the severe phase and gradually cutting down the dosage of medications to provide control of asthma symptoms. Relievers are medications that relax the bands of muscle surrounding the airways and are used to make breathing easier.

High

No

No

CAC-2a - Systemic Corticosteroids

National guidelines recommend using systemic corticosteroid medication (oral and IV medication that reduces inflammation and controls symptoms) in the severe phase and gradually cutting down the dosage of medications to provide control of the asthma symptoms. Systemic corticosteroids are a type of medication that works in the body as a whole. Systemic corticosteroids help control allergic reactions and reduce inflammation.

High

No

No

CAC-3 - Home Management Plan of Care

The Home Management Plan of Care document includes arrangements for follow-up care. It helps children with asthma and their caregivers develop a plan to manage the child’s asthma symptoms and to know when to take action. The plan of care should clearly tell the child and their caregiver when and how to use medication.

High

No

No

CMS Data - Heart Attack Mortality

This measure* estimates a hospital-level risk-standardized mortality rate (RSMS), defined as death from any cause within 30 days after the index admission date, for patients discharged from the hospital with a principal diagnosis of acute myocardial infarction (AMI).

Low

No

No

CMS Data - Heart Attack Readmission

This measure* is a hospital-specific, risk-standardized, all-cause 30-day readmission (defined as readmission for any cause within 30 days from the date of discharge of the index admission) for patients discharged from the hospital with a principal discharge diagnosis of acute myocardial infarction (AMI).

Low

No

No

CMS Data - Heart Failure Mortality

This measure* estimates a hospital-level risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for patients discharged from the hospital with a principal diagnosis of heart failure (HF).

Low

No

No

CMS Data - Heart Failure Readmission

This measure* is a hospital-specific, risk-standardized, all-cause 30-day readmission (defined as readmission for any cause within 30 days from the date of discharge of the index admission) for patients discharged from the hospital with a principal discharge diagnosis of heart failure (HF).

Low

No

No

CMS Data - Overall Mortality

Average mortality across Heart Attack, Heart Failure and Pneumonia.

Low

No

No

CMS Data - Overall Readmission

Average readmission across Heart Attack, Heart Failure and Pneumonia.

Low

No

No

CMS Data - Pneumonia Mortality

This measure* estimates a hospital-level, risk-standardized mortality rate (RSMR), defined as death from any cause within 30 days after the index admission date, for patients discharged from the hospital with a principal diagnosis of pneumonia.

Low

No

No

CMS Data - Pneumonia Readmission

This measure* is a hospital-specific, risk-standardized, all-cause 30-day readmission (defined as readmission for any cause within 30 days from the date of discharge of the index admission) for patients discharged from the hospital with a principal discharge diagnosis of pneumonia.

Low

No

No

ED-1

Average time, in minutes, from ED arrival to ED departure for patients admitted to the facility from the ED. Values are derived from your Core Measure Vendor File.

NOTE: The core measure aggregation is a median time, but this software takes the arithmetic average when aggregating.

There are 4 versions of this measure:

• 1a - Overall Rate
• 1b - Reporting Rate
• 1c - Observation Rate
• 1d - Mental Health/Psychiatric Rate

Low

No

No

Average time, in minutes, from the admit decision time to ED departure time for patients admitted to the facility from the ED. Values are derived from your Core Measure Vendor File.

NOTE: The core measure aggregation is a median time, but this software takes the arithmetic average when aggregating.

There are 3 versions of this measure:

• 2a - Overall Rate

• 2b - Reporting Measure

• 2c - Psychiatric/Mental Health Patients

HBIPS-1 - Admission Screening

Percent of all patients admitted to a hospital-based inpatient psychiatric setting who are screened within the first three days of admission for all of the following: risk of violence to self or others, substance use, psychological trauma history and patient strengths. Exclude: Patients for whom there is an inability to complete admission screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths within the first three days of admission and patients with a Length of Stay ≤ 3 days or ≥ 365 days. Values are derived from your Core Measure Vendor File.

There are 5 versions of this measure:

• 1a - Overall Rate
• 1b - Children (1 through 12 years)
• 1c - Adolescent (13 through 17 years)
• 1d - Adult (18 through 64 years)
• 1e - Older Adult ≥65 years

HBIPS-2 - Physical Restraint

The average number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint. Values are derived from your Core Measure Vendor File.

There are 5 versions of this measure:

• 2a - Overall Rate
• 2b - Children (1 through 12 years)
• 2c - Adolescent (13 through 17 years)
• 2d - Adult (18 through 64 years)
• 2e - Older Adult ≥65 years

HBIPS-3 - Seclusion

The average number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion. Values are derived from your Core Measure Vendor File.

There are 5 versions of this measure:

• 3a - Overall Rate
• 3b - Children (1 through 12 years)
• 3c - Adolescent (13 through 17 years)
• 3d - Adult (18 through 64 years)
• 3e - Older Adult ≥65 years

HBIPS-4 - Multiple Antipsychotic Medications at Discharge

Percent of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications. Values are derived from your Core Measure Vendor File.

There are 5 versions of this measure:

• 4a - Overall Rate
• 4b - Children (1 through 12 years)
• 4c - Adolescent (13 through 17 years)
• 4d - Adult (18 through 64 years)
• 4e - Older Adult ≥65 years

HBIPS-5 - Multiple Antipsychotic Medications at Discharge with Appropriate Justification

Percent of patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification. Exclude Patients who: expired, patients with an unplanned departure resulting in discharge due to elopement, patients with an unplanned departure resulting in discharge due to failing to return from leave, patients with a length of stay ≤ 3 days. Values are derived from your Core Measure Vendor File.

There are 5 versions of this measure:

• 5a - Overall Rate
• 5b - Children (1 through 12 years)
• 5c - Adolescent (13 through 17 years)
• 5d - Adult (18 through 64 years)
• 5e - Older Adult ≥65 years

HBIPS-6 - Post Discharge Continuing Care Plan

Percent of all patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan created. Exclude population: who expired, patients with an unplanned departure resulting in discharge due to elopement, patients or their guardians who refused aftercare, patients or guardians who refused to sign authorization to release information, patients with an unplanned departure resulting in discharge due to failing to return from leave. Values are derived from your Core Measure Vendor File.

There are 5 versions of this measure:

• 6a - Overall Rate
• 6b - Children (1 through 12 years)
• 6c - Adolescent (13 through 17 years)
• 6d - Adult (18 through 64 years)
• 6e - Older Adult ≥65 years

No

HBIPS-7 - Post Discharge Continuing Care Plan Transmitted

Percent of all patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan provided to the next level of care clinician or entity. Exclude population: who expired, patients with an unplanned departure resulting in discharge due to elopement, patients or their guardians who refused aftercare, patients or guardians who refused to sign authorization to release information, patients with an unplanned departure resulting in discharge due to failing to return from leave. Values are derived from your Core Measure Vendor File.

There are 5 versions of this measure:

• 7a - Overall Rate
• 7b - Children (1 through 12 years)
• 7c - Adolescent (13 through 17 years)
• 7d - Adult (18 through 64 years)
• 7e - Older Adult ≥65 years

HF Core Measure Bundle

Heart failure (HF) patients which received all appropriate quality of care measures, including: HF-1 - Discharge Instructions, HF-2 - LVS Function, HF-3 - ACE or ARB at Discharge, HF-4 - Smoking Cessation

High

No

No

HF Overall

Sum of Numerators for all CHF measures/ Sum of Denominators for all CHF measures

High

No

No

HF-1 - Discharge Instructions

Heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.

High

No

No

HF-2 - LVS Function

Heart failure patients with documentation in the hospital record that an evaluation of the left ventricular systolic (LVS) function was performed before arrival, during hospitalization, or is planned for after discharge.

High

No

No

HF-3 - ACE or ARB at Discharge

Heart failure patients with left ventricular systolic dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACE inhibitor) contraindications or angiotensin receptor blocker (ARB) contraindications who are prescribed an ACE inhibitor or an ARB at hospital discharge.

High

No

No

HF-4 - Smoking Cessation

Heart failure patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during a hospital stay.

High

No

No

IMM Core Measure Bundle

Immunization (IMM) patients which received all appropriate quality of care measures, including IMM 1a and IMM 2

High

No

No

IMM Overall

Sum of numerators for all IMM measures divided by the sum of denominators for all IMM measures

High

No

No

IMM-1a - Pneumococcal Immunization - Overall Rate

This prevention measure addresses acute care hospitalized inpatients 65 years of age and older (IMM-1b) and inpatients aged between 5 and 64 years (IMM-1c) who are considered high risk and were screened for receipt of pneumococcal vaccine and were vaccinated prior to discharge if indicated. The numerator captures two activities; screening and the intervention of vaccine administration when indicated. Patients who had documented contraindications to pneumococcal vaccine, patients who were offered and declined pneumococcal vaccine, and patients who received pneumococcal vaccine anytime in the past are captured as numerator events.

High

No

No

IMM-1b - Pneumococcal Immunization - Age 65 and Older

This prevention measure addresses acute care hospitalized inpatients 65 years of age and older who are considered high risk and were screened for receipt of pneumococcal vaccine and were vaccinated prior to discharge if indicated. The numerator captures two activities; screening and the intervention of vaccine administration when indicated. Patients who had documented contraindications to pneumococcal vaccine, patients who were offered and declined pneumococcal vaccine, and patients who received pneumococcal vaccine anytime in the past are captured as numerator events.

High

No

No

IMM-1c - Pneumococcal Immunization - High Risk Populations (Age 5 through 64 years)

This prevention measure address acute care hospitalized inpatients aged between 5 and 64 years who are considered high risk and were screened for receipt of pneumococcal vaccine and were vaccinated prior to discharge if indicated. The numerator captures two activities; screening and the intervention of vaccine administration when indicated. Patients who had documented contraindications to pneumococcal vaccine, patients who were offered and declined pneumococcal vaccine, and patients who received pneumococcal vaccine anytime in the past are captured as numerator events.

High

No

No

IMM-2 - Influenza Immunization

This prevention measure addresses acute care hospitalized inpatients age 6 months and older who were screened for seasonal influenza immunization status and were vaccinated prior to discharge if indicated. The numerator captures two activities: screening and the intervention of vaccine administration when indicated. Patients who had documented contraindications to the vaccine, patients who were offered and declined the vaccine, and patients who received the vaccine during the current year's influenza season but prior to the current hospitalization are captured as numerator events.

High

No

No

NQI-1 - Iatrogenic Pneumothorax in Neonates O/E

Cases of iatrogenic pneumothorax in neonates (NQI 1). Observed over expected.

AHRQ has discontinued this measure as of V2019, so there is no longer O/E measure data being calculated for this NQI.

Low

No

No

NQI-2 - Neonatal Mortality O/E

Number of deaths among neonates. Observed over expected. (NQI 2)

Low

No

No

NQI-3 - Neonatal Blood Stream Infections O/E

Discharges with blood stream infections in neonates (NQI 3). Observed over expected.

Low

No

No

OP 1 - Median Time to Fibrinolysis

Median time from emergency department arrival to administration of fibrinolytic therapy in ED patients with ST-segment elevation or left bundle branch block on the ECG performed closest to ED arrival and prior to transfer.

Low

No

No

OP 2 - Fibrinolytic Therapy within 30 Minutes

Emergency Department AMI patients with ST-segment elevation or left bundle branch block on the ECG closest to arrival time receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less.

High

No

No

OP 3 - Median Time to Transfer to Another Facility for ACI

Average time, in minutes, from patient arrival to patient departure for all AMI patients transferred out for acute coronary intervention at another facility and did not have a contraindication to fibrinolytics. OP-3a is the rate for all cases transferred for ACI (OP-3b + 3c). Values are derived from your Core Measure Vendor File.

NOTE: The core measure aggregation is a median time, but this software takes the arithmetic average when aggregating.

There are 3 versions of this measure:

• 3a - Overall Rate
• 3b - Reporting Measure
• 3c - Quality Improvement Measure

Low

No

No

OP 4 - Aspirin at Arrival

Emergency Department AMI patients or chest pain patients (with probable cardiac chest pain) who received aspirin within 24 hours before ED arrival or prior to transfer.

High

No

No

OP 5 - Median Time to ECG

Average time, in minutes, from emergency department arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with Probable Cardiac Chest Pain). Values are derived from your Core Measure Vendor File.

NOTE: The core measure aggregation is a median time, but this software takes the arithmetic average when aggregating.

Low

No

No

OP 6 - Timing of Antibiotic Prophylaxis

Surgical patients with prophylactic antibiotics initiated within one hour* prior to surgical incision.*Patients who received vancomycin or a fluoroquinolone for prophylaxis should have the antibiotic initiated within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.

High

No

No

OP 7 - Prophylactic Antibiotic Selection for Surgical Patients

Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).

High

No

No

Average time, in minutes, from ED Arrival to ED Departure for all Discharged ED Patients. Values are derived from your Core Measure Vendor File.

NOTE: The core measure aggregation is a median time, but this software takes the arithmetic average when aggregating.

There are 4 versions of this measure:

• 18a - Overall Rate
• 18b - Reporting Measure
• 18c - Psychiatric/Mental Health Patients
• 18d - Transfer Patients

PC-01 - Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at >= 37 and < 39 weeks of gestation completed

See the Joint Commission website for more information.

Low

No

No

PC-02 - Cesarean Section (CS)

Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth;

See the Joint Commission website for more information.

Low

No

No

PC-03 - Antenatal Steroids

Patients at risk of preterm delivery at >=24 and <34 weeks gestation receiving antenatal steroids prior to delivering preterm newborns; count of patients with antenatal steroids initiated prior to delivering preterm newborns divided by patients delivering live preterm newborns with >=24 and <34 weeks gestation completed

See the Joint Commission website for more information.

High

No

No

PC-04 - HAC - Bloodstream Infections in Newborns

Staphylococcal and gram negative septicemias or bacteremias in high-risk newborns; count of newborns with septicemia or bacteremia divided by count of live newborns

See the Joint Commission website for more information.

Low

No

No

PC-05 - Exclusive Breast Milk Feeding

Exclusive breast milk feeding during the newborn's entire hospitalization; count of newborns that were fed breast milk only since birth divided by count of single term newborns discharged alive from the hospital

See the Joint Commission website for more information.

High

No

No

PC-05a - Exclusive Breast Milk Feeding considering mother's choice

Exclusive breast milk feeding during the newborn's entire hospitalization, excluding those whose mothers chose not to breastfeed; count of newborns that were fed breast milk only since birth divided by count of single term newborns discharged alive from the hospital, excluding those who were, by choice, not breastfed.

See the Joint Commission website for more information.

High

No

No

Unexpected complications among full term newborns with no preexisting conditions.

See the Joint Commission website for more information.

(Severe Complications Numerator + Moderate Complications Numerator) x 1,000

Final Denominator

PN Core Measure Bundle

Pneumonia (PN) patients which received all appropriate quality of care measures, including PN-2 - Pneumococcal Vaccine, PN-3b - Blood Culture, PN-4 - Smoking Cessation, PN-5c - Initial Antibiotic Timing, PN-6 - Initial Antibiotic Selection, PN-7 - Influenza Vaccination

High

No

No

PN Overall

Sum of numerators for all CAP measures / sum of denominators for all CAP measures

High

No

No

PN-2 - Pneumococcal Vaccine

Pneumonia inpatients age 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.

High

No

No

PN-3b - Blood Culture

Pneumonia patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics.

High

No

No

PN-4 - Smoking Cessation

Pneumonia patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during a hospital stay.

High

No

No

PN-5c - Initial Antibiotic Timing

Pneumonia inpatients that receive within 6 hours after arrival at the hospital. Evidence shows better outcomes for administration times less than four hours.

High

No

No

PN-6 - Initial Antibiotic Selection

Immunocompetent patients with pneumonia who receive an initial antibiotic regimen that is consistent with current guidelines.

High

No

No

PN-7 - Influenza Vaccination

Pneumonia patients age 50 years and older, hospitalized during October, November, December, January, or February who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated.

High

No

No

SCIP Core Measure Bundle

Surgery (SCIP) patients which received all appropriate quality of care measures, including SCIP-Inf -1a - Prophylactic Antibiotic, SCIP-Inf -2a - Antibiotic Selection, SCIP-Inf -3a - Antibiotic Discontinued, SCIP-Inf-6 - Appropriate Hair Removal, SCIP-Inf-9 - Urinary Catheter Removed, SCIP-Inf-10 - Perioperative Temperature Management, SCIP-VTE-1 - VTE Ordered, SCIP-VTE-2 - Appropriate VTE Therapy, SCIP-Card-2 - Beta-Blocker Therapy

High

No

No

SCIP Overall

Sum of Numerators for all SCIP measures / sum of denominators for all SCIP measures

High

Yes

Yes

SCIP-Card-2 - Beta-Blocker Therapy

Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period. The perioperative period for the SCIP cardiac measures is defined as 24 hours prior to surgical incision through discharge from post-anesthesia care/recovery area.

High

Yes

Yes

SCIP-Inf -1a - Prophylactic Antibiotic

Surgical patients who received prophylactic antibiotics within 1 hour prior to surgical incision.

High

Yes

Yes

SCIP-Inf -2a - Antibiotic Selection

Surgical patients who received the recommended antibiotics for their particular type of surgery.

High

Yes

Yes

SCIP-Inf -3a - Antibiotic Discontinued

Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.

High

Yes

Yes

SCIP-Inf-4 - Cardiac Patients Post-Op Blood Glucose

Cardiac surgery patients with controlled 6 A.M. blood glucose (<200 mg/dL) on postoperative day one (POD 1) and postoperative day two (POD 2) with surgery end date being postoperative day zero (POD 0).

High

No

No

SCIP-Inf-6 - Appropriate Hair Removal

Surgery patients with appropriate surgical site hair removal. No hair removal or hair removal with clippers or depilatory is considered appropriate. Shaving is considered inappropriate.

High

No

No

SCIP-Inf-9 - Urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero

Surgical patients with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero.

High

Yes

Yes

SCIP-Inf-10 - Surgery Patients with Perioperative Temperature Management

Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8° Fahrenheit/36° Celsius recorded within the 30 minutes immediately prior to or the 15 minutes immediately after Anesthesia End Time.

High

No

No

SCIP-VTE-1 - VTE Ordered

Surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 48 hours after surgery end time.

High

No

No

SCIP-VTE-2 - Appropriate VTE Therapy

Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 Hours prior to surgical incision time to 24 hours after surgery end time.

High

Yes

Yes

STK Core Measure Bundle

Stroke (STK) patients which received all appropriate quality of care measures, including STK-1, STK-2, STK-3, STK-4, STK-5, STK-6, STK-8, STK-10

High

No

No

STK Overall

Sum of numerators for all STK measures/ sum of denominators for all STK measures

High

Yes

Yes

STK-1 - VTE Prophylaxis

Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission

See the Joint Commission website for more information.

High

Yes

Yes

STK-2 - Discharged on Antithrombotic Therapy

Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge

See the Joint Commission website for more information.

High

Yes

Yes

STK-3 - Anticoagulant Therapy for Atrial Fibrillation/Flutter

Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.

See the Joint Commission website for more information.

High

Yes

Yes

STK-4 - Thrombolytic Therapy

Acute ischemic stroke patients who arrive at this hospital within 2 hours of the time they were last known to be well and for whom IV t-PA was initiated at this hospital within 3 hours of the time they were last known to be well.

See the Joint Commission website for more information.

High

Yes

Yes

STK-5 - Antithrombotic Therapy

Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.

See the Joint Commission website for more information.

High

Yes

Yes

STK-6 - Discharged on Statin Medication

Ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.

See the Joint Commission website for more information.

High

Yes

Yes

STK-8 - Stroke Education

Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke.

See the Joint Commission website for more information.

High

Yes

Yes

STK-10 - Assessed for Rehabilitation

Percent of ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. Exclude population: less than 18 years of age, patients who have a Length of Stay greater than 120 days, patients with Comfort Measures Only documented, patients enrolled in clinical trials, patients admitted for Elective Carotid Intervention, patients discharged to another hospital, patients who left against medical advice, patients who expired, patients discharged to home for hospice care, and patients discharged to a health care facility for hospice care. Values are derived from your Core Measure Vendor File.

See the Joint Commission website for more information.

High

No

No

SUB-2 - Alcohol Use Brief Intervention Provided or Offered

Percentage of patients who screened positive for unhealthy alcohol use to whom a brief intervention was provided, offered or refused. Exclude: patients less than 18 years of age, patients who are cognitively impaired, patients who a have a duration of stay less than or equal to one day or greater than 120 days, patients with Comfort Measures Only documented. Values are derived from your Core Measure Vendor File.

High

No

No

High

No

No

High

No

No

TOB-2 - Tobacco Use Treatment Provided or Offered

Percent of patients identified as tobacco product users within the past 30 days who received or refused practical counseling to quit AND received or refused FDA approved cessation medications during the hospital stay. Exclude patients who: less than 18 years of age, are cognitively impaired, have a duration of stay less than or equal to one day and greater than 120 days. Values are derived from your Core Measure Vendor File.

High

No

No

VTE Core Measure Bundle

Venous Thromboembolism (VTE) patients which received all appropriate quality of care measures, including VTE-1, VTE-2, VTE-3, VTE-4, VTE-5, VTE-6

High

No

No

VTE Overall

Sum of numerators for all VTE measures/ sum of denominators for all VTE measures

High

No

No

VTE-1 - VTE Prophylaxis

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.

High

Yes

Yes

VTE-2 - ICU VTE

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).

High

Yes

Yes

VTE-3 - Anticoagulation Overlap Therapy

This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral intravenous or subcutaneous anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a reason for discontinuation of overlap therapy.

High

Yes

Yes

VTE-4 - Heparin Therapy and Monitoring

This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages and had their platelet counts monitored using defined parameters such as a nomogram or protocol.

High

Yes

Yes

VTE-5 - Discharge Instructions

This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions.

High

No

No

Volume

Count of inpatient discharges

High

No

No

Gender - Female

Number of female patients divided by the total number of discharges

N/A

No

No

Gender - Male

Number of male patients divided by the total number of discharges

N/A

No

No

Average # of CC Diagnoses

Average number of CC diagnoses on each encounter

N/A

Yes

Yes

Average # of MCC Diagnoses

Average number of MCC diagnoses on each encounter

N/A

Yes

Yes

Average # of Secondary Diagnoses

Average number of secondary diagnoses on each encounter

N/A

Yes

Yes

Procedures

Average number of procedures on each encounter

N/A

Yes

Yes

% APR-DRG with Risk = 1

Percent of patients with APR-DRG Risk of Mortality (ROM) = 1 (minor). ROM indicates the likelihood of dying during the hospital stay:

Number of encounters with ROM=1 divided by the total number of discharges

N/A

Yes

Yes

% APR-DRG with Risk = 2

Percent of patients with APR-DRG Risk of Mortality (ROM) = 2 (moderate). ROM indicates the likelihood of dying during the hospital stay:

Number of encounters with ROM=2 divided by the total number of discharges

N/A

Yes

Yes

% APR-DRG with Risk = 3

Percent of patients with APR-DRG Risk of Mortality (ROM) = 3 (major). ROM indicates the likelihood of dying during the hospital stay:

Number of encounters with ROM=3 divided by the total number of discharges

N/A

Yes

Yes

% APR-DRG with Risk = 4

Percent of patients with APR-DRG Risk of Mortality (ROM) = 4 (extreme). ROM indicates the likelihood of dying during the hospital stay:

Number of encounters with ROM=4 divided by the total number of discharges

N/A

Yes

Yes

% APR-DRG with Severity = 1

Percent of patients with APR-DRG Severity of Illness (SOI) = 1 (minor). SOI is a measure of how sick the patient is, defined as the extent of physiologic decompensation or organ system loss of function:

Number of encounters with SOI=1 divided by the total number of discharges

N/A

Yes

Yes

% APR-DRG with Severity = 2

Percent of patients with APR-DRG Severity of Illness (SOI) = 2 (moderate). SOI is a measure of how sick the patient is, defined as the extent of physiologic decompensation or organ system loss of function:

Number of encounters with SOI=2 divided by the total number of discharges

N/A

Yes

Yes

% APR-DRG with Severity = 3