Core measures

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

ASC-1 Patient Burn

The number of discharges (patient encounters) who experience a burn prior to discharge from the ASC

See the QualityNet website for more information.

Low

No

No

ASC-2 Patient Fall

The number of discharges (patient encounters) who experience a fall within the ASC

See the QualityNet website for more information.

Low

No

No

ASC-3 Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant

The number of discharges (patient encounters) who experience a wrong site, side, patient, procedure, or implant

See the QualityNet website for more information.

Low

No

No

ASC-4 Hospital Transfer/Admission

The percentage of ASC admissions (patients) who are transferred or admitted to a hospital upon discharge from the ASC

See the QualityNet website for more information.

Low

No

No

ASC-5 Prophylactic Intravenous (IV) Antibiotic Timing

Intravenous (IV) antibiotics given for prevention of surgical site infection were administered on time

NOTE: Measures ASC-5, -6, and -7 have been removed from the program beginning with January 1, 2017 encounters.

See the QualityNet website for more information.

Low

No

No

ASC-6 Safe Surgery Checklist Use

The use of a Safe Surgery Checklist for surgical procedures that includes safe surgery practices during each of the three critical perioperative periods: the period prior to the administration of anesthesia, the period prior to skin incision, and the period of closure of incision and prior to the patient leaving the operating room

NOTE: Measures ASC-5, -6, and -7 have been removed from the program beginning with January 1, 2017 encounters.

See the QualityNet website for more information.

Low

No

No

ASC-7 ASC Facility Volume Data on Selected ASC Surgical Procedures

The aggregate count of selected surgical procedures

NOTE: Measures ASC-5, -6, and -7 have been removed from the program beginning with January 1, 2017 encounters.

See the QualityNet website for more information.

Low

No

No

ASC-8 Influenza Vaccination Coverage among Healthcare Personnel

Percentage of Healthcare Personnel (HCP) who have received a flu vaccine.

See the QualityNet website for more information.

Facilities must report vaccination data for three categories of HCP: employees on payroll; licensed independent practitioners (who are physicians, advanced practice nurses, and physician assistants affiliated with the hospital but not on payroll); and students, trainees, and volunteers aged 18 or older. Show in Clinical Analytics only for personnel in the Physician Master File sent to Clinical Analytics.

Low

No

No

ASC-9 Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients

Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

See the QualityNet website for more information.

Low

No

No

ASC-10 Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use

Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp(s) in previous colonoscopy findings, who had a follow-up interval of 3 or more years since their last colonoscopy

See the QualityNet website for more information.

Low

No

No

ASC-11 Cataracts - Improvement in Patient's Visual Function within 90 days Following Cataract Surgery

Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey

See the QualityNet website for more information.

Low

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

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

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

High

No

No

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

Low

No

No

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

Low

No

No

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

Low

No

No

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

High

No

No

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

High

No

No

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

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

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

Median time from emergency department arrival to time of transfer to another facility for acute coronary intervention

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

Median time from emergency department arrival to ECG (performed in the ED prior to transfer) for AMI or chest pain patients (with probable cardiac chest pain).

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

OP - 8 MRI Lumbar Spine for Low Back Pain

Percentage of MRI (Magnetic Resonance Imaging) of the Lumbar Spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy

See the QualityNet website for more information.

High

No

No

OP - 9 Mammography Follow-Up Rates

Percentage of patients with mammography screening studies that are followed by a diagnostic mammography, ultrasound, or Magnetic Resonance Imaging (MRI) of the breast in an outpatient or office setting within 45 days

See the QualityNet website for more information.

High

No

No

OP - 10 Abdomen CT Use of Contrast Material

Percentage of abdomen studies that are performed with and without contrast out of all abdomen studies performed (those with contrast, those without contrast, and those with both)

See the QualityNet website for more information.

High

No

No

OP - 11 Thorax CT - Use of Contrast Material

Percentage of thorax studies that are performed with and without contrast out of all thorax studies performed (those with contrast, those without contrast, and those with both)

See the QualityNet website for more information.

High

No

No

OP - 12 The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their ONC-Certified EHR System as Discrete Searchable Data

The extent to which a provider uses an Office of the National Coordinator for Health Information Technology (ONC) certified electronic health record (EHR) system that incorporates an electronic data interchange with one or more laboratories allowing for direct electronic transmission of laboratory data in the EHR as discrete searchable data elements

See the QualityNet website for more information.

High

No

No

OP - 13 Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery

Percentage of Stress Echocardiography, Single Photon Emission Computed Tomography, Myocardial Perfusion Imaging (SPECT MPI), Cardiac Computed Tomography Angiography (CCTA), or Stress Magnetic Resonance Imaging (MRI) studies performed at a hospital outpatient facility in the 30 days prior to an ambulatory low-risk, non-cardiac surgery performed anywhere

See the QualityNet website for more information.

High

No

No

OP - 14 Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT

Percentage of Brain CT studies with a simultaneous Sinus CT (i.e., Brain and Sinus CT studies performed on the same day at the same facility)

See the QualityNet website for more information.

High

No

No

OP-15 Use of Brain Computed Tomography (CT) in the ED for Atraumatic Headache

Percent of ED patients with atraumatic headache who are given a brain CT

This measure was discontinued by CMS as of January 1, 2017

High

No

No

OP - 17 Tracking Clinical Results between Visits

The extent to which a provider uses an Office of the National Coordinator for Health Information Technology (ONC) certified electronic health record (EHR) system to track pending laboratory tests, diagnostic studies (including common preventive screenings), or patient referrals

See the QualityNet website for more information.

High

No

No

OP-18a Median Time from ED Arrival to ED Departure for Discharged ED Patients - Overall Rate

Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department

See the QualityNet website for more information.

Low

No

No

OP-18b Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure

Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department

See the QualityNet website for more information.

Low

No

No

OP-18c Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients

Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department

See the QualityNet website for more information.

Low

No

No

OP-18d Median Time from ED Arrival to ED Departure for Discharged ED Patients - Transfer Patients

Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department

See the QualityNet website for more information.

Low

No

No

OP-20 Door to Diagnostic Evaluation by a Qualified Medical Personnel

Median time from ED arrival to provider contact for Emergency Department patients

See the QualityNet website for more information.

Low

No

No

OP-21 Median Time to Pain Management for Long Bone Fracture

Median time, in minutes, from emergency department arrival to time of initial oral, intranasal, or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture

Low

No

No

Percent of patients who leave the Emergency Department (ED) without being evaluated by a physician/advanced practice nurse/physician’s assistant (physician/APN/PA)

See the QualityNet website for more information.

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

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

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

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

SUB-2a - Alcohol Use Brief Intervention Treatment

Percent of patients who screened positive for unhealthy alcohol use, and did not refuse intervention, to whom a brief intervention was provided. 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

SUB-3 - Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge

Percent of patients meeting the criteria for an alcohol or other drug use disorder who were provided or offered a prescription at discharge for medication for treatment of alcohol or drug use disorder OR a referral for addictions treatment. Exclude: patients less than 18 years of age, patient drinking at unhealthy levels who do not meet criteria for an alcohol use disorder, patients who are cognitively impaired, patients who expire, patients discharged to another hospital, patients who left against medical advice, patients discharged to another healthcare facility, patients discharged to home or another healthcare facility for hospice care, patients who have a length of stay less than or equal to three days or greater than 120 days, patients who do not reside in the United States, patients receiving Comfort Measures Only documented. Values are derived from your Core Measure Vendor File.

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

TOB-2a - Tobacco Use Treatment

Percent of patients identified as tobacco product users within the past 30 days who received counseling AND medication as well as those who received counseling and had reason for not receiving the medication. 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

TOB-3 - Tobacco Use Treatment Provided or Offered at Discharge

Percent of patients identified as tobacco product users within the past 30 days who were referred to or refused evidence-based outpatient counseling AND received or refused a prescription for FDA-approved cessation medication upon discharge. 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