Statewide Quality Reporting and Measurement System
2016 Required Measures for Critical Access Hospitals
Proposed June 2015
Collection
method
Submission
method
Population
Chart Abstracted
eCQM/chart
abstracted
eCQM/chart
abstracted
eCQM/chart
abstracted
eCQM/chart
abstracted
QualityNet
All payer
QualityNet
All payer
QualityNet
All payer
QualityNet
All payer
QualityNet
All payer
OP-1 Median time to fibrinolysis
OP-2 Fibrinolytic therapy received within 30 minutes of emergency department (ED)
arrival
Chart Abstracted
QualityNet
All payer
Chart Abstracted
QualityNet
All payer
OP-3 Median time to transfer to another facility for acute coronary intervention
Chart Abstracted
QualityNet
All payer
OP-4 Aspirin at arrival
Chart Abstracted
QualityNet
All payer
OP-5 Median time to ECG
Chart Abstracted
QualityNet
All payer
OP-18 Median time from ED arrival to ED departure for discharged ED patients
Chart Abstracted
QualityNet
All payer
OP-20 Door to diagnostic evaluation by a qualified medical professional
Chart Abstracted
QualityNet
All payer
OP-21 ED-median time to pain management for long bone fracture
OP-22 ED-patient left without being seen (numerator/denominator one time per year
for the previous year)
OP-23 ED-head CT scan results for acute ischemic stroke or hemorrhagic stroke who
received head CT scan interpretation within 45 minutes of arrival)
Chart Abstracted
QualityNet
All payer
Chart Abstracted
QualityNet
All payer
Chart Abstracted
QualityNet
All payer
OP-25 Safe surgery checklist
Web entry
QualityNet
All payer
Catheter-Associated Urinary Tract Infection (CAUTI) (hospital wide)
Chart Abstracted
NHSN
All payer
Healthcare Personnel Influenza Vaccination (combined with OP-27)
OP-27 Influenza Vaccination Coverage among Healthcare Personnel (combined with
HCP)
Chart Abstracted
NHSN
All payer
Chart Abstracted
NHSN
All payer
EDTC-1 Administrative communication
Chart Abstracted
MHA
All payer
EDTC-2 Vital signs
Chart Abstracted
MHA
All payer
EDTC-3 Medication information
Chart Abstracted
MHA
All payer
EDTC-4 Patient information
Chart Abstracted
MHA
All payer
EDTC-5 Physician information
Chart Abstracted
MHA
All payer
EDTC-6 Nursing information
Chart Abstracted
MHA
All payer
EDTC-7 Procedures and tests
Chart Abstracted
MHA
All payer
EDTC- 8 All or None composite
Chart Abstracted
MHA
All payer
Measure
Collection
method
Submission
method
Population
Measure
Inpatient
IMM-2 Influenza immunization
PC-1 Elective delivery prior to 39 completed weeks gestation
VTE-1 Venous thromboembolism prophylaxis
ED-1 Median time from ED arrival to ED departure for ED admitted patients
ED-2 Median time from admit decision to departure for ED admitted patients
Outpatient
Infection
ED Transfer Communication
Statewide Quality Reporting and Measurement System
2016 Required Measures for Critical Access Hospitals
Proposed June 2015
Collection
method
Submission
method
Population
Survey
QualityNet
All payer
READM-30-HF Heart Failure (HF) 30-Day Readmission Rate
Claims
Billing
Medicare
READM-30-PN Pneumonia (PN) 30-Day Readmission Rate
READM-30-COPD Chronic Obstructive Pulmonary Disease (COPD) 30-Day Readmission
rate
Claims
Billing
Medicare
Claims
Billing
Medicare
Survey
Online link
All payer
EHR
HIT survey
All payer
Measure
Patient Experience of Care
Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)
( > 500 admissions in previous year)3 item Care Transition set and 2 About You items
Readmissions
Health Information Technology
Health information technology survey
End of Life
Stage 2 Meaningful Use Advance Directive Measure