Appendix E
2016 Proposed PPS Measures; CAH Measures
Population
HAC
RRP
VBP
Minnesota Statewide Quality Reporting and Measurement System (SQRMS)
2016 Required Measures for PPS Hospitals - Proposed April 2015
Collection
method
Submission
method
AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival
chart abstracted
QualityNet
x
All payer
PN-6 Initial antibiotic selection for CAP immunocompetent patient
chart abstracted
QualityNet
x
All payer
SCIP-2 Received prophylactic antibiotic consistent with recommendations
SCIP-3 Prophylactic antibiotic discontinued within 24 hrs of surgery end
time or 48 hrs for cardiac surgery
chart abstracted
QualityNet
x
All payer
chart abstracted
QualityNet
x
SCIP-9 Postoperative urinary catheter removal on post operative day 1 or 2
SCIP-Card 2 Pre-admission beta-blocker and perioperative period beta
blocker
chart abstracted
QualityNet
x
chart abstracted
QualityNet
x
SCIP VTE 2 Received VTE prophylaxis within 24 hrs prior to or after surgery
chart abstracted
QualityNet
x
All payer
IMM-2 Influenza immunization
chart abstracted
QualityNet
x
All payer
Measure
Clinical Care - Process
All payer
All payer
All payer
Clinical Care - Outcome
MORT-30-AMI
Acute Myocardial Infarction (AMI) 30-Day Mortality Rate
Claims
Billing
x
Medicare
MORT-30-HF
Heart Failure (HF) 30-Day Mortality Rate
Claims
Billing
x
Medicare
MORT-30-PN
Pneumonia (PN) 30-Day Mortality Rate
Claims
Billing
x
Medicare
Survey
QualityNet
x
All payer
PSI 90 Complication/Patient Safety for Selected Indicators (composite)
(3, 6-8, 12-15)
Claims
Billing
x
x
Medicare
Central Line Associated Bloodstream Infection (CLABSI)
Chart Abstracted
NHSN
x
x
All payer
Catheter-Associated Urinary Tract Infection (CAUTI)
Chart Abstracted
NHSN
x
x
All payer
Surgical Site Infections (SSI) following colon surgery
Chart Abstracted
NHSN
x
x
All payer
Surgical Site Infections (SSI) following abdominal hysterectomy
Chart Abstracted
NHSN
x
x
All payer
Claims
Billing
x
Patient Experience of Care
Hospital Consumer Assessment of Healthcare Providers and Systems Survey
(HCAHPS)
Safety
Efficiency
Medicare Spending per Beneficiary
Stratis Health | www.stratishealth.org
61
Medicare
Population
HAC
RRP
VBP
Collection
method
Submission
method
READM-30-AMI Acute Myocardial Infarction (AMI) 30-Day Readmission
Rate
Claims
Billing
x
Medicare
READM-30-HF Heart Failure (HF) 30-Day Readmission Rate
Claims
Billing
x
Medicare
READM-30-PN Pneumonia (PN) 30-Day Readmission Rate
READM-30-TH/TKA: 30 day all-cause risk-standardized readmission
rate(RSRR) for elective primary Total Hip(THA) /Total Knee
Arthroplasty(TKA)
READM-30-COPD Chronic Obstructive Pulmonary Disease (COPD) 30-Day
Readmission rate
Claims
Billing
x
Medicare
Claims
Billing
x
Medicare
Claims
Billing
x
Medicare
Collection
method
Submission
method
Survey
email
All Payer
EHR
HIT survey
All Payer
Measure
HAC
RRP
Population
Measure
VBP
Readmissions
Health Information Technology
Health information technology survey
End of Life
Stage 2 Meaningful Use Advance Directive Measure
CMS Incentive Programs Composite Measures
Total Performance Score (TPS) with domain and measure scores
None
None
x
Combined
Readmission Reduction Program (number of measures w/excess
readmissions) (RRP) Score with excess readmission scores
None
None
*
Medicare
Total Hospital Acquired Conditions (HAC) Score with domain and measure
scores
None
None
Combined
x
*currently there is a total payment adjustment based on excess readmission but no readmissions score. The proposal is to count each
readmission measure with excess readmissions as one.
Stratis Health | www.stratishealth.org
62
Statewide Quality Reporting and Measurement System Required Measures
for Critical Access Hospitals - Proposed April 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
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
Stratis Health | www.stratishealth.org
63
Submission
method
Population
Measure
Collection
method
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
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
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
Stratis Health | www.stratishealth.org
64