2017 Hospital Measure Summary - Stratis Health2017 Hospital Measure Summary Minnesota Statewide...

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2017 Hospital Measure Summary Minnesota Statewide Quality Reporting & Measurement System (SQRMS)

and FY2019 for Center for Medicare & Medicaid Services (CMS)

Contents Key ................................................................................................................................................................... 1

Chart Abstracted Measures .............................................................................................................................. 2

Submitted to QualityNet .............................................................................................................................. 2

Web-Based Submitted to QualityNet .......................................................................................................... 3

Submitted to Minnesota Department of Health through Minnesota Hospital Association ......................... 3

Submitted to Minnesota Department of Health through Minnesota Stroke Registry .................................. 3

Submitted to National Healthcare Safety Network (NHSN) ....................................................................... 4

Structural Measures and DACA ...................................................................................................................... 4


Survey Measures .............................................................................................................................................. 4

Submitted to Minnesota Hospital Association ............................................................................................. 4


Claims-Based Measures ................................................................................................................................... 6

Inpatient Outcome Measures ....................................................................................................................... 6

Inpatient Payment Measures ........................................................................................................................ 7

Outpatient Measures .................................................................................................................................... 7

CMS Incentive Program Measures .................................................................................................................. 8

Composite Measures .................................................................................................................................... 8

Electronic Clinical Quality Measures .............................................................................................................. 8


Retired/Removed Measures ............................................................................................................................. 9

Chart Abstracted Measures Submitted to QualityNet .................................................................................. 9

Claims-Based Inpatient Outcome Measures ................................................................................................ 9

Structural Measures Submitted to QualityNet ............................................................................................. 9

Electronic Clinical Quality Measures (eCQM) Submitted to QualityNet ................................................. 10

Acronyms ....................................................................................................................................................... 11

References ...................................................................................................................................................... 12

Key (Red = changed this year) Facility Type Required Measures Voluntary Measures MBQIP Measures

R – Required by CMS V – Voluntary for CMS C – Required nationally

r – Required by SQRMS a – Additional nationally


Chart Abstracted Measures

Chart Abstracted Measures

Submitted to QualityNet

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Inpatient Venous Thromboembolism (VTE)

VTE-6: Incidence of Potentially Preventable VTE R x

Inpatient Severe Sepsis and Septic Shock

Sepsis: Severe Sepsis and Septic Shock: Management Bundle R x

Inpatient Immunization (IMM)

IMM-2: Influenza Immunization r R C x

Inpatient Emergency Department (ED)

ED-1*: Median Time from ED Arrival to ED Departure for

Admitted ED Patients r R a x

ED-2*: Admit Decision Time to ED Departure Time for

Admitted Patients r R a x

Outpatient Acute Myocardial Infarction & Chest Pain

OP-1: Median Time to Fibrinolysis r R C x

OP-2: Fibrinolytic Therapy Received Within 30 Minutes of ED

Arrival r R C x

OP-3: Median Time to Transfer to Another Facility for Acute

Coronary Intervention r R C x

OP-4: Aspirin at Arrival r R C x

OP-5: Median Time to ECG r R C x

Outpatient Emergency Department (ED)-Throughput

OP-18: Median Time from ED Arrival to ED Departure for

Discharged ED Patients r R C x

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

Professional r R C x

OP-22: Left Without Being Seen r R C x

Outpatient Pain Management

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

Fracture r R C x

Outpatient Stroke

OP-23: Head CT or MRI Scan Results for Acute Ischemic Stroke

or Hemorrhagic Stroke Patients who Received Head CT or MRI

Scan Interpretation Within 45 Minutes of ED Arrival

r R a x

*Measure is listed twice, as both chart-abstracted and eCQM


Chart Abstracted Measures Web-Based Submitted to QualityNet

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Inpatient Measures

PC-01*: Elective Delivery r R a x x

Outpatient Measures

OP-26: Hospital Outpatient Volume on Selected Outpatient

Surgical Procedures R

x

OP-29: Appropriate Follow-Up Interval for Normal Colonoscopy

in Average Risk Patients R

x

OP-30: Colonoscopy Interval for Patients with a History of

Adenomatous Polyps – Avoidance of Inappropriate Use R

x

OP-31: Cataracts – Improvement in Patient’s Visual Function

Within 90 Days Following Cataract Surgery V

x

OP-33: External Beam Radiotherapy for Bone Metastases R x


Chart Abstracted Measures Submitted to Minnesota Department of Health

through Minnesota Hospital Association

Facility

Type

Program

Inclusion C

AH

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Emergency Department Transfer Communications (EDTC)

EDTC-1: Administrative Communication r C

EDTC-2: Vital Signs r C

EDTC-3: Medication Information r C

EDTC-4: Patient Information r C

EDTC-5: Physician Information r C

EDTC-6: Nursing Information r C

EDTC-7: Procedures and Tests r C

EDTC All or None Composite r C

Chart Abstracted Measures Submitted to Minnesota Department of Health

through Minnesota Stroke Registry

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Stroke

Door-to-Imaging Initiated Time r r

Time to Intravenous Thrombolytic Therapy r r


Chart Abstracted Measures Submitted to National Healthcare Safety Network

(NHSN)

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Healthcare Associated Infections (HAI)

Central Line-Associated Bloodstream Infection (CLABSI) R a x x x

Catheter-Associated Urinary Tract Infections (CAUTI) r R a x x x

Surgical Site Infections (SSI) Colon Procedures R x x x

Surgical Site Infections (SSI) Hysterectomy Procedures R x x x

Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia R a x x x

Clostridium difficile Infection (CDI or C. difficile) R a x x x

OP-27/HCP - Influenza Vaccination Coverage Among

Healthcare Personnel (Combined reporting for inpatient &

outpatient)

r R C x x

Structural Measures and DACA

Structural Measures and DACA Submitted to QualityNet

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Inpatient Structural Measures

Patient Safety Culture: Hospital Survey on Patient Safety Culture R a x

Safe Surgery Checklist: Safe Surgery Checklist Use R x

Inpatient Data Accuracy and Completeness Acknowledgment

(DACA) R x

Outpatient Structural Measures

OP-12: The Ability for Providers with HIT to Receive

Laboratory Data Electronically Directly into their ONC-Certified

EHR System as Discrete Searchable Data

R x

OP-17: Tracking Clinical Results between Visits R x

OP-25: Safe Surgery Checklist Use r R a x

Survey Measures

Surveys Submitted to Minnesota Hospital Association

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Health Information Technology (HIT)

HIT Survey r r


Surveys Submitted to QualityNet

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Inpatient Patient Experience of Care

Hospital Consumer Assessment of Healthcare Providers &

Systems (HCAHPS) (Required for Critical Access Hospitals with

≥ 500 admissions in the previous year) r Rr C x x


Claims-Based Measures

Claims-based Inpatient Outcome Measures

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Risk-Standardized Mortality Measures

MORT-30-AMI: Acute Myocardial Infarction 30-Day Mortality

Rate R x x

MORT-30-HF: Heart Failure 30-Day Mortality Rate R x x

MORT-30-PN: Pneumonia 30-Day Mortality Rate R x x

MORT-30-STK: Stroke 30-Day Mortality Rate R x

MORT-30-COPD: Chronic Obstructive Pulmonary Disease 30-

Day Mortality Rate R x

MORT-30-CABG: Coronary Bypass Graph Surgery 30-Day

Mortality Rate R x

Risk-Standardized Readmission Measures

READM-30-AMI: Acute Myocardial Infarction 30-Day All

Cause Readmission Rate R x x

READM -30-HF: Heart Failure 30-Day All Cause Readmission

Rate r R a x x

READM -30-PN: Pneumonia 30-Day All Cause Readmission

Rate r R a x x

READM -30-STK: Stroke 30-Day Readmission Rate R x

READM -30-COPD: Chronic Obstructive Pulmonary Disease

30-Day All Cause Readmission Rate r R a x x

READM -30-CABG: Coronary Bypass Graph Surgery 30-Day

All Cause Readmission Rate R x x

READM -30-THA/TKA: Total Hip Arthroplasty and/or Total

Knee Arthroplasty 30-Day All Cause Readmission Rate R x x

READM -30-HWR: Hospital-Wide All-Cause Unplanned

Readmission R x

Acute Myocardial Infarction (AMI) Excess Days R x

Heart Failure (HF) Excess Days R x

Pneumonia (PN) Excess days New! R x

Risk-Standardized Complication Measure

Hip/Knee Complications: Elective Primary Total Hip

Arthroplasty and/or Total Knee Arthroplasty Complication Rate R x x

Agency for Healthcare Research & Quality Measures

PSI-04: Death Rate Among Surgical Patients with Serious

Treatable Complications r Rr x

PSI-90: Patient Safety & Adverse Events Composite r Rr x x x

IQI-91: Mortality for Selected Measures Composite r r


Claims-based Inpatient Payment Measures

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Medicare Spending Per Beneficiary Measure

MSPB: Medicare Spending Per Beneficiary R x x

Risk-Standardized Payment Measures

AMI Payment: Acute Myocardial Infarction 30-Day Episode-of-

Care R x

HF Payment: Heart Failure 30-Day Episode-of-Care R x

PN Payment: Pneumonia 30-Day Episode-of-Care R x

THA/TKA Payment: Primary Elective Total Hip Arthroplasty

and/or Total Knee Arthroplasty Episode-of-Care R x

Clinical Episode-Based Payment Measures

Aortic Aneurysm (AA) Procedure New! R x

Cellulitis New! R x

Cholecystectomy (Chole) and Common Duct Exploration (CDE)

New! R x

Gastrointestinal (GI) Hemorrhage New! R x

Kidney/Urinary Tract Infection (UTI) New! R x

Spinal Fusion (SFusion) New! R x

Claims-based Outpatient Measures

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

P

OQ

R

IQR

VB

P

RR

P

HA

C

Imaging Efficiency Measures

OP-8: MRI Lumbar Spine for Low Back Pain R x

OP-9: Mammography Follow-up Rates R x

OP-10: Abdomen CT - Use of Contrast Material R x

OP-11: Thorax CT - Use of Contrast Material R x

OP-13: Cardiac Imaging for Preoperative Risk Assessment for

Non-Cardiac Low-Risk Surgery R x

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

and Sinus Computed Tomography (CT) R x

Outcome Measures

OP-32: Facility 7-Day Risk Standardized Hospital Visit Rate

after Outpatient Colonoscopy R x


CMS Incentive Program Measures

Composite Measures

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

P

OQ

R

IQR

VB

P

RR

P

HA

C

Value-based Purchasing (VBP) Program

Total Performance Score (TPS) r x

Readmission Reduction Program (RRP)

Excess Readmissions Score r *

Hospital Acquired Condition (HAC) Reduction Program

Total HAC Score r x

*Weighted summary calculated for Minnesota hospitals.

Electronic Clinical Quality Measures Electronic Clinical Quality Measures (eCQM)

Submitted to QualityNet Hospitals participating in IQR must select minimum of 8

Counts Toward

IQR Requirement

Inpatient Acute Myocardial Infarction (AMI)

AMI-8a: Primary PCI Received Within 90 Minutes of Hospital Arrival Yes

Inpatient Children’s Asthma Care (CAC)

CAC-3: Home Management Plan of Care Document Given to Patient/Caregiver Yes

Inpatient Emergency Department (ED)

ED-1*: Median Time from ED Arrival to ED Departure for Admitted ED Patients Yes

ED-2*: Admit Decision Time to ED Departure Time for Admitted Patients Yes

Inpatient Perinatal/Neonatal Care

PC-01*: Elective delivery Yes

PC-05: Exclusive Breast Milk Feeding Yes

EHDI-1a: Hearing Screening Prior to Discharge Yes

Inpatient Stroke (STK)

STK-2: Discharged an Antithrombotic Therapy Yes

STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter Yes

STK-5: Antithrombotic Therapy by the End of Hospital Day Two Yes

STK-6: Discharged on Statin Medication Yes

STK-8: Stroke Education Yes

STK-10: Assessed for Rehabilitation Yes


VTE-1: Venous Thromboembolism Prophylaxis Yes

VTE-2: Intensive Care Unit Venous Thromboembolism Prophylaxis Yes

Outpatient Emergency Department (ED)

ED-3: Median Time from ED Arrival to ED Department for Discharged ED Patients

No



Retired/Removed Measures

Chart Abstracted Measures Submitted to QualityNet

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C


STK-4: Thrombolytic Therapy Removed! by CMS R R


VTE-5: Venous Thromboembolism Removed! by CMS R R

Claims-Based Inpatient Outcome Measures

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Nursing Sensitive Care Measure

Death Among Surgical Patients with Serious Treatable

Complications Removed! by State of Minnesota r r

Structural Measures Submitted to QualityNet

Facility

Type

Program

Inclusion

CA

H

PP

S

MB

QIP

OQ

R

IQR

VB

P

RR

P

HA

C

Inpatient Structural Measures

Participation in a Systematic Clinical Database Registry for

Nursing Sensitive Care Removed! by CMS R R

Participation in a Systematic Clinical Database Registry for

General Surgery Removed! by CMS R R


Electronic Clinical Quality Measures (eCQM) Submitted to QualityNet

Included in the

IQR Program?

Inpatient Acute Myocardial Infarction (AMI)

AMI-2 Aspirin Prescribed at Discharge Removed! by CMS Voluntary

AMI-7a: Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival

Removed! by CMS Voluntary

AMI-10: Statin Prescribed at Discharge Removed! by CMS Voluntary

Inpatient Pneumonia (PN)

PN-6: Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in

Immunocompetent Patients Removed! by CMS Voluntary

Inpatient Surgical Care Improvement Project (SCIP)

SCIP-Inf-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical

Incision Removed! by CMS

Voluntary

SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients Removed! by

CMS

Voluntary

SCIP-Inf-9: Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day

2 with Day of Surgery Being Day Zero Removed! by CMS

Voluntary

Inpatient Perinatal/Neonatal Care

HTN: Healthy Term Newborn Removed! by CMS Voluntary


STK-4: Thrombolytic Therapy Removed! by CMS Voluntary


VTE-3: VTE Patients with Anticoagulation Overlap Therapy Removed! by CMS Voluntary

VTE-4: VTE Patients Receiving Unfractionated Heparin with Dosages/Platelet Count

Monitoring by Protocol or Nomogram Removed! by CMS

Voluntary

VTE-5: VTE Discharge Instructions Removed! by CMS Voluntary

VTE-6: Incidence of Potentially-Preventable VTE Removed! by CMS Voluntary


Acronyms AA – Aortic Aneurysm

AMI – Acute Myocardial Infarction

CABG – Coronary Artery Bypass Graft

CAC – Children’s Asthma Care

CAH – Critical Access Hospital

CAUTI – Catheter-Associated Urinary Tract Infection

CDE – Common Duct Exploration

CDI – Clostridium difficile Infection

CMS – Centers for Medicare and Medicaid Services

COPD – Chronic Obstructive Pulmonary Disease

CT – Computed Tomography

DACA – Data Accuracy and Completeness Acknowledgement

eCQM – Electronic Clinical Quality Measure

ECG – Electrocardiogram

ED – Emergency Department

EDTC – Emergency Department Transfer Communication

EHDI – Early Hearing Detection and Intervention

EHR – Electronic Health Record

HAC – Hospital-Acquired Condition (Reduction Program)

HAI – Healthcare-Associated Infection

HCAHPS – Hospital Consumer Assessment of Healthcare Providers and Systems

HCP – Healthcare Personnel

HF – Heart Failure

HIT – Health Information Technology

IMM – Immunization

IQR – Inpatient Quality Reporting (Program)

MBQIP – Medicare Beneficiary Quality Improvement Project

MORT – Mortality

MRI – Magnetic Resonance Imaging

MRSA – Methicillin-resistant Staphylococcus aureus

MSPB – Medicare Spending per Beneficiary

OP – Outpatient

OQR – Outpatient Quality Reporting (Program)

PC – Perinatal Care

PCI – Percutaneous Coronary Intervention

PN – Pneumonia

PPS – Prospective Payment System

PSI – Patient Safety Indicator

READM – Readmissions

RRP – Readmission Reduction Program

SSI – Surgical Site Infection

SQRMS – Statewide Quality Reporting Measurement System

STK – Stroke

THA – Total Hip Arthroplasty

TKA – Total Knee Arthroplasty

TPS – Total Performance Score

UTI – Urinary Tract Infection

VBP – Value-Based Purchasing (Program)

VTE – Venous Thromboembolism


References

eCQMs for Eligible Hospitals Table January 2017

https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/eCQM_Addendum_EH_Measures_Table.p

df (Referenced January 31, 2017)

Electronic Clinical Quality Measures (eCQMs) Overview

https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier

2&cid=1228773849716 (Referenced January 31, 2017)

Fiscal Year 2019 Measures: Hospital Value-Based Purchasing



Hospital Inpatient Quality Reporting Program Changes: FY 2019 Payment Determination (CY 2017

Reporting Period) http://www.qualityreportingcenter.com/wp-content/uploads/2016/10/IQR_FY-

2019_Program-Changes_10.13.2016_vFINAL_508.pdf (Referenced January 31, 2017)

Hospital IQR FY 2019 Measures

https://www.qualitynet.org/dcs/BlobServer?blobkey=id&blobnocache=true&blobwhere=12288906317

74&blobheader=multipart%2Foctet-stream&blobheadername1=Content-

Disposition&blobheadervalue1=attachment%3Bfilename%3DIQR_FY2019_CMS_Msrs_CY2017.pdf

&blobcol=urldata&blobtable=MungoBlobs (Referenced January 31, 2017)

Hospital IQR Program Important Dates and Deadlines

http://www.qualityreportingcenter.com/wp-

content/uploads/2017/01/IQR_ImpDatesDdlns_20170118_vFINAL508.pdf (Referenced January 31,

2017)

Hospital Readmission Reduction Program: Overview



Measures: Hospital-Acquired Condition (HAC) Reduction Program



Minnesota Statewide Quality Reporting and Measurement System: Appendices to Minnesota

Administrative Rules, Chapter 4654, December 2016

http://www.health.state.mn.us/healthreform/measurement/measures/appendices.pdf (Referenced

January 31, 2017)

Outpatient Quality Reporting Measures



Prepared by Stratis Health under contract with Minnesota Community Measurement,

funded by the Minnesota Department of Health.

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/eCQM_Addendum_EH_Measures_Table.pdf



https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228773849716




http://www.qualityreportingcenter.com/wp-content/uploads/2016/10/IQR_FY-2019_Program-Changes_10.13.2016_vFINAL_508.pdf

http://www.qualityreportingcenter.com/wp-content/uploads/2016/10/IQR_FY-2019_Program-Changes_10.13.2016_vFINAL_508.pdf

https://www.qualitynet.org/dcs/BlobServer?blobkey=id&blobnocache=true&blobwhere=1228890631774&blobheader=multipart%2Foctet-stream&blobheadername1=Content-Disposition&blobheadervalue1=attachment%3Bfilename%3DIQR_FY2019_CMS_Msrs_CY2017.pdf&blobcol=urldata&blobtable=MungoBlobs




http://www.qualityreportingcenter.com/wp-content/uploads/2017/01/IQR_ImpDatesDdlns_20170118_vFINAL508.pdf

http://www.qualityreportingcenter.com/wp-content/uploads/2017/01/IQR_ImpDatesDdlns_20170118_vFINAL508.pdf





http://www.health.state.mn.us/healthreform/measurement/measures/appendices.pdf



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