MEASURES

Emergency Department Transfer Communication

Emergency Department

Percentage of patients who are transferred from an ED to another health care facility that have all necessary communication with the receiving facility.

Importance

Timely, accurate, and direct communication facilitates the handoff to the receiving facility, provides continuity of care, and avoids medical errors and redundant tests.

Sample Size

Quarterly:

0-44 - submit all cases
> 45 - submit 45 cases

Monthly:

0-15 - submit all cases
> 15 - submit 15 cases
Data Elements
  1. Home Medications
  2. Allergies and/or Reactions
  3. Medications Administered in ED
  4. ED Provider Note
  5. Mental Status/Orientation Assessment
  6. Reason for Transfer and/or Plan of Care
  7. Tests and/or Procedures Performed
  8. Tests and/or Procedures Results
Resources
Stratis Health EDTC
Data Reported To

MBQIP-DB

Data Source
  • Manual Chart Abstraction
  • Retrospective data sources for required data elements include administrative data and medical records.
Reporting Period

Quarterly

Improvement

Increase in the rate (percentage)

Data Collection Approach

Chart Abstracted, composite of EDTC data elements 1-8, using an all or none approach

Cases to Submit

Patients admitted to the emergency department and transferred from the emergency department to another health care facility (e.g., other hospital, nursing home, hospice, etc.)

Fibrinolytic Therapy Received Within 30 Minutes

Patient Experience/Outpatient

Percentage of outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival.

Importance

Time-to-fibrinolytic therapy is a strong predictor of outcome in patients with AMI. Nearly 2 lives per 1,000 patients are lost per hour of delay. National guidelines recommend fibrinolytic therapy within 30 minutes of hospital arrival for patients with STEMI.

Sample Size

Quarterly:

0-80 - submit all cases
> 80 - see specifications manual

Monthly:

Monthly sample size requirements are based on anticipated quarterly patient population
Data Elements

• Arrival Time
• Birthdate
• Discharge Code
• E/M Code
• Fibrinolytic Administration
• Fibrinolytic Administration Date
• Fibrinolytic Administration Time
• ICD-10-CM Principal Diagnosis Code
• Initial ECG Interpretation
• Outpatient Encounter Date
• Reason For Fibrinolytic Therapy Delay

Data Reported To

HARP

Measure Set

AMI

Reporting Period

Quarterly

Improvement

Increase in rate (percent)

Data Collection Approach

Chart Abstracted

Cases to Submit

Patients seen in a Hospital Emergency Department for whom all of the following are true:

• Discharged/transferred to a short-term general hospital for inpatient care or to a Federal Healthcare facility

• A patient age ≥ 18 years

• An ICD-10-CM Principal Diagnosis Code for AMI An ICD-10-CM Principal Diagnosis Code for AMI as defined in Appendix A, OP Table1.1, of the CMS Hospital OQR Specifications Manual.

Median Time to Transfer to Another Facility for Acute Coronary Intervention

Patient Experience/Outpatient

Median number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital.
Note: Hospital Compare described measure as "average number of minutes"

Importance

The early use of primary angioplasty in patients with STEMI results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is. Times to treatment in transfer patients undergoing primary PCI may influence the use of PCI as an intervention. Current recommendations support a door-to-balloon time of 90 minutes or less.

Sample Size

Quarterly:

0-80 - submit all cases
> 80 - see specifications manual

Monthly:

Monthly sample size requirements are based on anticipated quarterly patient population
Data Elements

• Arrival Time
• Birthdate
• Discharge Code
• ED Departure Date
• ED Departure Time
• E/M Code
• Fibrinolytic Administration
• ICD-10-CM Principal Diagnosis Code
• Initial ECG Interpretation
• Outpatient Encounter Date
• Reason for Not Administering Fibrinolytic Therapy
• Transfer for Acute Coronary Intervention

Data Reported To

HARP

Measure Set

AMI

Reporting Period

Quarterly

Improvement

Decrease in median value (time)

Data Collection Approach

Chart Abstracted

Cases to Submit

Patients seen in a Hospital Emergency Department for whom all of the following are true:

• Discharged/transferred to a short-term general hospital for inpatient care or to a Federal Healthcare facility

• A patient age ≥ 18 years

• An ICD-10-CM Principal Diagnosis Code for AMI as defined in Appendix A, OP Table1.1, of the CMS Hospital OQR Specifications Manual.

Median Time from ED Arrival to ED Departure for Discharged ED Patients

Emergency Department

Average time patients spent in the emergency department before being sent home

Importance

Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care, potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised.

Sample Size
Quarterly:
0-900 - Submit 63 cases
> 900 - Submit 96 cases
Monthly:
0-900 - Submit 63 cases
> 900 - Submit 96 cases
Note:
Monthly sample size requirements for this measure are based on the quarterly patient population.
Data Elements

• Arrival Time
• Discharge Code
• E/M Code
• ED Departure Date
• ED Departure Time
• ICD-10-CM Principal Diagnosis Code
• Outpatient Encounter Date

Resources
Data Reported To

HARP

Data Source

Hospital Tracking

Reporting Period

Quarterly

Improvement

Decrease in median value (time)

Data Collection Approach

Chart Abstracted

Cases to Submit

Patients seen in a Hospital Emergency Department that have an E/M code in Appendix A, OP Table 1.0 of the CMS Hospital OQR Specifications Manual.

Patient Left Without Being Seen

Emergency Department

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

Importance

Reducing patient wait time in the ED helps improve access to care, increase capability to provide treatment, reduce ambulance refusals/diversions, reduce rushed treatment environments, reduce delays in medication administration, and reduce patient suffering.

Sample Size

No Sampling
Report all cases

Data Elements

• Numerator: What was the total number of patients who left without being evaluated by a physician/APN/PA?
• Denominator: What was the total number of patients who presented to the ED?

Resources
Data Reported To

HARP

Measure Set

ED Throughput

Reporting Period

Yearly

Improvement

Decrease in rate (percent)

Data Collection Approach

Hospital Tracking

Cases to Submit

Definition of patients who present to the ED:
Patients who presented to the ED are those that signed in to be evaluated for emergency services.

Definition of provider includes:
• Residents/interns
• Institutionally credentialed provider
• APN/APRNs

Hospital Consumer Assessment of Healthcare Providers and Systems

Patient Experience

Percentage of patients surveyed who reported “Yes” or “Always” to questions involving their hospital stay

Importance

Growing research shows positive associations between patient experience and health outcomes, adherence to recommended medication and treatments, preventive care, health care resource use and quality and safety of care.

Sample Size

Sampling determined by HCAHPS vendor or self-administered if in compliance with program requirements

Data Elements
  • Communication with Doctors
  • Communication with Nurses
  • Responsiveness of Hospital Staff
  • Communication about Medicines
  • Discharge Information
  • Cleanliness of the Hospital Environment
  • Quietness of the Hospital Environment
  • Transition of Care
Resources
Data Reported To

HARP

Measure Set

HCAHPS

Reporting Period

Quarterly

Improvement

Increased in percent always

Data Collection Approach

Survey (typically conducted by a certified vendor)

Cases to Submit

Patients discharged from the hospital following at least one overnight stay sometime between 48 hours and 6 weeks ago who are over the age of 18 and did not have a psychiatric principal diagnosis at discharge.

Antibiotic Stewardship

Patient Safety

Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Annual Survey

Importance

Improving antibiotic use in hospitals is imperative to improving patient outcomes, decreasing antibiotic resistance, and reducing healthcare costs. According to the Centers for Disease Control and Prevention (CDC), 20-50 percent of all antibiotics prescribed in U.S. acute care hospital are either unnecessary or inappropriate, which leads to serious side effects such as adverse drug reactions and Clostridium difficile infection. Overexposure to antibiotics also contributes to antibiotic resistance, making antibiotics less effective.

In 2014, CDC released the “Core Elements of Hospital Antibiotic Stewardship Programs” that identifies key structural and functional aspects of effective programs and elements designed to be flexible enough to be feasible in hospitals of any size.

Sample Size

No Sampling
Report all information as requested

Data Elements

Questions as answered on the Patient Safety Component Annual Hospital Survey inform whether the hospitals have successfully implemented the following core elements of antibiotic stewardship:

• Leadership
• Accountability
• Drug Expertise
• Action
• Tracking
• Reporting
• Education

Resources
Data Reported To

NHSN

Reporting Period

Yearly

Improvement

Increase in number of core elements met

Data Collection Approach

Hospital Tracking

Cases to Submit

N/A
This measure uses administrative data and not claims to determine the measure's denominator population.

Admit Decision Time to ED Departure Time for Admitted Patients

Patient Safety/Inpatient

Median time from admit decision time to time of departure from the emergency department for admitted patients.

Importance

Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care, potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised.

Sample Size

Quarterly:

0-152 - 100% of initial pt. pop
153-764 - 153
765-1529 - 20% of initial pt. pop
>1529 - 306

Monthly:

<51 - 100% of initial population
51-254 - 51
255-509 - 20% of initial pt. pop
>509 - 102
Data Elements

• Decision to Admit Date
• Decision to Admit Time
• ED Departure Date
• ED Departure Time
• ED Patient
• ICD-10-CM Principal Diagnosis Code

Data Reported To

HARP

Measure Set

Emergency Department

Reporting Period

Quarterly

Improvement

Decrease in the median value

Data Collection Approach

Chart Abstracted

Cases to Submit

Global Initial Patient Population: All patients discharged from acute inpatient care with a length of stay less than or equal to 120 days.

Influenza Vaccination Coverage Among Health Care Personnel

Patient Safety

Percentage of health care workers given influenza vaccination

Importance

1 in 5 people in the U.S. get influenza each season. Combined with pneumonia, influenza is the 8th leading cause of death, with two-thirds of those attributed to patients hospitalized during the flu season.

Sample Size

No Sampling
Report all cases

Data Elements

3 categories (all with separate denominators) of HCP working in the facility at least one day b/w 10/1-3/31:
• employees on payroll
• licensed independent practitioners
• students, trainees and volunteers 18yo+

A fourth optional category is available for reporting other contract personnel HCP workers who:
• Received vaccination at the facility
• Received vaccination outside the facility
• Did not receive vaccination due to contraindication
• Did not receive vaccination due to declination

Resources
Data Reported To

NHSN

Data Source
Administrative Data
Reporting Period

Yearly

Improvement

Increase in rate (percent)

Data Collection Approach

Hospital Tracking

Cases to Submit

Each facility in a system needs to be registered separately and HCPs should be counted in the sample population for every facility at which s/he works. Facilities must complete a monthly reporting plan for each year or data reporting period. All data reporting is aggregate (whether monthly, once a season, or at a different interval).

Additional Measures

Care Coordination Outpatient Patient Engagement Patient Safety/Inpatient
Discharge Planning § (formerly OP-4)
Aspirin at Arrival § 		Emergency Department Patient Experience Survey § CLABSI
Central Line-Associated Bloodstream Infection
Medical Reconciliation § (formerly OP-5)
Median Time to EDG § 		CAUTI
Catheter-Associated Urinary Tract Infection
Swing Bed Care § (formerly OP-20)
Door to Diagnostic Evaluation by a Qualified Medical Professional § 		CDI
Clostridioides Difficile Infection
Claims-Based Measures
Measures are automatically calculated for hospitals using Medicare Administrative Claims Data 		MRSA
Methicillin-resistant Staphylococcus Aureus
SSIs
Surgical Site Infections Colon or Hysterectomy
PC-01
Elective Delivery
Falls §
Adverse Drug Events (ADE) §
Patient Safety Culture Survey
(formerly IMM-2)
Inpatient Influenza Vaccination §

§No nationally standardized or standard reported measure currently available, however, Flex programs can propose work on these measures if there is a data collection mechanism in place.

Archived Measures

Care Coordination Emergency Department Global Measures Patient Experience/Outpatient Patient Safety/Inpatient
OP-1
Median Time to Fibrinolysis 		ED-1
Median Time from ED Arrival to ED Departure for Admitted ED Patients
OP-21
Median Time to Pain Management for Long Bone Fracture 		ED-2
Admit Decision Time to ED Departure Time for Admitted Patients
OP-2
Fibrinolytic Therapy Received Within 30 Minutes
OP-3
Median Time to Transfer to another Facility for Acute Coronary Intervention

Hybrid Hospital-Wide Readmission

Care Coordination

Hospital-level, all-cause, risk-standardized readmission measure that focuses on unplanned readmissions 30 days of discharge from an acute hospitalization.

Importance

Returning to the hospital for unplanned care disrupts patients’ lives, increases risk of harmful events like healthcare-associated infections, and results in higher costs absorbed by the health care system. High readmission rates of patients with clinically manageable conditions in primary care settings, such as diabetes and bronchial asthma, may identify quality-of-care problems in hospital settings. A measure of readmissions encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions and costs.

Sample Size

No Sampling
Report on all information requested in denominator and numerator

Data Elements

Numerator

If a patient has more than one unplanned admission (for any reason) within 30 days after discharge from the index admission, only one is counted as a readmission. The measure looks for a dichotomous yes or no outcome of whether each admitted patient has an unplanned readmission within 30 days. However, if the first readmission after discharge is considered planned, any subsequent unplanned readmission is not counted as an outcome for that index admission because the unplanned readmission could be related to care provided during the intervening planned readmission rather than during the index admission.

Denominator

1. Enrolled in Medicare FFS Part A for the 12 months prior to the date of admission and during the index admission;
2. Aged 65 or over;
3. Discharged alive from a non-federal short-term acute care hospital;
4. Not transferred to another acute care facility.

Exclusions

The measure excludes index admissions for patients:

1. Admitted to Prospective Payment System (PPS)-exempt cancer hospitals;
2. Without at least 30 days post-discharge enrollment in Medicare FFS;
3. Discharged against medical advice (AMA);
4. Admitted for primary psychiatric diagnoses;
5.Admitted for rehabilitation; or
6. Admitted for medical treatment of cancer

Resources
Data Reported To
HARP
Data Source
  • Manual Chart Abstraction
  • Retrospective data sources for required data elements include administrative data and medical records.
Reporting Period

Yearly

Improvement

No actual measure score will be generated by hospitals. Instead, hospitals will report the data values for each of the core clinical data elements for all encounters in the Initial Population. These core clinical data elements will be linked to administrative claims data and used by CMS to calculate results for the Hybrid HWR measure.

Data Collection Approach

Hybrid – chart extraction of electronic clinical data and administrative claims data.

Cases to Submit

  1. Enrolled in Medicare FFS Part A for the 12 months prior to the date of admission and during the index admission;
  2. Aged 65 or over;
  3. Discharged alive from a non-federal short-term acute care hospital;
  4. Not transferred to another acute care facility

Screening for Social Drivers of Health

Care Coordination

The Screening for Social Drivers of Health Measure assesses whether a hospital implements screening for all patients that are 18 years or older at time of admission for food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety.

Importance

The recognition of health disparities and impact of health-related social needs (HRSN) has been heightened in recent years. Economic and social factors, known as drivers of health, are known to affect health outcomes and costs, and exacerbate health inequities. This measure is derived from the Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) model and has been tested in large populations across states. The intent of this measure is to help ensure hospitals are considering and addressing social needs in the care they provide to their community.

Sample Size
No sampling – report on all information requested in denominator and numerator.
Data Elements

Numerator

The number of patients admitted to an inpatient hospital stay who are 18 years or older on the date of admission and are screened for all of the following five HRSNs: Food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety during their hospital inpatient stay

Denominator

The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission.

Exclusions

The following patients would be excluded from the denominator:

(1) Patients who opt-out of screening.
(2) Patients who are themselves unable to complete the screening during their inpatient stay and have no legal guardian or caregiver able to do so on the patient’s behalf during their inpatient stay.
(3) Patients who expire during the inpatient stay.

Resources
Data Reported To
HARP
Data Source
Hospital tracking
Reporting Period

Yearly

Improvement

Increase in the rate.

Data Collection Approach

Chart Abstracting

Cases to Submit

The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission.

Screen Positive for Social Drivers of Health

Care Coordination

The Screen Positive Rate for Social Drivers of Health Measure provides information on the percent of patients admitted for an inpatient hospital stay who are 18 years or older on the date of admission, were screened for an HRSN (health-related social needs), and who screen positive for one or more of the following five HRSNs: Food insecurity, housing instability, transportation problems, utility difficulties, or interpersonal safety.

Importance

The recognition of health disparities and impact of health-related social needs (HRSN) has been heightened in recent years. Economic and social factors, known as drivers of health, are known to affect health outcomes and costs, and exacerbate health inequities. This measure is derived from the Center for Medicare and Medicaid Innovation’s Accountable Health Communities (AHC) model and has been tested in large populations across states. The intent of this measure is to help ensure hospitals are considering and addressing social needs in the care they provide to their community.

Sample Size
No sampling – report on all information requested in denominator and numerator.
Data Elements

CMS is not recommending specific value sets currently.

Numerator

The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission, who were screened for all five HSRN, and who screen positive for having a need in one or more of the following five HRSNs (calculated separately): Food insecurity, housing instability, transportation needs, utility difficulties, or interpersonal safety.

Denominator

The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission and are screened for all of the following five HSRN (food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety) during their hospital inpatient stay.

Exclusions

The following patients would be excluded from the denominator:

(1) Patients who opt-out of screening.
(2) Patients who are themselves unable to complete the screening during their inpatient stay and have no legal guardian or caregiver able to do so on the patient’s behalf during their inpatient stay.
(3) Patients who expire during the inpatient stay.

Resources
Data Reported To
HARP
Data Source
Hospital tracking
Reporting Period

Yearly

Improvement

This measure is not an indication of performance

Data Collection Approach

Chart abstraction

Cases to Submit

The result of this measure would be calculated as five separate rates. Each rate is derived from the number of patients admitted for an inpatient hospital stay and who are 18 years or older on the date of admission, screened for an HRSN, and who screen positive for each of the five HRSNs—food insecurity, housing instability, transportation needs, utility difficulties, or interpersonal safety—divided by the total number of patients 18 years or older on the date of admission screened for all five HRSNs.

Critical Access Hospital Quality Infrastructure

Global

Structural measure to assess CAH quality infrastructure based on the nine (9) core elements of CAH quality infrastructure

Importance

This measure will provide state and national comparison information to assess your CAH infrastructure, QI processes, and areas of improvement for each facility. Using this measure, SFPs can plan quality activities to improve CAH quality infrastructure. Data will provide timely, accurate, and useful CAH quality-related information to help inform state-level technical assistance for CAH improvement activities. This measure will provide hospital and state specific information to help inform the future of MBQIP and national technical assistance and data analytic needs.

Sample Size
No sampling – Report all information as requested.
Data Elements

Data is collected via the National CAH Quality Inventory and Assessment based on the nine (9) core elements of CAH quality infrastructure:

  • Leadership Responsibility & Accountability
  • Quality Embedded within the Organization’s Strategic Plan
  • Workforce Engagement & Ownership
  • Culture of Continuous Improvement through Behavior
  • Culture of Continuous Improvement through Systems
  • Integrating Equity into Quality Practices
  • Engagement of Patients, Partners, and Community
  • Collecting Meaningful and Accurate Data
  • Using Data to Improve Quality
Resources
Data Reported To
Flex Monitoring Team (FMT) administered Qualtrics platform
Data Source
N/A
Reporting Period

Yearly

Improvement

Increase in number of core elements met

Data Collection Approach

Hospital Tracking

Cases to Submit

N/A - This measure uses administrative data to determine the measure's denominator population.

Hospital Commitment to Health Equity

Global

This structural measure assesses hospital commitment to health equity. Hospitals will receive points for responding to questions in five (5) different domains of commitment to advancing health equity.

Importance

The recognition of health disparities and inequities has been heightened in recent years and it is particularly relevant in rural areas. Rural risk factors for health disparities include geographic isolation, lower socioeconomic status, higher rates of health risk behaviors, limited access to health care specialists and sub-specialists, and limited job opportunities. Rural residents are also less likely to have employer-provided health insurance coverage, and if they are poor, often are not covered by Medicaid. The intent of this measure is to help ensure hospitals are considering and addressing equity in the care they provide to their community.

Sample Size
No sampling – Report all information as requested.
Data Elements

Data is used to assess hospital commitment to health equity in the following domain areas:

  • Domain 1 – Equity is a Strategic Priority
  • Domain 2 – Data Collection
  • Domain 3 – Data Analysis
  • Domain 4 – Quality Improvement
  • Domain 5 – Leadership Engagement
Resources
Data Reported To
HARP
Data Source
N/A
Reporting Period

Yearly

Improvement

Increase in the total score (up to 5 points).

Data Collection Approach

Attestation - Hospital Tracking

Cases to Submit

N/A - This measure assesses hospital and leadership commitment.

Safe Use of Opioids Personnel

Patient Safety

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on two or more opioids, or an opioid and benzodiazepine concurrently at discharge.

Importance

Unintentional opioid overdose fatalities have become an epidemic and major public health concern in the United States. Concurrent prescriptions of opioids, or opioids and benzodiazepines, places patients at a greater risk of unintentional overdose due to increased risk of respiratory depression. Patients who have multiple opioid prescriptions have an increased risk for overdose, and rates of fatal overdose are ten (10) times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone. A measure that calculates the proportion of patients with two or more opioids or opioids and benzodiazepines concurrently has the potential to reduce preventable mortality and reduce costs associated with adverse events related to opioids.

Sample Size

No Sampling
Report all patients that meet data elements

Data Elements

Numerator

Inpatient hospitalizations where the patient is prescribed or continuing to take two or more opioids or an opioid and benzodiazepine at discharge.

Denominator

The number of patients who are admitted to a hospital inpatient stay and who are 18 years or older on the date of admission.

Exclusions

Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge.

Resources
Data Reported To

HARP

Data Source
Certified electronic health record technology (CEHRT)
Reporting Period

Yearly

Improvement

Decrease in rate

Data Collection Approach

Electronic Extraction from EHRs via Quality Reporting Document Architecture (QRDA) Category I File

Cases to Submit

Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge.