Core Measures
Emergency Department Transfer Communication
Care Transitions
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
• Q1
• Q2
• Q3
• Q4
• Q5
• Q6
• Q7
• Q8
• ALL-EDTC
Data Reported To
Measure Set
EDTC
Reporting Period
Quarterly
Improvement
Increased on rate (percent)
Data Collection Approach
Chart Abstracted
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
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
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
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
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
Outpatient
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 21 cases
> 900 - submit 32 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
Data Reported To
Measure Set
ED Throughput
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
Outpatient
Percentage of patients who left the emergency department before being seen
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?
Data Reported To
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 Engagement
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
Data Reported To
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/Inpatient
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
Data Reported To
Measure Set
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 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
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/Inpatient
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 of the facility
• Did not receive vaccination due to contraindication
• Did not receive vaccination due to declination
Data Reported To
Measure Set
Web-Based (Preventive Care)
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 Transitions | 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 standardly 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 Transitions | Outpatient | Patient Engagement | 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 |
||
|
OP-3 Median Time to Transfer to another Facility for Acute Coronary Intervention |