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1 2017 Hospital Measure Summary Minnesota Statewide Quality eporting & Measurement System (SQMS) and FY2019 for Center for Medicare & Medicaid Services (CMS) Contents Key... 1 Chart Abstracted Measures Web-Based... 3 Submitted to Minnesota Department of Health through Minnesota Hospital Association... 3 Submitted to Minnesota Department of Health through Minnesota Stroke egistry... 3 Submitted to National Healthcare Safety Network (NHSN)... 4 Structural Measures and DACA Survey Measures... 4 Submitted to Minnesota Hospital Association Claims-Based Measures... 6 Inpatient Outcome Measures... 6 Inpatient Payment Measures... 7 Outpatient Measures... 7 CMS Incentive Measures... 8 Composite Measures... 8 Electronic Clinical Quality Measures etired/emoved Measures... 9 Chart Abstracted Measures... 9 Claims-Based Inpatient Outcome Measures... 9 Structural Measures... 9 Electronic Clinical Quality Measures (ecqm) Acronyms eferences Key (ed = changed this year) equired Measures Measures Measures equired by CMS V for CMS C equired nationally r equired by SQMS a Additional nationally Stratis Health
2 Chart Abstracted Measures Chart Abstracted Measures OQ IQ P Inpatient Venous Thromboembolism (VTE) VTE-6: Incidence of Potentially Preventable VTE Inpatient Severe Sepsis and Septic Shock Sepsis: Severe Sepsis and Septic Shock: Management Bundle Inpatient Immunization (IMM) IMM-2: Influenza Immunization r C Inpatient Emergency Department (ED) ED-1*: Median Time from ED Arrival to ED Departure for Admitted ED Patients ED-2*: Admit Decision Time to ED Departure Time for Admitted Patients Outpatient Acute Myocardial Infarction & Chest Pain r a r a OP-1: Median Time to Fibrinolysis r C OP-2: Fibrinolytic Therapy eceived Within 30 Minutes of ED Arrival r C OP-3: Median Time to Transfer to Another for Acute Coronary Intervention r C OP-4: Aspirin at Arrival r C OP-5: Median Time to ECG r C Outpatient Emergency Department (ED)-Throughput OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients r C OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional r C OP-22: Left Without Being Seen r C Outpatient Pain Management OP-21: Median Time to Pain Management for Long Bone Fracture Outpatient Stroke OP-23: Head CT or MI Scan esults for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who eceived Head CT or MI Scan Interpretation Within 45 Minutes of ED Arrival *Measure is listed twice, as both chart-abstracted and ecqm r C r a Stratis Health
3 Chart Abstracted Measures Web-Based OQ IQ P Inpatient Measures PC-01*: Elective Delivery r a Outpatient Measures OP-26: Hospital Outpatient Volume on Selected Outpatient Surgical Procedures OP-29: Appropriate Follow-Up Interval for Normal Colonoscopy in Average isk Patients OP-30: Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use OP-31: Cataracts Improvement in Patient s Visual Function V Within 90 Days Following Cataract Surgery OP-33: Eternal Beam adiotherapy for Bone Metastases *Measure is listed twice, as both chart-abstracted and ecqm Chart Abstracted Measures Submitted to Minnesota Department of Health through Minnesota Hospital Association OQ IQ P 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 egistry OQ IQ P Stroke Door-to-Imaging Initiated Time r r Time to Intravenous Thrombolytic Therapy r r Stratis Health
4 Chart Abstracted Measures Submitted to National Healthcare Safety Network (NHSN) OQ IQ P Healthcare Associated Infections (HAI) Central Line-Associated Bloodstream Infection (CLABSI) a Catheter-Associated Urinary Tract Infections (CAUTI) r a Surgical Site Infections (SSI) Colon Procedures Surgical Site Infections (SSI) Hysterectomy Procedures Methicillin-resistant Staphylococcus aureus (MSA) Bacteremia a Clostridium difficile Infection (CDI or C. difficile) a OP-27/HCP - Influenza Vaccination Coverage Among Healthcare Personnel (Combined reporting for inpatient & outpatient) r C Structural Measures and DACA Structural Measures and DACA OQ IQ P Inpatient Structural Measures Patient Safety Culture: Hospital Survey on Patient Safety Culture a Safe Surgery Checklist: Safe Surgery Checklist Use Inpatient Data Accuracy and Completeness Acknowledgment (DACA) Outpatient Structural Measures OP-12: The Ability for Providers with HIT to eceive Laboratory Data Electronically Directly into their ONC-Certified EH System as Discrete Searchable Data OP-17: Tracking Clinical esults between Visits OP-25: Safe Surgery Checklist Use r a Survey Measures Surveys Submitted to Minnesota Hospital Association OQ IQ P Health Information Technology (HIT) HIT Survey r r Stratis Health
5 Surveys OQ IQ P Inpatient Patient Eperience of Care Hospital Consumer Assessment of Healthcare Providers & Systems (HPS) (equired for Critical Access Hospitals with 500 admissions in the previous year) r r C Stratis Health
6 Claims-Based Measures Claims-based Inpatient Outcome Measures OQ IQ P isk-standardized Mortality Measures MOT-30-AMI: Acute Myocardial Infarction 30-Day Mortality ate MOT-30-HF: Heart Failure 30-Day Mortality ate MOT-30-PN: Pneumonia 30-Day Mortality ate MOT-30-STK: Stroke 30-Day Mortality ate MOT-30-COPD: Chronic Obstructive Pulmonary Disease 30- Day Mortality ate MOT-30-CABG: Coronary Bypass Graph Surgery 30-Day Mortality ate isk-standardized eadmission Measures EADM-30-AMI: Acute Myocardial Infarction 30-Day All Cause eadmission ate EADM -30-HF: Heart Failure 30-Day All Cause eadmission ate r a EADM -30-PN: Pneumonia 30-Day All Cause eadmission ate r a EADM -30-STK: Stroke 30-Day eadmission ate EADM -30-COPD: Chronic Obstructive Pulmonary Disease 30-Day All Cause eadmission ate r a EADM -30-CABG: Coronary Bypass Graph Surgery 30-Day All Cause eadmission ate EADM -30-THA/TKA: Total Hip Arthroplasty and/or Total Knee Arthroplasty 30-Day All Cause eadmission ate EADM -30-HW: Hospital-Wide All-Cause Unplanned eadmission Acute Myocardial Infarction (AMI) Ecess Days Heart Failure (HF) Ecess Days Pneumonia (PN) Ecess days New! isk-standardized Complication Measure Hip/Knee Complications: Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty Complication ate Agency for Healthcare esearch & Quality Measures PSI-04: Death ate Among Surgical Patients with Serious Treatable Complications r r PSI-90: Patient Safety & Adverse Events Composite r r IQI-91: Mortality for Selected Measures Composite r r Stratis Health
7 Claims-based Inpatient Payment Measures OQ IQ P Medicare Spending Per Beneficiary Measure MSPB: Medicare Spending Per Beneficiary isk-standardized Payment Measures AMI Payment: Acute Myocardial Infarction 30-Day Episode-of- Care HF Payment: Heart Failure 30-Day Episode-of-Care PN Payment: Pneumonia 30-Day Episode-of-Care THA/TKA Payment: Primary Elective Total Hip Arthroplasty and/or Total Knee Arthroplasty Episode-of-Care Clinical Episode-Based Payment Measures Aortic Aneurysm (AA) Procedure New! Cellulitis New! Cholecystectomy (Chole) and Common Duct Eploration (CDE) New! Gastrointestinal (GI) Hemorrhage New! Kidney/Urinary Tract Infection (UTI) New! Spinal Fusion (SFusion) New! Claims-based Outpatient Measures P OQ IQ P Imaging Efficiency Measures OP-8: MI Lumbar Spine for Low Back Pain OP-9: Mammography Follow-up ates OP-10: Abdomen CT - Use of Contrast Material OP-11: Thora CT - Use of Contrast Material OP-13: Cardiac Imaging for Preoperative isk Assessment for Non-Cardiac Low-isk Surgery OP-14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT) Outcome Measures OP-32: 7-Day isk Standardized Hospital Visit ate after Outpatient Colonoscopy Stratis Health
8 CMS Incentive Measures Composite Measures P OQ IQ P Value-based Purchasing () Total Performance Score (TPS) r eadmission eduction (P) Ecess eadmissions Score r * Hospital Acquired Condition () eduction Total Score r *Weighted summary calculated for Minnesota hospitals. Electronic Clinical Quality Measures Electronic Clinical Quality Measures (ecqm) Hospitals participating in IQ must select minimum of 8 Inpatient Acute Myocardial Infarction (AMI) AMI-8a: Primary PCI eceived Within 90 Minutes of Hospital Arrival Inpatient Children s Asthma Care (CAC) CAC-3: Home Management Plan of Care Document Given to Patient/Caregiver Inpatient Emergency Department (ED) ED-1*: Median Time from ED Arrival to ED Departure for Admitted ED Patients ED-2*: Admit Decision Time to ED Departure Time for Admitted Patients Inpatient Perinatal/Neonatal Care PC-01*: Elective delivery PC-05: Eclusive Breast Milk Feeding EHDI-1a: Hearing Screening Prior to Discharge Inpatient Stroke (STK) STK-2: Discharged an Antithrombotic Therapy STK-3: Anticoagulation Therapy for Atrial Fibrillation/Flutter STK-5: Antithrombotic Therapy by the End of Hospital Day Two STK-6: Discharged on Statin Medication STK-8: Stroke Education STK-10: Assessed for ehabilitation Inpatient Venous Thromboembolism (VTE) VTE-1: Venous Thromboembolism Prophylais VTE-2: Intensive Care Unit Venous Thromboembolism Prophylais Outpatient Emergency Department (ED) ED-3: Median Time from ED Arrival to ED Department for Discharged ED Patients *Measure is listed twice, as both chart-abstracted and ecqm Counts Toward IQ equirement No Stratis Health
9 etired/emoved Measures Chart Abstracted Measures OQ IQ P Inpatient Stroke (STK) STK-4: Thrombolytic Therapy emoved! by CMS Inpatient Venous Thromboembolism (VTE) VTE-5: Venous Thromboembolism emoved! by CMS Claims-Based Inpatient Outcome Measures OQ IQ P Nursing Sensitive Care Measure Death Among Surgical Patients with Serious Treatable Complications emoved! by State of Minnesota r r Structural Measures OQ IQ P Inpatient Structural Measures Participation in a Systematic Clinical Database egistry for Nursing Sensitive Care emoved! by CMS Participation in a Systematic Clinical Database egistry for General Surgery emoved! by CMS Stratis Health
10 Electronic Clinical Quality Measures (ecqm) Inpatient Acute Myocardial Infarction (AMI) AMI-2 Aspirin Prescribed at Discharge emoved! by CMS AMI-7a: Fibrinolytic Therapy eceived within 30 Minutes of Hospital Arrival emoved! by CMS AMI-10: Statin Prescribed at Discharge emoved! by CMS Inpatient Pneumonia (PN) PN-6: Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients emoved! by CMS Inpatient Surgical Care Improvement Project (SCIP) SCIP-Inf-1: Prophylactic Antibiotic eceived Within One Hour Prior to Surgical Incision emoved! by CMS SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients emoved! by CMS SCIP-Inf-9: Urinary Catheter emoved on Postoperative Day 1 or Postoperative Day 2 with Day of Surgery Being Day Zero emoved! by CMS Inpatient Perinatal/Neonatal Care HTN: Healthy Term Newborn emoved! by CMS Inpatient Stroke (STK) STK-4: Thrombolytic Therapy emoved! by CMS Inpatient Venous Thromboembolism (VTE) VTE-3: VTE Patients with Anticoagulation Overlap Therapy emoved! by CMS VTE-4: VTE Patients eceiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram emoved! by CMS VTE-5: VTE Discharge Instructions emoved! by CMS VTE-6: Incidence of Potentially-Preventable VTE emoved! by CMS Included in the IQ? Stratis Health
11 Acronyms AA Aortic Aneurysm AMI Acute Myocardial Infarction CABG Coronary Artery Bypass Graft CAC Children s Asthma Care Critical Access Hospital CAUTI Catheter-Associated Urinary Tract Infection CDE Common Duct Eploration 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 EH Electronic Health ecord Hospital-Acquired Condition (eduction ) HAI Healthcare-Associated Infection HPS Hospital Consumer Assessment of Healthcare Providers and Systems HCP Healthcare Personnel HF Heart Failure HIT Health Information Technology IMM Immunization IQ Inpatient Quality eporting () Medicare Beneficiary Quality Improvement Project MOT Mortality MI Magnetic esonance Imaging MSA Methicillin-resistant Staphylococcus aureus MSPB Medicare Spending per Beneficiary OP Outpatient OQ Outpatient Quality eporting () PC Perinatal Care PCI Percutaneous Coronary Intervention PN Pneumonia Prospective Payment System PSI Patient Safety Indicator EADM eadmissions P eadmission eduction SSI Surgical Site Infection SQMS Statewide Quality eporting Measurement System STK Stroke THA Total Hip Arthroplasty TKA Total Knee Arthroplasty TPS Total Performance Score UTI Urinary Tract Infection Value-Based Purchasing () VTE Venous Thromboembolism Stratis Health
12 eferences ecqms for Eligible Hospitals Table January Guidance/Legislation/EHIncentives/Downloads/eCQM_Addendum_EH_Measures_Table.p df (eferenced January 31, 2017) Electronic Clinical Quality Measures (ecqms) Overview 2&cid= (eferenced January 31, 2017) Fiscal Year 2019 Measures: Hospital Value-Based Purchasing 3&cid= (eferenced January 31, 2017) Hospital Inpatient Quality eporting Changes: FY 2019 Payment Determination (CY 2017 eporting Period) _-Changes_ _vFINAL_508.pdf (eferenced January 31, 2017) Hospital IQ FY 2019 Measures 74&blobheader=multipart%2Foctet-stream&blobheadername1=Content- Disposition&blobheadervalue1=attachment%3Bfilename%3DIQ_FY2019_CMS_Msrs_CY2017.pdf &blobcol=urldata&blobtable=mungoblobs (eferenced January 31, 2017) Hospital IQ Important Dates and Deadlines (eferenced January 31, 2017) Hospital eadmission eduction : Overview 2&cid= (eferenced January 31, 2017) Measures: Hospital-Acquired Condition () eduction 3&cid= (eferenced January 31, 2017) Minnesota Statewide Quality eporting and Measurement System: Appendices to Minnesota Administrative ules, Chapter 4654, December (eferenced January 31, 2017) Outpatient Quality eporting Measures 3&cid= (eferenced January 31, 2017) Prepared by Stratis Health under contract with Minnesota Community Measurement, funded by the Minnesota Department of Health. Stratis Health
Core = Core required measures for all CAH nationally r = Required by State of Minnesota X = Additional for MBQIP
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