50198 Federal Register / Vol. 75, No. 157 / Monday, August 16, 2010 / Rules and Regulations
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1 50198 Federal Register / Vol. 75, No. 157 / Monday, August 16, 2010 / Rules and Regulations mstockstill on DSKH9S0YB1PROD with RULES2 VerDate Mar<15> :02 Aug 13, 2010 Jkt PO Frm Fmt 4701 Sfmt 4725 E:\FR\FM\16AUR2.SGM 16AUR2 ER16AU10.039</GPH>
2 50208 Federal Register / Vol. 75, No. 157 / Monday, August 16, 2010 / Rules and Regulations RHQDAPU measures, but not necessarily the sole mechanism to submit data for RHQDAPU measures. Set out below are the 57 RHQDAPU program quality measures to be used for the FY 2013 payment determination: BILLING CODE P mstockstill on DSKH9S0YB1PROD with RULES2 VerDate Mar<15> :02 Aug 13, 2010 Jkt PO Frm Fmt 4701 Sfmt 4725 E:\FR\FM\16AUR2.SGM 16AUR2 ER16AU10.043</GPH>
3 Federal Register / Vol. 75, No. 157 / Monday, August 16, 2010 / Rules and Regulations mstockstill on DSKH9S0YB1PROD with RULES2 VerDate Mar<15> :02 Aug 13, 2010 Jkt PO Frm Fmt 4701 Sfmt 4700 E:\FR\FM\16AUR2.SGM 16AUR2 ER16AU10.044</GPH>
4 CMS-1518-F/1430-F 579 the NHSN, 1 claims-based measure (Medicare Spending Per Beneficiary), and 1 structural measure (Participation in a Systematic Clinical Database Registry for General Surgery). As a result, there will be a total of 59 measures in the FY 2014 Hospital IQR measure set, but we will only be collecting data on 55 of those measures for purposes of the FY 2014 payment determination. The 59 measures are listed below, and the 4 measures for which we will not be collecting data are designated with the word SUSPENDED. Hospital IQR Program Measures for FY 2014 Payment Determination Reflecting Retirement of 4 Measures, Suspension of Data Collection for 4 measures and Adoption of 3 New Measures Acute Myocardial Infarction (AMI) AMI-1 Aspirin at arrival [SUSPENDED ] AMI-2 Aspirin prescribed at discharge AMI-3 ACEI/ARB for left ventricular systolic dysfunction [SUSPENDED ] AMI-5 Beta-blocker prescribed at discharge [SUSPENDED] AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI) AMI-10 Statin Prescribed at Discharge Heart Failure (HF) HF-1 Discharge instructions HF-2 Evaluation of left ventricular systolic function HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction Pneumonia (PN) PN-3b Blood culture performed in the emergency department prior to first antibiotic received in hospital PN-6 Appropriate initial antibiotic selection Surgical Care Improvement Project (SCIP) SCIP INF-1 Prophylactic antibiotic received within 1 hour prior to surgical incision SCIP INF-2: Prophylactic antibiotic selection for surgical patients SCIP INF-3 Prophylactic antibiotics discontinued within 24
5 CMS-1518-F/1430-F 580 Hospital IQR Program Measures for FY 2014 Payment Determination Reflecting Retirement of 4 Measures, Suspension of Data Collection for 4 measures and Adoption of 3 New Measures hours after surgery end time (48 hours for cardiac surgery) SCIP INF-4: Cardiac surgery patients with controlled 6AM postoperative serum glucose SCIP INF-6 Appropriate Hair Removal [SUSPENDED ] SCIP INF-9: Postoperative urinary catheter removal on post operative day 1 or 2 with day of surgery being day zero SCIP INF-10: Surgery patients with perioperative temperature management SCIP Cardiovascular-2: Surgery Patients on a Beta Blocker prior to arrival who received a Beta Blocker during the perioperative period SCIP INF -VTE-1: Surgery patients with recommended Venous Thromboembolism (VTE) prophylaxis ordered SCIP-VTE-2: Surgery patients who received appropriate VTE prophylaxis within 24 hours pre/post surgery Mortality Measures (Medicare Patients) Acute Myocardial Infarction (AMI) 30-day mortality rate Heart Failure (HF) 30-day mortality rate Pneumonia (PN) 30-day mortality rate Patients' Experience of Care HCAHPS survey Readmission Measure (Medicare Patients) Acute Myocardial Infarction 30-day Risk Standardized Readmission Measure Heart Failure 30-day Risk Standardized Readmission Measure Pneumonia 30-day Risk Standardized Readmission Measure AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite Measures PSI 06: Iatrogenic pneumothorax, adult PSI 11: Post Operative Respiratory Failure PSI 12: Post Operative PE or DVT PSI 14: Postoperative wound dehiscence PSI 15: Accidental puncture or laceration IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) IQI 19: Hip fracture mortality rate Complication/patient safety for selected indicators (composite) Mortality for selected medical conditions (composite)
6 CMS-1518-F/1430-F 581 Hospital IQR Program Measures for FY 2014 Payment Determination Reflecting Retirement of 4 Measures, Suspension of Data Collection for 4 measures and Adoption of 3 New Measures AHRQ PSI and Nursing Sensitive Care PSI 04 Death among surgical in patients with serious treatable complications Structural measures Participation in a Systematic Database for Cardiac Surgery Participation in a Systematic Clinical Database Registry for Stroke Care Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care Participation in a Systematic Clinical Database Registry for General Surgery** Healthcare-Associated Infections Central Line Associated Bloodstream Infection Surgical Site Infection* Catheter-Associated Urinary Tract Infection** Hospital Acquired Condition Measures Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Pressure Ulcer Stages III & IV Falls and Trauma: (Includes: Fracture Dislocation Intracranial Injury Crushing Injury Burn Electric Shock) Vascular Catheter-Associated Infection Catheter-Associated Urinary Tract Infection (UTI) Manifestations of Poor Glycemic Control Emergency Department Throughput ED-1 Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the hospital* ED-2 Median time from admit decision to time of departure from the emergency department for emergency department patients admitted to the inpatient status* Prevention: Global Immunization Measures Immunization for Influenza * Immunization for Pneumonia* Cost Efficiency Medicare Spending per Beneficiary** * Measures finalized in the FY 2011 IPPS/LTCH PPS final rule for the FY 2014 payment determination ** Additional measures adopted in this final rule for FY 2014 payment determination
7 CMS-1518-F/1430-F 609 Personnel Influenza Vaccination), the Stroke measure set (8 measures) and the VTE measure set (6 measures). As a result, there will be a total of 76 measures in the FY 2015 Hospital IQR measure set, but we will only be collecting data on 72 of those measures for purposes of the FY 2015 payment determination. The 76 measures are listed below, and the 4 measures for which we will not be collecting data are designated with the word SUSPENDED. Hospital IQR Program Measures for FY 2015 Payment Determination Acute Myocardial Infarction (AMI) Measures AMI-1 Aspirin at arrival [SUSPENDED] AMI-2 Aspirin prescribed at discharge AMI-3 ACEI/ARB for left ventricular systolic dysfunction [SUSPENDED] AMI-5 Beta-blocker prescribed at discharge [SUSPENDED] AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI) AMI-10 Statin Prescribed at Discharge Heart Failure (HF) Measures HF-1 Discharge instructions HF-2 Evaluation of left ventricular systolic function HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction Stroke Measure Set STK-1 VTE prophylaxis** STK-2 Antithrombotic therapy for ischemic stroke** STK-3 Anticoagulation therapy for Afib/flutter** STK-4 Thrombolytic therapy for acute ischemic stroke** STK-5 Antithrombotic therapy by the end of hospital day** STK-6 Discharged on Statin** STK-8 Stroke education** STK-10 Assessed for rehab** VTE Measure Set
8 CMS-1518-F/1430-F 610 Hospital IQR Program Measures for FY 2015 Payment Determination VTE-1 VTE prophylaxis** VTE-2 ICU VTE prophylaxis** VTE-3 VTE patients with anticoagulation overlap therapy** VTE-4 Patients receiving un-fractionated Heparin with doses/labs monitored by protocol** VTE-5 VTE discharge instructions** VTE-6 Incidence of potentially preventable VTE** Pneumonia (PN) Measures PN-3b Blood culture performed in the emergency department prior to first antibiotic received in hospital PN-6 Appropriate initial antibiotic selection Surgical Care Improvement Project (SCIP) Measures SCIP INF-1 Prophylactic antibiotic received within 1 hour prior to surgical incision SCIP INF-2: Prophylactic antibiotic selection for surgical patients SCIP INF-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery) SCIP INF-4: Cardiac surgery patients with controlled 6AM postoperative serum glucose SCIP INF-6 Appropriate Hair Removal [SUSPENDED] SCIP INF-9: Postoperative urinary catheter removal on post operative day 1 or 2 with day of surgery being day zero SCIP INF-10: Surgery patients with perioperative temperature management SCIP Cardiovascular-2: Surgery Patients on a Beta Blocker prior to arrival who received a Beta Blocker during the perioperative period SCIP INF -VTE-1: Surgery patients with recommended Venous Thromboembolism (VTE) prophylaxis ordered SCIP-VTE-2: Surgery patients who received appropriate VTE prophylaxis within 24 hours pre/post surgery Mortality Measures (Medicare Patients) Acute Myocardial Infarction (AMI) 30-day mortality rate Heart Failure (HF) 30-day mortality rate Pneumonia (PN) 30-day mortality rate Patients' Experience of Care Measure HCAHPS survey Readmission Measures (Medicare Patients) Acute Myocardial Infarction 30-day Risk Standardized Readmission Measure Heart Failure 30-day Risk Standardized Readmission Measure
9 CMS-1518-F/1430-F 611 Hospital IQR Program Measures for FY 2015 Payment Determination Pneumonia 30-day Risk Standardized Readmission Measure AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite Measures PSI 06: Iatrogenic pneumothorax, adult PSI 11: Post Operative Respiratory Failure PSI 12: Post Operative PE or DVT PSI 14: Postoperative wound dehiscence PSI 15: Accidental puncture or laceration IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) IQI 19: Hip fracture mortality rate Complication/patient safety for selected indicators (composite) Mortality for selected medical conditions (composite) AHRQ PSI and Nursing Sensitive Care PSI-4 Death among surgical inpatients with serious treatable complications Structural Measures Participation in a Systematic Database for Cardiac Surgery Participation in a Systematic Clinical Database Registry for Stroke Care Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care Participation in a Systematic Clinical Database Registry for General Surgery* Healthcare-Associated Infections Measures Central Line Associated Bloodstream Infection Surgical Site Infection Catheter-Associated Urinary Tract Infection* MRSA Bacteremia** Clostridium difficile (C. difficile)** Healthcare Provider Influenza Vaccination** Hospital Acquired Condition Measures Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Pressure Ulcer Stages III & IV Falls and Trauma: (Includes: Fracture Dislocation Intracranial Injury Crushing Injury Burn Electric Shock) Vascular Catheter-Associated Infection Catheter-Associated Urinary Tract Infection (UTI)
10 CMS-1518-F/1430-F 612 Hospital IQR Program Measures for FY 2015 Payment Determination Manifestations of Poor Glycemic Control Emergency Department Throughput Measures ED-1 Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the hospital ED-2 Median time from admit decision to time of departure from the emergency department for emergency department patients admitted to the inpatient status Prevention: Global Immunization Measures Immunization for Influenza Immunization for Pneumonia Cost Efficiency Medicare Spending per Beneficiary* * New quality measures for the FY 2014 payment determination ** New quality measures for FY 2015 payment determination 4. Possible New Quality Measures and Measure s for Future Years We anticipate that as EHR technology evolves, and more infrastructure is put in place, we will have the capacity to accept electronic reporting of all of the clinical chartabstracted measures that are currently part of the Hospital IQR Program or have been proposed for adoption into the program. We intend for this future progress to significantly reduce the administrative burden on hospitals under the Hospital IQR Program. We recognize that considerable work needs to be done by measure owners and developers to make this possible with respect to the clinical quality measures that we proposed. This includes completing electronic specifications for measures, pilot testing, reliability, and validity testing, and implementing such specifications into EHR technology to capture and calculate the results, and implementing the systems. We believe that at a future date, such as 2015, CMS and hospitals will be able to switch to
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