Core = Core required measures for all CAH nationally r = Required by State of Minnesota X = Additional for MBQIP

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1 Key: 2016 Hospital Measure Summary Minnesota Statewide Quality eporting and Measurement System (SQMS) and FY2018 for Center for Medicare and Medicaid Services () January 2016 = equired by Core = Core required measures for all nationally r = equired by State of Minnesota X = Additional for V = Voluntary for C = Chart abstracted measure v = Voluntary for State of Minnesota e = electronic clinical quality measure incentive Inpatient Acute Myocardial Infarction (AMI) AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival emoved! By State and by for the chart abstracted measure v r e/c Inpatient Stroke (STK) STK-1 Venous thromboembolism (VTE) prophylaxis emoved by! C STK-4 Thrombolytic therapy e/c STK-6 Discharged on statin medication emoved! By chart abstracted measure e/c STK-8 Stroke education emoved! By chart abstracted measure e/ C Inpatient Venous Thromboembolism (VTE) VTE-1 Venous thromboembolism prophylaxis emoved! By chart abstracted measure e/ C VTE-2 ICU VTE prophylaxis emoved! By chart abstracted measure e/ C VTE-3 VTE patients with anticoagulation overlap therapy emoved! By chart abstracted measure e/ C VTE-5 Venous thromboembolism Warfarin therapy discharge instructions e/c VTE-6 Hospital acquired potentially-preventable venous thromboembolism e/c Sepsis Severe Sepsis and Septic Shock: Management bundle C Inpatient Prevention: Global Immunization Measures IMM-2 Influenza immunization r C Core Inpatient Emergency Department Throughput ED-1 Median time from ED arrival to ED departure for ED admitted patients New! equired by state for ED-2 Median time from admit decision to departure for ED admitted patients New! equired by state for r e/c X r e/c X Outpatient Acute Myocardial Infarction (AMI) and Chest Pain OP-1 Median time to fibrinolysis New! equired by state for r Core OP-2 Fibrinolytic therapy received within 30 minutes of emergency department (ED) arrival r Core OP-3 Median time to transfer to another facility for acute coronary intervention r Core OP-4 Aspirin at arrival r X OP-5 Median time to ECG r Core 1

2 incentive Outpatient ED Throughput OP-18 Median time from ED arrival to ED departure for discharged ED patients New! equired by state for OP-20 Door to diagnostic evaluation by a qualified medical professional New! equired by state for OP-22 ED-patient left without being seen (numerator/denominator one time per year for the previous year) New! equired by state for Outpatient Pain OP-21 ED-median time to pain management for long bone fracture New! equired by state for Outpatient Stroke OP-23 ED-head CT scan results for acute ischemic stroke or hemorrhagic stroke who received head CT scan interpretation within 45 minutes of arrival) New! equired by state for r X r Core r Core r Core r X Submitted to NHSN incentive Inpatient Healthcare Associated Infections (HAI) Central Line Associated Bloodstream Infection (CLABSI) (NICU/PICU for state) emoved! for pediatrics by state r Surgical Site Infections (SSI) following colon surgery x x Surgical Site Infections (SSI) following abdominal hysterectomy x x Catheter-Associated Urinary Tract Infection (CAUTI) x x x x X New! equired by state for r MSA Bacteremia x x Clostridium Difficile (C.difficile or CDI) x x Healthcare Personnel Influenza Vaccination * New! equired by state for r Core Outpatient Healthcare Associated Infections OP-27 Influenza Vaccination Coverage among Healthcare Personnel * New! equired by state for * Combined data r Core Submitted to MDH through MN Stroke egistry incentive Stroke Door-to-imaging initiated time r r Door-to- needle time time to intravenous thrombolytic therapy r r 2

3 Submitted to MDH through MHA incentive Vermont Oxford Network Late sepsis or meningitis in very low birth weight neonates (Level III NICU) emoved! by state for NICU r r Emergency Department Transfer Communication EDTC-1 Administrative communication r Core EDTC-2 Vital signs r Core EDTC-3 Medication information r Core EDTC-4 Patient information r Core EDTC-5 Physician information r Core EDTC-6 Nursing information r Core EDTC-7 Procedures and tests r Core EDTC- All or ne composite r Core Medication Orders Pharmacist CPOE/Verification of Medication Orders within 24 hrs retired by ^ Chart Abstracted Web-based Measures incentive Inpatient Perinatal Care PC-1 Elective delivery prior to 39 completed weeks gestation r e/c x X Outpatient OP-26 Hospital outpatient volume data on selected outpatient surgical procedures OP-29 Endoscopy/Poly Surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients (numerator/denominator one time per year) OP-30 Endoscopy/Poly surveillance: colonoscopy interval for patients with a history of adenomatous polyps avoidance of inappropriate use (numerator/denominator one time per year) OP-31 Cataracts improvement in patient s visual function within 90 days following cataract surgery (numerator/denominator one time per year) OP-33 External Beam adiotherapy for Bone Metastases New! V Structural Measures and DACA incentive Inpatient Structural Measures Patient safety culture New! Participation in a Systematic Clinical Database egistry for Nursing Sensitive Care Participation in a Systematic Clinical Database egistry for General Surgery Safe Surgery Checklist 3

4 Inpatient Data Accuracy and Completeness Acknowledgement Electronic acknowledgment for Fiscal year payment Outpatient Structural Measure OP-12 The ability for providers with HIT to receive laboratory data electronically directly into their qualified/certified EH system as discrete searchable data OP-17 Tracking clinical results between visits OP-25 Safe surgery checklist New! equired by state for r X Surveys Surveys Submitted to MHA incentive Health Information Technology (HIT) Health information technology survey r r Surveys incentive Inpatient Patient Experience of Care Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HPS) ( > 500 admissions in previous year for ) includes 3 item Care Transition set and 2 About You items CTM new to! r x Core Claims Measures Claims Measures incentive 30-Day isk-standardized Mortality ates MOT-30-AMI Acute Myocardial Infarction (AMI) 30-Day Mortality ate emoved! by state for r x MOT-30-HF Heart Failure (HF) 30-Day Mortality ate emoved! by state for r x MOT-30-PN Pneumonia (PN) 30-Day Mortality ate emoved! by state for r x MOT-30-STK Stroke (STK) 30-Day Mortality ate MOT-30-COPD Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality ate MOT-30-CABG Coronary Bypass Graph Surgery (CABG) 30-Day Mortality rate 30-Day isk-standardized eadmission ates EADM-30-AMI Acute Myocardial Infarction (AMI) 30-Day eadmission ate x EADM-30-HF Heart Failure (HF) 30-Day eadmission ate New! equired by state for EADM-30-PN Pneumonia (PN) 30-Day eadmission ate New! equired by state for EADM-30-HW Hospital wide all-cause unplanned readmissions r x X r x X 4

5 Claims Measures incentive EADM-30-TH/TKA: 30 day all-cause risk-standardized readmission rate(s) for elective primary Total Hip(THA) /Total Knee Arthoplasty(TKA) EADM-30-STK Stroke (STK) 30-Day eadmission ate EADM-30-COPD Chronic Obstructive Pulmonary Disease (COPD) 30-Day eadmission rate New! equired by state for EADM-30-CABG Coronary Bypass Graph Surgery (CABG) 30-Day eadmission rate Inpatient Surgical Complications Hip/Knee Complication: Hospital-level isk-standardized Complication ate (SC) following Elective Primary Total Hip (THA)/Total Knee Arthoplasty (TKA) x r x X Agency for Healthcare esearch and Quality (AHQ) Measures PSI 04 Death Among Surgical Patients with Serious, Treatable Complications (Harmonized with NSC measure for FY2011) PSI 18 Obstetric trauma vaginal delivery with instrument emoved! equired by state r r PSI 19 Obstetric trauma vaginal delivery without instrument emoved! by state r r PSI 90 Complication/Patient Safety for Selected Indicators (composite) (3, 6-8, 12-15) IQI 91 Mortality for Selected Medical Conditions (composite) (15,16,17,18,19,20) r r PDI 6 Pediatric heart surgery mortality rate emoved! by state for pediatrics r r r PDI 7 Pediatric heart surgery volume emoved! by state for pediatrics r r r PDI 19 Pediatric patient safety for selected indicators composite (1,2,5,8,9,10,11,12) emoved! by state for pediatrics r r r r x x r r r Nursing Sensitive Care Measure Death Among Surgical Patients with Serious Treatable Complications (Harmonized with PSI 4 measure, Failure to escue) r r Cost Efficiency Medicare Spending per Beneficiary x Acute Myocardial Infarction(AMI) Payment per Episode of Care Heart Failure(HF) Payment per Episode of Care Pnneumonia(PN) Payment per Episode of Care Total Knee(TKA)/total hip arthroplasty(tha) Payment per Episode of Care New! AMI Excess days New! HF Excess days New! Outpatient Imaging OP-8 MI lumbar spine for low back pain OP-9 Mammography follow-up rates OP-10 Abdominal CT - use of contrast material OP-11 Thorax CT - use of contrast material OP-13 Cardiac imaging for preoperative risk assessment for non-cardiac low risk surgery OP-14 Simultaneous use of brain computed tomography (CT) and sinus computed tomography (CT) OP-15 Use of brain computed tomography (CT) in the emergency department for atraumatic headache emoved! by Outpatient Outcome OP-32: Facility 7-Day isk-standardized Hospital Visit ate after Outpatient Colonoscopy New! 5

6 Incentive Program Measures Composite Measures incentive Value-based Purchasing () Program Total Performance Score New! for state r x eadmission eduction Program () Excess eadmissions Score New! for state r * Hospital Acquired Condition () Program Total Score New! for state r x *currently there is a total payment adjustment based on excess readmission but no readmissions score. A weighted summary will be calculated 6

7 Electronic Clinical Quality Measures ecqm Hospitals select at least 4 7

8 Electronic Clinical Quality Measures (ecqm) Electronic Clinical Quality Measures Hospitals select at least 4 Included in Inpatient Quality eporting Program? Also a chartabstracted measure? Inpatient Acute Myocardial Infarction (AMI) AMI-2 Aspirin prescribed at discharge AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival AMI-8a Timing of receipt of primary Percutaneous Coronary Intervention (PCI) AMI-10 Statin prescribed at discharge Inpatient Pneumonia (PN) PN-6 Initial antibiotic selection for CAP in immunocompetent patient Inpatient Surgical Care Improvement Project (SCIP) SCIP-Inf-1 Prophylactic antibiotic received within one hour prior to surgical incision SCIP-Inf-2 Prophylactic antibiotic selection for surgical patients SCIP-Inf-9 Urinary catheter removed on postoperative day 1 (POD 1) or postoperative Day 2 (POD 2) with day of surgery being day Inpatient Stroke (STK) STK-2 Discharged on antithrombotic therapy STK-3 Anticoagulation therapy for atrial fibrillation/flutter STK-4 Thrombolytic therapy required Yes STK-5 Antithrombolytic therapy by end of hospital day 2 STK-6 Discharged on statin medication STK-8 Stroke education STK-10 Assessed for rehabilitation Inpatient Venous Thromboembolism (VTE) VTE-1 Venous thromboembolism prophylaxis VTE-2 ICU VTE prophylaxis VTE-3 VTE patients with anticoagulation overlap therapy VTE-4 VTE Patients receiving unfractionated Heparin with dosages/platelet count monitored by protocol or nomogram VTE-5 Venous thromboembolism Warfarin therapy discharge instructions required Yes VTE-6 Hospital acquired potentially-preventable venous thromboembolism required Yes Inpatient Emergency Department Throughput ED-1 Median time from ED arrival to ED departure for ED admitted patients required Yes ED-2 Median time from admit decision to departure for ED admitted patients required Yes Outpatient Emergency Department Throughput ED-3 Median Time from ED arrival to ED departure for discharged ED patients not included/ OPmeasure Inpatient Perinatal/Neonatal Care PC-01 Elective delivery prior to 39 completed weeks gestation required Yes PC-05 Exclusive Breast Milk Feeding and the subset measure PC-05a Exclusive Breast Milk Feeding Considering Mother s Choice HTN Document Given to Patient/Caregiver Healthy Term Newborn EHDI-1a Hearing Screening Prior to Hospital Discharge 8

9 Asthma Care (CAC) CAC-3 Home Management Plan of Care (HMPC) document given to patient/caregiver 1/13/2016 This material was prepared by Stratis Health, under contract with the Minnesota Community Measurement funded by the Minnesota Department of Health. 9