FY X Time (48 hrs for cardiac surgery) SCIP-Inf-4 Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood

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1 Valuebased 2013 Hospital Measure Summary Data Collection for Inpatient Quality Reporting FY2015 and Outpatient Reporting CY2014 January 2013 Key: = Required by both CMS and State of Minnesota = Required by CMS only 0 = Required by State only = Special circumstances pending Inpatient Acute Myocardial Infarction (AMI) AMI-1 Aspirin at Arrival suspended by both CMS and state AMI-2 Aspirin Prescribed at Discharge 0 AMI-3 ACEI or ARB for LVSD - suspended by both CMS and state AMI-5 Beta-Blocker Prescribed at Discharge - suspended by both CMS and state AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival 0 AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI) 0 AMI-10 Statin Prescribed at Discharge 0 AMI-ACM Appropriate care (calculated by Stratis Health) Inpatient Heart Failure (HF) HF-1 Discharge Instructions 0 HF-2 Evaluation of LVS Function 0 HF-3 ACEI or ARB for LVSD 0 HF-ACM Appropriate care (calculated by Stratis Health) Inpatient Pneumonia (PN) PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic 0 Received in Hospital PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient 0 PN-ACM Appropriate care (calculated by Stratis Health) Inpatient Surgical Care Improvement Project (SCIP) SCIP-Inf-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 0 SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients 0 SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End 0 Time (48 hrs for cardiac surgery) SCIP-Inf-4 Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood 0 Glucose SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal - suspended by CMS and state SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative FY Day 2 (POD 2) with Day of Surgery being Day Zero SCIP-Inf-10 Surgery Patients with Perioperative Temperature Management 0 SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period 0 SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered - retired by CMS! SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery 0, 14, then removed 1

2 Valuebased Inpatient Prevention: Global Immunization Measures IMM-1a Pneumococcal immunization (PPV23) overall rate 0 IMM-1b Pneumococcal immunization (PPV23) age 65 and older IMM-1c Pneumococcal immunization (PPV23) high risk populations (6 64 yrs) IMM-2 Influenza immunization 0 Inpatient Emergency Department Throughput ED-1a Median time from ED arrival to ED departure for ED admitted patients - overall rate ED-1b Median time from ED arrival to ED departure for ED admitted patients - reporting measure ED-1c Median time from ED arrival to ED departure for ED admitted patients - observation patients ED-1d Median time from ED arrival to ED departure for ED admitted patients - psychiatric/mental health patients ED-2a Median time from admit decision to departure for ED admitted patients - overall rate ED-2b Median time from admit decision to departure for ED admitted patients - reported measure ED-2c Median time from admit decision to departure for ED admitted patients - psychiatric/mental health patients 0 0 Hospital Outpatient Acute Myocardial Infarction (AMI) and Chest Pain OP-1 Median time to fibrinolysis 0 OP-2 Fibrinolytic therapy received within 30 minutes of emergency department (ED) arrival 0 OP-3 Median time to transfer to another facility for acute coronary intervention 0 OP-4 Aspirin at arrival 0 OP-5 Median time to ECG 0 OP-16 Troponin results for emergency department acute myocardial infarction (AMI) patients or chest pain patients (with probable cardiac chest pain) within 60 minutes of arriva l- new for CMS and state 0 Hospital Outpatient Surgery OP-6 Timing of antibiotic prophylaxis (initiated within 1 hour prior to surgical incision) 0 OP-7 Prophylactic antibiotic selection for surgical patients 0 Hospital Outpatient Efficiency OP-18 Median time from ED arrival to ED departure for discharged ED patients OP-19 Transition record with specified elements received by discharged patients suspended by CMS but need to enter data to avoid error! OP-20 Door to diagnostic evaluation by a qualified medical professional OP-21 ED-median time to pain management for long bone fracture OP-22 ED-patient left without being seen (numerator/denominator one time per year for the previous year) 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 2

3 Valuebased Stroke STK-1 Venous thromboembolism prophylaxis New! STK-2 Discharged on antithrombotic therapy New! STK-3 Anticoagulation therapy for atrial fibrillation/flutter New! STK-4 Thrombolytic therapy New! STK-5 Antithrombolytic therapy by end of hospital day 2 New! STK-6 Discharged on statin New! STK-8 Stroke education New! STK-10 Assessed for rehabilitation New! Venous Thromboembolism (VTE) VTE-1 Venous Thromboembolism Prophylaxis New! VTE-2 ICU VTE prophylaxis New! VTE-3 VTE patients with anticoagulation overlap therapy New! VTE-4 Patients receiving unfractionated Heparin with dosages/platelet count monitored by protocol New! VTE-5 Venous thromboembolism discharge instructions New! VTE-6 Incidence of potentially-preventable venous thromboembolism New! Perinatal Care PC-1 Elective delivery prior to 39 completed weeks gestation New! (web-based entry) Submitted to NHSN Healthcare Associated Infections (HAI) Central Line Associated Bloodstream Infection (CLABSI) Only NICU/PICU for state 0 FY2015 Surgical Site Infections (SSI) Catheter-Associated Urinary Tract Infection (CAUTI) MRSA Bacteremia New! Clostridium Difficile (C.difficile or CDI) New! Healthcare Personnel Influenza Vaccination New! 0 Submitted to MDH through MN Stroke Registry Stroke NIH stroke scale performed in initial evaluation Removed by state! Door-to-imaging performed within 25 min 3

4 Submitted to MDH through MHA Asthma Care (CAC) May also be submitted through TJC to Hospital Compare CAC-3 Home Management Plan of Care (HMPC) document given to patient/caregiver 0 Vermont Oxford Network Late sepsis or meningitis in very low birth weight neonates (Level III NICU) Emergency Department Transfer Communication Administrative communication 0 Vital signs 0 Medication information 0 Patient information 0 Physician information 0 Nursing information 0 Procedures and tests 0 Structural Measures and DACA Hospital Inpatient 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 Hospital Inpatient Data Accuracy and Completeness Acknowledgement Electronic acknowledgment for FY2012 payment Hospital Outpatient Structural Measure OP-12 The ability for providers with HIT to receive laboratory data electronically directly into their qualified/certified EHR system as discrete searchable data OP-17 Tracking clinical results between visits OP-25 Safe surgery checklist New! OP-26 Hospital outpatient volume data on selected outpatient surgical procedures New! 4

5 Readmissio n Surveys Surveys Submitted to MHA Health Information Technology (HIT) Health information technology survey Surveys Patient Experience of Care Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HPS) ( > 500 admissions in previous year for ) New! 3 item Care Transition set and 2 About You items required by CMS Claims Measures Claims Measures 30-Day Risk-Standardized Mortality Rates MORT-30-AMI Acute Myocardial Infarction (AMI) 30-Day Mortality Rate 0 FY2014 MORT-30-HF Heart Failure (HF) 30-Day Mortality Rate 0 FY2014 MORT-30-PN Pneumonia (PN) 30-Day Mortality Rate 0 FY Day Risk-Standardized Rates READM-30-AMI Acute Myocardial Infarction (AMI) 30-Day Rate READM-30-HF Heart Failure (HF) 30-Day Rate READM-30-PN Pneumonia (PN) 30-Day Rate HWR Hospital wide all-cause unplanned readmissions New! Hip/Knee : 30 day all-cause risk-standardized readmission rate (RSRR) for elective primary Total Hip (THA)/Total Knee Arthoplast (TKA) New! Surgical Complications Hip/Knee Complication: Hospital-level Risk-Standardized Complication Rate (RSCR) following Elective Primary Total Hip (THA)/Total Knee Arthoplasty (TKA) New! Agency for Healthcare Research and Quality (AHRQ) Measures PSI 3 Pressure ulcer PSI 04 Death Among Surgical Patients with Serious, Treatable Complications (Harmonized with NSC measure for FY2011) PSI 06 Iatrogenic Pneumothorax, Adult removed by CMS! PSI 11 Postoperative respiratory failure removed by CMS! PSI 12 Postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT) removed by CMS! 5 0 PSI 14 Postoperative Wound Dehiscence removed by CMS! PSI 15 Accidental Puncture or Laceration removed by CMS! PSI 18 Obstetric trauma vaginal delivery with instrument

6 Claims Measures PSI 19 Obstetric trauma vaginal delivery without instrument PSI 90 Complication/Patient Safety for Selected Indicators (composite) (3,6-8, 12-15) 0 IQI 4 Abdominal aortic aneurysm (AAA) repair volume IQI 5 Coronary artery bypass graft (CABG) volume IQI 6 Percutaneous transluminal coronary angioplasty (PTCA) volume IQI 11 Abdominal Aortic Aneurysm (AAA) Mortality Rate (with or without volume) - retired by CMS! IQI 12 Coronary artery bypass graft (CABG) mortality rate IQI 19 Hip Fracture Mortality Rate - retired by CMS! IQI 30 Percutaneous transluminal coronary angioplasty (PTCA) mortality rate IQI 91 Mortality for Selected Medical Conditions (composite) (15,16,17,18,19,20) - retired by CMS! PDI 6 Pediatric heart surgery mortality rate 0 PDI 7 Pediatric heart surgery volume 0 PDI 19 Pediatric patient safety for selected indicators composite (1,2,5,8,9,10,11,12) 0 FY2015 Nursing Sensitive Care Measure Death Among Surgical Patients with Serious Treatable Complications (Harmonized with PSI 4 measure, Failure to Rescue) Hospital-Acquired Condition (HAC) Measures Foreign Object Retained After Surgery removed from inpatient quality reporting! Air Embolism - removed from inpatient quality reporting! Blood Incompatibility - removed from inpatient quality reporting! Pressure Ulcer Stages III & IV - removed from inpatient quality reporting! Falls and Trauma: (Includes; Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, other injuries) - removed from inpatient quality reporting! Vascular Catheter-Associated Infections - removed from inpatient quality reporting! Catheter-Associated Urinary Tract Infection (UTI) - removed from inpatient quality reporting! Manifestations of Poor Glycemic Control - removed from inpatient quality reporting! Cost Efficiency Medicare Spending per Beneficiary FY2015 Hospital Outpatient Imaging OP-8 MRI 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) 6

7 Future CMS Measures: collection begins in 2014 CY 2014 Reporting deferred OP-15 Use of brain computed tomography (CT) in the emergency department for atramatic headache CY2015 Outpatient measures OP-24 Cardiac rehabilitation patient referral from an outpatient setting FY2016 Inpatient structural measures Inpatient Safe Surgery Checklist Use 7 01/25/2013 This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C