CMS/TJC Specification Core Measures Update
2015
CMS Chart-Abstracted Only Facilities
January 2015 Discharges
Required Measure Sets
Removed Measure Sets
AMI-7a Fribolysis therapy within 30 min of arrival
SCIP INF-4 Cardiac Patients with Cotrolled Post-op Glucose
STK-1 VTE Prophylaxis
STK-4 Thrombolytic Therapy
STK-6 Discharged on Statin Medication
STK-8 Stroke Education
VTE-1 Venous Thromboembolism Prophylaxis
VTE-2 ICU Venous Thromboembolism Prophylaxis
VTE-3 VTE Patients with Anticoagulation Therapy
VTE-5 Warfarin Therapy Discharge Instructions
VTE-6 Hospital Acquired Potentially-Preventable VTE
PC-01 Elective Delivery
ED-1a Mean Time ED Arrival to ED Departure Overall Rate
ED-2a ED Admit Decision Time to ED Departure Overall Rate
IMM-2 Influenza Immunization
OP-1 Hop Mean Time to Fibrinolysis
OP-2 Fibrinolytic Therapy Received within 30 minutes of Arrival
OP-3 Median time to transfer to Another facility for Acute coronary
Intervention
OP-4 Aspirin on Arrival
OP-5 Median time to ECG
OP-18 Median time from Ed Arrival to ED Departure for Discharged ED
Patients
OP-20 Door to diagnositc Evaluation by a Qualified Medical Personnel
OP- 23 Head CT or MRI Scan Results for Acute Ischemic Stroke or
Hemorrhagic Stroke Patients who Received Head CT or MRI Scan
OP-21 Median time to Pain Management for Long Bone Fracture
OP-29 Endoscopy Polyp Surveliance Appropriate Follow up Interval for
Normal Colonoscopy in Average Risk Patients
OP-30 Endoscopy Polyp Surveliance Colonoscopy Interval for Patients with
a History of Adenomatous Polyps Avoidance of Inappropriate use
Chart Abstracted Only Facilities
MO-14-37-PR
AMI-2 Aspirin Prescribed at Discharge
HF-1 All Discharge Instructions
HF-3 ACEI or ARB for LVSD
SCIP-Inf-6 Appropriate Hair Removal
OP-6 Hop Surgery Timing of Antibiotic Prophylaxis
OP-7 Hop Surgery Antibiotic Selection
Data on quality measures are collected in a variety of ways, Chart Abstracted Only Facilities are facilities that are
not participants in the Electronic Clinical Quality Meaure (eCQM) program.
Healthcare Business Solutions
2015
CMS Voluntary Submitted Measures
Supported Through September 30, 2015 Discharges
AMI-1 Aspirin at Arrival
AMI-3 ACE or ARB for LVSD
AMI-5 Beta Blocker Prescribed at Discharge
AMI-8 AMI Mean time to Primary PCI
AMI-8a Primary PCI Within 90 Minutes of Arrival
HF-2 Evaluation of LVS Function
PN-6 Antibiotic Selection for ICU/non-ICU Patients
PN-6a-Antibiotic Selection for ICU Patients
PN-6b Antibiotic Selection for Non-ICU Patients
SCIP-Inf-1a Antibiotic Within One Hour of Incision-Overall
SCIP-Inf-2a Antibiotic Selection-Overall
SCIP-Inf-3a Antibiotic Discontinued Within 24 Hours of Anesthesia End Time-Overall
SCIP-Inf-9 Urinary Catheter Removed POD1 or POD2
SCIP-CARD-2 Beta Blocker Prior to Admission and Periop
SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24
Hours Prior to Ansthesia End Time to 24 hours After Anesthesia End Time
STK-2 Discharged on Antithrombotic Therapy
STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-5 Antithrombotic Therapy By End of Hospital Day 2
STK-10 Assessed for Rehabilitation
VTE-4 Patients Receiving UFH with Dosage/Platelet Monitoring
CMS will continue voluntary collection of these measures to support quality improvement efforts through
September 30, 2015 discharges. These measures will be removed from the Specifications Manual, Version 4.5,
which will be posted April 1, 2015, effective beginning with October 1, 2015 discharges. These will be accepted by
CMS as Chart Abstracted Measures.
Chart Abstracted Only Facilites: Data on quality measures are collected in a variety of ways, Chart Abstracted
Only Facilities are facilities that are not participants in the Electronic Clinical Quality Meaure (eCQM) program.
Healthcare Business Solutions
2015
TJC Chart-Abstracted Only Facilities
January 2015 Discharges
Required Measure Sets
Removed Measure Sets
AMI-7a Fribolysis therapy within 30 min of arrival
SCIP INF-4 Cardiac Patients with Cotrolled Post-op Glucose
STK-1 VTE Prophylaxis
STK-2 Discharged on Antithrombotic Therapy
STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-4 Thrombolitic Therapy
STK-5 Antithrombotic Therapy by End of Hospital Day 2
STK-6 Discharged on Statin Medication
STK-8 Stroke Education
STK-10 Assessed for Rehabilitation
VTE-1 Venous Thromboembolism Prophylaxis
VTE-2 ICU Venous Thromboembolism Prophylaxis
VTE-3 VTE Patients with Anticoagulation Therapy
VTE-5 Warfarin Therapy Discharge Instructions
VTE-6 Hospital Acquired Potentially-Preventable VTE
ED-1a Mean Time ED Arrival to ED Departure Overall Rate
ED-2a ED Admit Decision Time to ED Departure Overall Rate
IMM-2 Influenza Immunization
PC-01 Elective Delivery Prior to 39 Weeks Gestation
PC-02 Cesarean Section
PC-03 Antenatal Steroids
PC-04 Health Care-Associated Bloodstream Infection in Newborns
PC-05 Exclusive Breast Milk Feeding
CAC-3 home Management Plan of Care (HMPC) Document Given to
Patient/Caregiver
HBIPS-1 Admission Screening for Violence Risk, Substance Abuse,
Psychological Trauma history and Patient Strenghts Completed
HBIPS-2 Hours of Physical Restraint Use
HBIPS-3 Hours of Seclusion Use
HBIPS-4 Patients Discharged on Multiple Antipsychotic Medications
HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with
Appropriate Justification
HBIPS-6 Post Discharge Continuing Care Plan Created
HBIPS-7 Post Discharge Continuing Care Plan Transmitted to the Next
Level of Care Provider Upon Discharge
OP-1 Hop Mean Time to Fibrinolysis
OP-2 Fibrinolytic Therapy Received within 30 min or Arrival
OP-3 Median time to transfer to Another facility for Acute coronary
Intervention
OP-4 Aspirin on Arrival
OP-5 Median time to ECG
OP-18 Median time from Ed Arrival to ED Departure for Discharged ED
Patients
OP-20 Door to diagnositc Evaluation by a Qualified medical Personnel
OP- 23 Head CT or MRI Scan Results for Acute Ischemic Stroke or
Hemorrhagic Stroke Patients who Received Head CT or MRI Scan
OP-21 Median time to Pain Management for Long Bone Fracture
Chart Abstracted Only
Facilities
AMI-1 Aspirin at Arrival
AMI-2 Aspirin Prescribed at Discharge
AMI-3 ACE or ARB for LVSD
AMI-5 Beta Blocker Prescribed at Discharge
AMI-8 AMI Mean time to Primary PCI
AMI-8a Primary PCI Within 90 Minutes of Arrival
HF-1 All Discharge Instructions
HF-2 Evaluation of LVS Function
HF-3 ACEI or ARB for LVSD
PN-3a Blood Culture 24 Hours Prior to/After Arrival to ICU
PN-6 Antibiotic Selection for ICU/non-ICU Patients
PN-6a-Antibiotic Selection for ICU Patients
PN-6b Antibiotic Selection for Non-ICU Patients
SCIP-CARD-2 Beta Blocker Prior to Admission and Periop
SCIP-Inf-1a Antibiotic Within One Hour of Incision-Overall
SCIP-Inf-2a Antibiotic Selection-Overall
SCIP-Inf-3a Antibiotic Discontinued Within 24 Hours of Anesthesia End
Time-Overall
SCIP-Inf-6 Appropriate Hair Removal
SCIP-Inf-9 Urinary Catheter Removed POD1 or POD2
VTE-4 Patients Receiving UFH with Dosage/Platelet Monitoring
OP-6 Hop Surgery Timing of Antibiotic Prophylaxis
OP-7 Hop Surgery Antibiotic Selection
Data on quality measures are collected in a variety of ways, Chart Abstracted Only Facilities are facilities that are
not participants in the Electronic Clinical Quality Meaure (eCQM) program.
Healthcare Business Solutions
2015
CMS/TJC Requirement Inpatient Crosswalk 2015
Measure
AMI-1
AMI-2
AMI-3
AMI-5
AMI-7
AMI-7a
AMI-8
AMI-8a
AMI-10
ED-1
ED-2
STK-1
STK-2
STK-3
STK-4
STK-5
STK-6
STK-8
STK-10
VTE-1
VTE-2
VTE-3
VTE-4
VTE-5
VTE-6
HF-1
HF-2
HF-3
IMM-1
IMM-2
PN-3a
PN-3b
PN-6
SCIP-Inf-1
SCIP-Inf-2
SCIP-Inf-3
SCIP-Inf-4
SCIP Inf-6
SCIP-Inf-9
SCIP-Card-2
SCIP-VTE-2
Sepsis
SUB-1
Measure Name
Aspirin at Arrival
Aspirin Prescribed at Discharge
ACEI or ARB for LVSD
Beta-Blocker Prescribed at Discharge
Median Time to Fibrinolysis
Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
Median Time to Primary PCI
Primary PCI Received Within 90 Minutes of Hospital Arrival
Statin Prescribed at Discharge
Median Time from ED Arrival to ED Departure for Admitted ED Patients
Decision to Admit Time to ED Departure Time for Admitted ED Patients
Venous Throboembolism (VTE) Prophylaxis
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Atrial Flutter
Thrombolytic Therapy
Antithrombotic Therapy by End of Hospital Day 2
Discharged on Statin Medication
Stroke Education
Assessed for Rehabilitation
Venous Throboembolism (VTE) Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis
Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
Venous Throboembolism Patients Receiving Unfractinated Heparin with
Dosages/Platelet Count Monitoring my Nomogram
Venous Thromboembolism Warfarin Therapy Discharge Instructions
Hospital Acquired Potentially-Preventable Venous Thromboembolism
Discharge Instructions
Evaluation of LVS Function
ACEI or ARB for LVSD
Pneumococcal Immunization
Influenza Immunization
Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital
Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours
of Hospital Arrival
Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic
Received in Hospital
Initial Antibiotic Selectionfor Community Aquired Pneumonia (CAP) in
Immunocompetent Patients
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
Prophylactic Antibiotic Selection for Surgical Patients
Prophylactic Antibiotics Discontinued Within 24 hours After Surgery End Time
Cardiac Surgery Patients with Controlled Postoperative Blood Glucose
Surgery Patients with Appropriate Hair Removal
Urinary Catheter Removed on POD1 or POD2 with Day of Surgery Being Zero
Surgery Patients with Perioperative Beta-Blocker Therapy Prior to Arrival Who
Received a Beta-Blocker During the Perioperative Period
Surgery Patients Who Received Appropriate Venous Thromboembolism
Prophylaxis Within 24 Hours Prior to Ansthesia End Time to 24 hours After
Anesthesia End Time
Severe Sepsis and Septic Shock: Management Bundle
Alcohol Use Screening
Hospital IQR Program
CMS
Voluntary*
Removed
Voluntary*
Voluntary*
Removed
Required
Voluntary*
Voluntary*
Removed
Required
Required
Required
Voluntary*
Voluntary*
Required
Voluntary*
Required
Required
Voluntary*
Required
Required
Required
For
The Joint Commission
IPFQR* Program For CMS
Removed
Removed
Removed
Removed
Removed
Required
Removed
Removed
Removed
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Optional to Report
as eCQM
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Voluntary*
Removed
Y
Required
Required
Removed
Voluntary*
Removed
Removed
Required
Required
Required
Removed
Removed
Removed
Removed
Required
Y
Y
Removed
Removed
Removed
Removed
Voluntary*
Removed
Y
Voluntary*
Voluntary*
Voluntary*
Required
Removed
Voluntary*
Removed
Removed
Removed
Required
Removed
Removed
Y
Y
Voluntary*
Removed
Voluntary*
Removed
Suspended
Voluntary
Required
Y
Required
Healthcare Business Solutions
2015
CMS/TJC Requirement Inpatient Crosswalk continued
Measure
Measure Name
Hospital IQR Program
CMS
For
The Joint Commission
SUB-2
Alcohol Use Brief Intervention Provided or Offered
Voluntary
SUB-3
Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge
Voluntary
SUB-4
TOB-1
TOB-2
TOB-3
TOB-4
Voluntary
Voluntary
Voluntary
Voluntary
Voluntary
PC-01
PC-02
PC-03
PC-04
PC-05
CAC-1
CAC-2
Alcohol and Drug Use: Assessing Status after Discharge
Tobacco Use Screening
Tobacco Use Treatment Provided or Offered
Tobacco Use Treatment Provided or Offered at Discharge
Tobacco Use: Assessing Status After Discharge
Admission Screening for Violence Risk, Substance Use, Psychological Trauma
History and Patient Strengths completed
Hours of Physical Restraint Use
Hours of Seclusion Use
Patients Discharged on Multiple Antipsychotic Medications
Patients Discharged on Multiple Antipsychotic Medications with Appropriate
Justifications
Post-Discharge Continuing Care Plan Created
Post-Discharge Continuing Care Plan Transmitted to Next Level of Care Provider
Within Five Days of Discharge
Elective Delivery Prior to 39 Completed Weeks of Gestation
Cesarean Section
Antenatal Steroids
Healthcare Associated Bloodstream Infections in Newborns
Exclusive Breast Milk Feeding
Relievers for Inpatient Asthma
Systemic Corticosteroids for Inpatient Asthma
CAC-3
Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
HBIPS-1
HBIPS-2
HBIPS-3
HBIPS-4
HBIPS-5
HBIPS-6
HBIPS-7
IPFQR* Program For CMS
Optional to Report
as eCQM
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Removed
Removed
Y
Required
Y
Y
KEY
Required
Measure collection is required for either CMS or TJC reporting programs or both.
Removed
Measure collection is not required, and the measure has been removed completely from the specifications manual.
Suspended
Measure collection is not required.
Voluntary*
CMS will continue voluntary collection of these measures to support quality improvement efforts through September 30, 2015 discharges. These measures will be removed from the
Specifications Manual, Version 4.5, which will be posted April 1, 2015, effective beginning with October 1, 2015 discharges.
Voluntary
TJC Hospitals may choose to report.
IPFQR*
Inpatient Psychiatric Facility Quality Reporting Program
Chart
Abstracted
Only Facilities
Data on quality measures are collected in a variety of ways, Chart Abstracted Only Facilites are facilities that are not participants in the Electronic Clinical Quality Meaure (eCQM)
program.
Healthcare Business Solutions
2015
CMS/TJC Requirement Outpatient Crosswalk 2015
Measure
OP-1
OP-2
OP-3b
OP-3c
OP-4a
OP-4b
OP-5a
OP-5b
OP-5c
OP-6
OP-7
OP-18
OP-20
OP-21
OP-23
Measure Name
HOP Mean Time to Fibrinolysis
Fibrinolytic Therapy Received within 30 Minutes
HOP Mean Time to Transfer to Facility for Acute Coronary Intervention
HOP Mean Time to Transfer with Reason for No Fibrinolytics
Aspirin on Arrival
Aspirin on Arrival-AMI
HOP Mean Time to ECG
HOP Mean Time to ECG-AMI
HOP Mean Time to ECG-Chest Pain
Timing of Antibiotic Selection
Antibiotic Selection
Median Time from ED Arrival to ED Departure for Discharged ED Patients
Door to Diagnostic Evaluation by a Qualified Medical Professional
Median Time to Pain Management for Long Bone Fracture
ED-Head or MRI Scan Results for Acute Ischemic or Hemorrhagic Stroke who Received Head CT or MRI Scan
Interpretation within 45 Minutes of Arrival
OPQR Program for CMS
The Joint Commission
Required
Required
Required
Required
Required
Required
Required
Required
Required
Removed
Removed
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Removed
Removed
Required
Required
Required
Required
Required
OP-29
Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients
Required
OP-30
Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History
Required
KEY
Required
Measure collection is required for either CMS or TJC reporting programs or both.
Removed
Measure collection is not required, and the measure has been removed completely from the specifications manual.
Chart
Abstracted
Only Facilities
Data on quality measures are collected in a variety of ways, Chart Abstracted Only Facilites are facilities that are not participants in the Electronic Clinical Quality Meaure (eCQM)
program.
As required and optional measures continue to change, Primaris has the flexibility to absorb your hospital’s changing
needs. Our outsourced quality measures abstraction solution is crafted to your specifications and available on a long-term,
short-term, or interim basis.
Request a proposal today.
1.800.735.6776 | online@primaris.org
Healthcare Business Solutions