Option Year 1
Metrics
January 14, 2014
100 E. Grand Ave., Ste. 360 • Des Moines, IA 50309-1800
Office: 515.283.9330 • Fax: 515.698.5130
www.ihconline.org
Overview
• Goal: To decrease reporting burden for hospitals
• Begins with January 2014 data
• Color coding
• IPOP
• Program is being updated for OY1 data collection. Changes will
be made available later this quarter.
• Each hospital must report separately
• Metric counts
• Current custom metrics will be evaluated individually for
decision on 2014 data collection
• New customs will be assessed individually for relevancy
• NHNS metrics will have an option for self-reporting
Readmissions
Readmissions
Process
Numerator
Denominator
Observed Interactions Where Teach Back is Used by Nurses per the Number of Observations
Number of observations of nurses where teach-back is used to assess understanding Number of observations of nurse teaching
Discharged Patients with Community Providers Included in Post-Discharge Needs Evaluation
Number of patient discharges included in the denominator population that are
Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed patients
compliant with community providers being included in the post-discharge needs
evaluation
Discharged Patients with Follow-up Appointment Scheduled Before Discharge
Number of patient discharges included in the denominator population with follow-up Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed patients
appointment scheduled before discharge in accordance with risk assessment
Discharged Patients Where Critical Information is Shared Appropriately
Number of patient discharges included in the denominator population where critical Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed patients
information is transmitted to the next site of care (e.g. office, LTC, HH)
Outcome
Numerator
Percent of All-Cause, 30-Day Readmissions
Number of patient discharges in the denominator population that meet criteria for
inclusion as a readmission all-cause, 30-day methodology
Denominator
Number of discharges for Acute Care patients reported in the month of discharge
date
CAUTI
CAUTI (Catheter-Associated Urinary Tract Infection)
Process
Numerator
Denominator
Unnecessary Urinary Catheters (Urinary catheters not meeting criteria for appropriate insertion)
Number of patients in the denominator population with new indwelling urinary catheters
inserted without appropriate indication documented at the time of insertion
Number of patients with new indwelling urinary catheter insertions for Acute Care, Skilled
Nursing Care and Swing Bed patients
Efficiency
Numerator
Denominator
Rate of Urinary Catheter Utilization per Patient Day
Number of patient days in the denominator population with urinary catheter in place
Number of patient days for Acute Care, Skilled Nursing Care and Swing Bed patients
Emergency Department Catheter Utilization
Number of indwelling urinary catheter placements in the Emergency Department
Number of patients admitted to Acute Care, Skillled Nursing Care or Swing Bed status
through the Emergency Department
Outcome
Numerator
Denominator
Hospital-Acquired, Catheter-Associated UTI Rate per Catheter Day
Number of hospital-acquired UTIs for patients in the denominator population per NHSN
guidelines
Number of urinary catheter days for Acute Care, Skilled Nursing Care and Swing Bed
patients OR for NHSN-defined units
CLABSI
CLABSI (Central Line-Associated Bloodstream Infection)
Process
Numerator
Denominator
Inpatients with Full Bundle PICC Line and/or Central Line Catheter Insertion Compliance per the Number of patients with PICC Line and/or Central Lines Inserted
Number of patients in the denominator population with full PICC line and/or central line Number of PICC line and/or central line insertions for Acute Care, Skilled Nursing Care
catheter insertion bundle compliance
and Swing Bed patients
Inpatients with Full Bundle PICC Line and/or Central Line Catheter Maintenance Compliance per the Number of Central Line Catheter Days
Number of patients in the denominator population with full PICC line and/or central line Number of PICC line and/or central line insertions for Acute Care, Skilled Nursing Care
maintenance bundle compliance
and Swing Bed patients
Outcome
Numerator
Hospital-Acquired, Central Line-Associated Bloodstream Infection Rate per Catheter Day
Number of hospital-acquired, central line-associated bloodstream infections for the
patients in the denominator population per NHSN guidelines
Denominator
Number of central line catheter days for Acute Care, Skilled Nursing Care and Swing Bed
patients
SSI
SSI (Surgical Site Infection)
Process
Numerator
Denominator
Acute Surgical Inpatients with Full SCIP Compliance per the Number of SCIP Surgical Episodes
Number of surgical inpatients in the denominator population with full surgical infection
prevention bundle compliance for SCIP 1, 2, 3, 9 (CMS IQR)
Number of SCIP 1, 2, 3, 9 inpatient surgical episodes
Outcome – SSI – NHSN Reporting Hospitals – select 4 surgery types from the following:
Numerator
Colon Surgical Site Infection Rate per Inpatient Colon Surgical Episodes
Number of hospital-acquired colon surgical site infections in the denominator population per
NHSN guidelines
Denominator
Number of NHSN-defined colon surgical episodes
Abdominal Hysterectomy Surgical Site Infection Rate per Inpatient Abdominal Hysterectomy Surgical Episode
Number of hospital-acquired abdominal hysterectomy surgical site infections in the denominator Number of NHSN-defined abdominal hysterectomy surgical episodes
population per NHSN guidelines
Hip Replacement Surgical Site Infection Rate per Inpatient Hip Replacement Surgical Episodes
Number of hospital-acquired hip replacement surgical site infections in the denominator
population per NHSN guidelines
Number of NHSN-defined hip replacement surgical episodes
Knee Replacement Surgical Site Infection Rate per Inpatient Knee Replacement Surgical Episodes
Number of hospital-acquired knee replacement surgical site infections in the denominator
population per NHSN guidelines
Number of NHSN-defined knee replacement surgical episodes
Cardiac Surgery Surgical Site Infection Rate per Inpatient Cardiac Surgical Episodes
Number of hospital-acquired cardiac surgery surgical site infections in the denominator
population per NHSN guidelines
Number of NHSN-defined cardiac procedure surgical episodes
SSI (cont)
Outcome - Non-NHSN Reporting Hospitals
Numerator
Denominator
Colon Surgical Site Infection Rate per Inpatient Colon Surgical Episodes
Number of hospital-acquired colon surgical site infections in the denominator population Number of NHSN-defined colon surgical episodes
per NHSN guidelines
Abdominal Hysterectomy Surgical Site Infection Rate per Inpatient Abdominal Hysterectomy Surgical Episode
Number of hospital-acquired abdominal hysterectomy surgical site infections in the
Number of NHSN-defined abdominal hysterectomy surgical episodes
denominator population per NHSN guidelines
Hip Replacement Surgical Site Infection Rate per Inpatient Hip Replacement Surgical Episodes
Number of hospital-acquired hip replacement surgical site infections in the denominator Number of NHSN-defined hip replacement surgical episodes
population per NHSN guidelines
Knee Replacement Surgical Site Infection Rate per Inpatient Knee Replacement Surgical Episodes
Number of hospital-acquired knee replacement surgical site infections in the denominator Number of NHSN-defined knee replacement surgical episodes
population per NHSN guidelines
VAE
VAE (Ventilator-Associated Event)
Process
Numerator
Denominator
Percent of Ventilator Patients with Full Bundle Compliance
Number of ICU patients in the denominator population on mechanical ventilation with full Number of ICU patients on mechanical ventilation on day of week of sample
ventilator-associated prevention bundle compliance
Outcome
Numerator
VAC - All Units*
Number of events that meet VAC criteria
Number of ventilator days
IVAC - All Units*
Number of events that meet IVAC criteria
Number of ventilator days
Possible/Probable VAP Rate - All Units*
Number of events that meet possible/probable criteria
Number of ventilator days
*Hierarchy of definitions
If a patient meets criteria for VAC and IVAC, report as IVAC
If a patient meets criteria for VAC, IVAC and Possible VAP; report as Possible/Probable VAP
If a patient meets criteria for VAC, IVAC and Probable VAP; report as Possible/Probable VAP
If a patient meets criteria for VAC, IVAC, Possible and Probable VAP; report as Probable VAP
Denominator
Adverse Drug Events
ADE (Adverse Drug Events)
Process
Numerator
Denominator
Documented Blood Glucose Values Less Than 50 per Number of Measurements
Number of lab measurements with documented blood glucose <50
Number of patient blood glucose lab measurements
Documented INRs Greater Than 5 for Patients on Warfarin per Number of Measurements
Number of lab measurements with documented INR >5
Number of patient INR lab measurements
Stat Narcan Administered Outside of ED per the Number of Opioids Administered Outside of ED
Number of patients who received an opioid agent – exclude ED patients and
Number of patients in the denominator population treated with opioids who
opioid use for nausea or pruritus
received naloxone (Narcan)
Outcome
Numerator
Denominator
Adverse Drug Event Rate per 1,000 Patient Days
Number of adverse drug events in the denominator population
Number of patient days for Acute Care, Skilled Nursing and Swing Bed patients
AHRQ Statistical Brief #109 - Drug Complication per Inpatient Discharge
Number of adverse drug events that cause harm in the denominator population
Number of Acute Care discharges
Falls
FALLS & IMMOBILITY
Process
Numerator
Denominator
Inpatients Assessed for Fall Risk on Admission per the Number of patient Admissions
Number of patients in the denominator population that are assessed for fall risk on admission
Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patients
Outcome
Numerator
Denominator
Falls Resulting in No Apparent Injury Rate per Patient Day*
Number of patients in the denominator population that have unplanned descent to the floor resulting in no visible sign of
injury, stable vital signs and patient denial or pain or discomfort
Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn
and respite patients
Fall Resulting in Minor Injury Rate per Patient Day*
Number of patients in the denominator population that have unplanned descent to the floor resulting in minor cuts, minor
bleeding, minor skin abrasions, minor swelling and minor contusions or bruising
Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn
and respite patients
Fall Resulting in Moderate Injury Rate per Patient Day*
Number of patients in the denominator population that have unplanned descent to the floor resulting in excessive bleeding,
lacerations requiring sutures, temporary loss of consciousness or moderate head trauma
Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn
and respite patients
Fall Resulting in Major Injury Rate per Patient Day*
Number of patients in the denominator population that have unplanned descent to the floor resulting in fracture, subdural
hematoma, other major head trauma, cardiac arrest or patient requiring transfer to ICU or OR
Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn
and respite patients
Fall Resulting in Death Rate per Patient Day*
Number of patients in the denominator population that have unplanned descent to the floor resulting in death
Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed and Observation patient days - exclude newborn
and respite patients
Count of Assisted Falls
Number of Acute Care, Skilled Nursing Care, Swing Bed and Observation events where the patient is assisted or eased to the floor.
*Do not include patients assisted or eased to the floor
Fall Rate Resulting in Fracture or Dislocation
Number of patient discharges in the denominator population with non-POA, fall-related ICD-9/ICD-10 code with fracture or
dislocation (CMS HAC)
Number of Acute Care discharges
Pressure Ulcers
PRESSURE ULCERS
Process
Numerator
At-risk Inpatients Receiving Full Preventative Pressure Ulcer Care per Number of At-risk Inpatients
Number of at-risk patients in the denominator population receiving full pressure ulcer
preventative care
Denominator
Number of at-risk patients identified for Acute Care, Skilled Nursing Care and Swing Bed
patients
Outcome
Numerator
Denominator
Stage III, IV or Unstageable Pressure Ulcer Rate per Patient Day
Number of patients in the denominator population with non-POA secondary ICD-9/ICD-10 Number of discharges for Acute Care, Skilled Nursing and Swing Bed patients
code(s) for pressure ulcer AND secondary ICD-9/ICD-10 diagnosis code(s) for Stage III,
Stage IV or unstageable pressure ulcer (AHRQ PSI 3)
Stage II, III, IV or Unstageable Pressure Ulcer Rate per Patient Day
Number of patients in the denominator population with non-POA secondary ICD-9/ICD-10 Number of discharges for Acute Care, Skilled Nursing and Swing Bed patients
code(s) for pressure ulcer AND secondary ICD-9/ICD-10 diagnosis code(s) for Stage II, III,
Stage IV or unstageable pressure ulcer (adapted AHRQ PSI 3)
OB
Obstetrical Adverse Events
Process
Numerator
Denominator
Compliance Rate for Elective Induction Bundle
Number of patients in the denominator population with full elective labor induction
bundle compliance
Number of patients who have delivered and received oxytocin for elective induction
of labor
Outcome
Numerator
Denominator
Patients with Elective Deliveries Between 37-39 weeks per Patients Delivering Newborns From 37 - 39 Weeks Gestation
Number of elective maternal deliveries between 37-39 weeks gestation with no medical All deliveries between 37-39 weeks gestation
indication
OB (cont)
Obstetrical Adverse Events (cont)
Primary Cesarean Delivery Rate, Uncomplicated
Number of maternal inpatients with either MS-DRG code for Cesarean delivery or any-listed ICD-9/ICD-10 procedure code(s)
for Cesarean delivery without any-listed ICD-9/ICD-10 procedure code(s) for hysterotomy (AHRQ IQI 33)
Number of deliveries
Peripartum Hysterectomy Rate in Women With Placenta Previa
Number of peripartum hysterectomies in women with placenta previa and/or placenta accreta/percreta
Number of deliveries
Peripartum Hysterectomy Rate in Women Without Placenta Previa
Number of peripartum hysterectomies in women without placenta previa and/or placenta accreta/percreta
Number of deliveries
Birth Trauma Rate - Injury to Newborn
Number of Newborns with ICD-9/ICD-10 code(s) for birth trauma (AHRQ PSI 17)
Number of Newborns
Obstetrical Trauma Rate - Vaginal Delivery With Instrument
Number of vaginally-delivering, instrument-assisted Moms with ICD-9/ICD-10 code(s) for 3rd or 4th degree obstetric trauma
(AHRQ PSI 18)
Number of vaginal deliveries with ICD-9 procedure code(s) for instrument-assisted delivery
Obstetrical Trauma Rate - Vaginal Delivery Without Instrument
Number of vaginally-delivering, non instrument-assisted Moms with ICD-9/ICD-10 code(s) for 3rd or 4th degree obstetric
trauma (AHRQ PSI 19)
Number of vaginal deliveries without ICD-9 procedure code(s) for instrument-assisted delivery
Obstetrical Trauma Rate - Composite - UNDER DEVELOPMENT
Number of maternal inpatients with one or more of the following outcomes:
Extended postpartum length of stay (> 3 days for vaginal delivery/> 5 days for Cesarean delivery)
Transfer to ICU
Transfer to acute care hospital
Stroke
Seizure
Renal failure/kidney problems
Pumonary edema
Aspiration pneumonia
Placental abruption
Any blood transfusion
Cardiac arrhythmia
Resuscitation
Amniotic fluid embolism
Deep vein thrombosis
Number of deliveries
VTE
VTE (Venous Thromboembolism)
Process
Numerator
Percent of Inpatients VTE Appropriate Prophylaxis
Number of patients in the denominator population identified as at risk for VTE who
received appropriate prophylaxis or have documentation why no VTE prophylaxis was
given within 24 hours of hospital admission or surgery end time (CMS VTE 2)
Denominator
Number of patients admitted to Acute Care, Skilled Nursing Care or Swing Bed with
stays of >48 hours
Outcome
Numerator
Denominator
Inpatients Who Develop VTE per the Number Inpatient Discharges
Number of patients in the denominator population with non-POA secondary ICD-9/ICD-10 Number of discharges for Acute Care, Skilled Nursing and Swing Bed patients
code(s) for DVT or PE (AHRQ PSI 12)
Rate of Potentially Preventable Venous Thromboembolism
Number of patients in the denominator population who received no VTE prophylaxis prior Number of confirmed VTEs during hospitalization for Acute Care, Skilled Nursing Care
to VTE diagnostic test order date (CMS VTE 6)
and Swing Bed patients
Safety Across the Board
Safety Across the Board
Patient Safety for Selected Indicators - AHRQ PSI 90
The weighted average of the observed-to-expected ratios for the following component indicators:
PSI #3 - Pressure Ulcer Rate
PSI #6 - Iatrogenic Pneumothorax Rate
PSI #7 - Central Venous Catheter-Related Blood Stream Infection Rate
PSI #8 - Postoperative Hip Fracture Rate
PSI #9 - Perioperative Hemorrhage or Hematoma Rate
PSI #10 - Postoperative Physiologic and Metabolic Derangement Rate
PSI #11 - Postoperative Respiratory Failure Rate
PSI #12 - Perioperative Pulmonary Embolus or Deep Vein Thrombosis
PSI #13 - Postoperative Sepsis Rate
PSI #14 - Postoperative Wound Dehiscence Rate
PSI #15 - Accidental Puncture or Laceration Rate
Denominator
Numerator
Death Rate among Surgical Inpatients with Serious Treatable Complications
Death rate determined for each of these serious treatable conditions include: Pneumonia, pulmonary embolism or deep vein thrombosis, sepsis, shock or
cardiac arrest or gastrointestinal hemorrhage/acute ulcer. (AHRQ PSI 4)
Number of deaths for patients in the denominator population
Number of surgical discharges for inclusion/exclusion criteria:
Age 18 - 89
MDC 14 (pregnancy, childbirth and puerperium
Selected list of surgical ICD-9 procedures
Principal procedure occurring within 2 days of admission or admission
type elective
Principal procedure occurring within 2 days of admission or admission
type elective
AHRQ Never Event Composite - UNDER DEVELOPMENT
CMS HAC Rate Composite - UNDER DEVELOPMENT
Thank You
100 E. Grand Ave., Ste. 360 • Des Moines, IA 50309-1800
Office: 515.283.9330 • Fax: 515.698.5130
www.ihconline.org