K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals
AEA
Minimum Participation
Full Participation1
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives
2 points (not 3 points).
Maximum = 22 points
Outcome Measure for Any
One of the Following:
Anticoagulant
Opioid
Glucose Control
An overall measure of
ADEs
A) Related to all three of:
anticoagulant, opioid, and
glucose control
OR
B) Related to two of
anticoagulant, opioid, and
glucose control
AND
A measure of overall
ADEs or a different highfrequency ADE
Outcome Measure Including:
At least one outcome measure
meeting either A or B:
All falls with or without
Injury
A) All falls AND Injuries
from Falls and Trauma
(MCR FFS CMS HAC)
OR
B) All falls with injury (not
limited to subset of
patients with severe
injuries)


Adverse Drug Events
(ADE)
Falls
1
Outcome Measures Meeting
Either A or B:


Includes either submission or attestation that at least one corresponding process measure is being collected per AEA with the exception of EED which is a
required process measure for birthing hospitals
K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals
AEA
Minimum Participation
Full Participation1
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives
2 points (not 3 points).
Maximum = 22 points
Outcome Measure Meeting A:
Obstetrical – Earl Elective
Deliveries
(OB-EED)
Other Obstetrical
(OB-Other)
Pressure Ulcers
(PrU)
2
A) Joint Commission PC-01
Outcome Measures Meeting
A or B:
Outcome Measures Meeting
A and B:
A) At least two of: AHRQ
PSIs 17, 18, and 192
OR
B) Reporting Obstetrical
hemorrhage and
preeclampsia treatment
and management to
prevent morbidity and
mortality)
A) At least two of: AHRQ
PSIs 17, 18, and 19
AND
B) Reporting Obstetrical
hemorrhage and
preeclampsia treatment
and management to
prevent morbidity and
mortality)
Outcome Measure Including:
Outcome Measure Including:
Stage 3 and higher PrUs
Stage 2 and higher PrUs
AND
Stage 3 and greater PrUs
subset
PSI 17 – Birth Trauma Rate – Injury to Neonate; PSI 18 – Obstetric Trauma Rate – Vaginal Delivery With Instrument; PSI 19 – Obstetric Trauma Rate –
Vaginal Delivery without Instrument
K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals
AEA
Minimum Participation
Full Participation1
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives
2 points (not 3 points).
Maximum = 22 points
Surgical Site Infections
(SSI)
Outcomes Measures for 2 or
More of the Following
(separately or combined):
 Colon
 Hysterectomy
 Knee Replacement
 Hip Replacement
 Cardiac Surgeries (may be
specific to a common
subset of cardiac surgeries
such as Coronary Artery
Bypass Graft [CABG])
Outcomes Measures for 4 or
More of the Following
(separately or combined):
 Colon
 Hysterectomy
 Knee Replacement
 Hip Replacement
 Cardiac Surgeries (may be
specific to a common
subset of cardiac surgeries
such as CABG)
K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals
AEA
Minimum Participation
Full Participation1
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives
2 points (not 3 points).
Maximum = 22 points
Ventilator-Associated
Events
(VAE)
Adults Only
Outcome Measure Meeting A
or B:
Outcome Measures Meeting
A and B:
A) NHSN-defined
Ventilator-acquired
conditions (VACs) alone
(“respiratory status
component”) (ICU Only
or All Units)
OR
B) At least one of:
 Infection-related
Ventilator-Associated
Complication (IVACs)
(“infection/ inflammation
component”) (ICU Only
or All Units)
 Possible or Probable VAP
(ICU Only or All Units)
A) NHSN-defined
Ventilator-acquired
conditions (VACs) alone
(“respiratory status
component”) (ICU Only
and All Units)
AND
B) At least one of:
 Infection-related
Ventilator-Associated
Complication (IVACs)
(“infection/ inflammation
component”) (ICU Only
and All Units)
 Possible or Probable VAP
(ICU Only and All Units)
K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals
AEA
Minimum Participation
Full Participation1
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives
2 points (not 3 points).
Maximum = 22 points
Catheter-Associated
Urinary Tract Infection
(CAUTI)
Outcome Measure Meeting A
or B:
Outcome Measures Meeting
A and one of B:
A) NHSN/NDNQI CAUTI
Rate (ICU)
OR
B) NHSN/NDNQI CAUTI
Rate (All units)
A) NHSN/NDNQI CAUTI
Rate including both:
 ICU/NICU
 General units (including
specialty units) measured
separately and/or
combined
B) A catheter utilization
measure
 A utilization ratio
(catheter days per 10,000
patient days, or similar
with other denominator)
OR
 ED Catheterization rate
K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals
AEA
Minimum Participation
Full Participation1
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives
2 points (not 3 points).
Maximum = 22 points
Outcome Measure:


Central Line Associated
Blood Stream Infection
(CLABSI)
NHSN/NDNQI CLABSI
Rate ICU/NICU only
OR
Days since last CLABSI
Outcome Measures Meeting
A and B:
A) NHSN/NDNQI CLABSI
Rate including all:
 ICU/NICU
 General units (including
specialty units) measured
separately and/or
combined
 For larger hospitals, a
utilization ratio (central
line days per 10,000
patient days)
AND
B) Other HEN-defined
measure that applies to
small hospitals (<100
beds) (e.g., days since last
CLABSI)
Note: For larger hospitals,
measurement of house-wide
CLABSI rate may use an
alternative specification, such
as a measure with
denominator of patient days.
K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals
AEA
Minimum Participation
Full Participation1
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives
2 points (not 3 points).
Maximum = 22 points
Venous Thromboembolism
(VTE)
Outcome Measure meeting
either A or B:
Outcome Measures Meeting
A and B:
A) AHRQ PSI-12
OR
B) Potentially preventable
VTE Rate (meaningful
use or CMS definition,
VTE-6)
B) AHRQ PSI-12
AND
C) Potentially preventable
VTE Rate (meaningful
use or CMS definition,
VTE-6)
K-HEN Acute Care/Critical Access Hospitals Measures Alignment with PfP 40/20 Goals
AEA
Minimum Participation
Full Participation1
Note: HENs receives points for one level or another. That is, if a HEN meets the 2-point criteria and the 1-point criteria, the HEN receives
2 points (not 3 points).
Maximum = 22 points
Outcome Measures:
Only diagnosis-specific
readmission rates
Readmissions
Outcome Measures Meeting
A and B:
A) Broad measure, including
any of the following:
 30-day all payer all cause
readmissions
 30-day potentially
preventable readmissions
 An observed-to-expected
ratio of 30-day
readmissions for all
payers.
AND
B) HEN indicates if measure
counts only readmissions
to the hospital of the
index admission or to any
hospital; and any
exclusions (e.g. planned
readmissions) used