Partnership for Patients (PfP) Hospital Engagement Network (HEN)
Iowa Healthcare Collaborative (IHC) Metric and Measurement Toolkit
March 2014 Version 3.0
http://www.ihconline.org
515.283.9330
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 1
Table of Contents
INTRODUCTION ................................................................................................................................... 3
LOGON AND REGISTRATION SCREEN ..................................................................................... 5
WELCOME SCREEN ........................................................................................................................... 6
METRIC SELECTION SCREEN ...................................................................................................... 7
DATA ENTRY SCREEN ...................................................................................................................... 8
RUNNING REPORTS ........................................................................................................................... 9
FOCUS AREA METRICS .................................................................................................................. 10
FOCUS AREA MEASURE DEFINITIONS ................................................................................... 11
READMISSIONS (APP I) ................................................................................................................................... 11
CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (APP II) ........................................................ 13
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (APP III) .................................................... 15
SURGICAL SITE INFECTIONS (APP IV) ........................................................................................................ 17
VENTILATOR-ASSOCIATED EVENTS (APP V) ............................................................................................ 19
ADVERSE DRUG EVENTS (APP VI) .............................................................................................................. 21
FALLS & IMMOBILITY ..................................................................................................................................... 23
PRESSURE ULCERS (APP VII)........................................................................................................................ 25
OBSTETRICAL ADVERSE EVENTS (APP VIII/IX) ...................................................................................... 26
VENOUS THROMBOEMBOLISM (APP X) ...................................................................................................... 28
SAFETY ACROSS THE BOARD (GREEN) .................................................................................................... 29
APPENDICES ........................................................................................................................................ 30
APPENDIX I ........................................................................................................................................................ 31
APPENDIX II ....................................................................................................................................................... 32
APPENDIX III ..................................................................................................................................................... 34
APPENDIX IV ..................................................................................................................................................... 35
APPENDIX V ...................................................................................................................................................... 37
APPENDIX VI ..................................................................................................................................................... 38
APPENDIX VII ................................................................................................................................................... 39
APPENDIX VIII .................................................................................................................................................. 40
APPENDIX IX ..................................................................................................................................................... 41
APPENDIX X ...................................................................................................................................................... 42
APPENDIX XI ..................................................................................................................................................... 43
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Introduction
In the first two years of the HEN, IHC and the Iowa Hospital Association built a web-based PfP
HEN Reporting Database to track and monitor progress towards the 2014 PfP Aims, 40%
reduction in Hospital-acquired Conditions and 20% reduction in readmissions (40/20/14). This
PfP Reporting Database design supports the improvement work of the network hospitals and
allows for hospitals to monitor trends in Process and Outcomes measures.
The Reporting Database allows identified hospital leadership (e.g. – Quality Improvement
Advisor, Data Improvement Advisor) to securely/privately enter hospital performance metric
data and quality improvement (QI) project data. Importantly, the database serves as a Quality
Measurement and Reporting system (QMRS) for the HEN program. The database requires
hospital staff to login and complete and update work plans for all 10 PfP focus areas. The work
plan captures the project lead, clinical lead, physician lead, and front-line staff champion for all
10 focus areas. Also within the database, hospitals select the process and outcome metrics that
are reported for the 10 PfP focus areas. Hospitals, along with support from their Improvement
Advisor, continuously update the work plan throughout OY1 (Option Year 1) as interventions
are implemented, goals are attained, and improvements are made to their focus area work. The
database continuously captures the submission of monthly process and outcome measures for the
focus areas.
The database is populated with monthly hospital-specific numerator/denominator information. In
OY1, the HEN will use a three-pronged approach to expand reporting methodologies to include
manual data entry, uploaded results of grouping methodologies applied to statewide database
(SID) and data obtained from hospitals that confer rights of their data from CDC NHSN.
Hospital staff can access on-demand control charts after completing monthly data entry
requirements. Results for each of the process and outcome metrics allow visual display that
includes denominator results and a +1 standard deviation control. These control charts are a vital
tool that can be shared during hospital team meetings to track and to drive clinical improvement
efforts.
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 3
The Reporting Database allows IHC HEN Improvement Advisors and hospital HEN to
accomplish a variety of project management functions. The database allows IHC to assist
hospital project management designees in monitoring and tracking data management and
improvement activities. The IHC staff utilizes the database reporting functions to communicate
program performance to hospital leadership and designees. And, the IHC staff uses the database
to support IHC HEN contract program management and reporting functions.
The IHC HEN has evaluated measurements that align with the national 40/20/14 goals.
Historically, the IHC HEN encouraged the use of broad measures to generate the 40/20 reduction
across the network. However, based on two years of learning, some of the measure populations
currently being used by the IHC HEN are too narrow or not adequately defined. The evidence
suggests that broader measures should be used to further our progress to the 40/20/14 goals. In
order to align with national goals, the IHC HEN has proposed changes in the measures,
specifically in outcome metrics.
Monthly data are due 45 days after the end of a month



Self-reported measures must be entered into the IHC PfP HEN data collection tool
explained in this document.
Statewide database (SID – statewide inpatient database, SOD – statewide outpatient
database) statistics will be aggregated each month with available information. Monthly
control charts will be refreshed during an open quarter until verified quarterly data are
ready. Hospital contacts are encouraged to work with inpatient/outpatient data
submission personnel in their facilities in order to make results available in a timely
manner.
NHSN metrics that are conferred to IHC and entered within 45 days after the end of a
month will be downloaded for inclusion into control charts. Monthly control charts will
be refreshed during any subsequent month.
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Logon and Registration Screen
Log in using full email address as username and the secure password set up on registration.
Password is cap sensitive.
A forgot password feature is available if necessary. Enter email address into the field designated,
click on Send Password and current password will be automatically emailed to that address.
New users may register by following the New User Registration prompts. A confirmation email
will alert user when access is confirmed.
To access the PfP Hen Reporting Tool go to:
http://pfp.ihconline.org/
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 5
Welcome Screen
The Welcome screen allows the user:
 Access to select metrics for open months
 Access for entry of data in open months
 Informational messaging on monthly data entry status
 Access to run/control charts
 Access to the PfP Reporting Toolkit
 Ability to open an Outlook episode for help on the program
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Metric Selection Screen
Hospitals are required to report on at least 1 process and at least 1 outcome measure for
each of the 10 focus areas that match their service delivery (e.g. – hospitals that do not
deliver babies are excluded from the requirement to submit on OB Adverse Events). To
select the metrics, each hospital will determine their options. Mark the checkbox to the left of
the desired metrics. Choices will be continued in any subsequent month but changes to reporting
options are available at any time.
For a list of the metrics see pages 10 – 23.
Navigation buttons at the top and bottom of the page include:
 Save/Return Home – saves any changes and takes user back to the Welcome page
 Save/Enter Data – saves any changes and takes user to the data entry page
 Return Home – does not save changes and takes user to the Welcome page
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 7
Data Entry Screen
General rules applying to all metrics:
 All facilities must select at least 1 process and at least 1 outcome measure per focus area
 Interventions may be entered for each month in which they occur (NOTE: this
information will appear on reports)
 Fields are numeric only. Do not use decimals or characters
 Edits will apply only upon selection of Complete Month
 Discharges are reported in the month of the discharge date
Navigation buttons at the top and bottom of the page include:
 Save Data – saves any changes and user remains on data entry page
 Save Data/Return Home – saves any changes and takes user to the Welcome page
 Run Edits – applies system edits against all fields and returns data entry problems
 Complete Month – saves all changes, communicates that data entry is done for the month,
runs edits and takes user to the Welcome page if no data issues are found. If edits are
highlighted, they must be corrected in order to save data entered
Closing a month for data inclusion on monthly control charts
 All data are due 45 days after the end of a month to be included in that month’s control
charts
 “Complete Month” must be selected and all edits corrected in order to be included in
monthly control charts
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Running Reports
Running Reports – Select View Run Charts on the Welcome page to generate hospital-specific
report.
 On-demand reports display monthly data points for completed months with 1 Standard
Deviation control
 Statewide comparative results are shown for quarterly verified data
 Report questions or concerns to your Improvement Advisor if you have issues
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 9
Focus Area Metrics
The 10 focus areas include:
 Readmissions
 CAUTI (Catheter-Associated Urinary Tract Infections)
 CLABSI (Central Line-Associated Bloodstream Infections)
 SSI (Surgical Site Infections)
 VAE (Ventilator-Associated Events)
 Falls & Immobility
 Pressure Ulcers
 ADE (Adverse Drug Events)
 VTE (Venous Thromboembolism)
 Obstetrical Adverse Events
In an effort to minimize the reporting burden, additional data resources will be employed. For
pages 10 – 23, color-coded metric definitions are explained:
 BLUE – self-reported (monthly numerator and denominator entered into PfP HEN
reporting tool),
 GREEN – added from statewide databases (SID/SOD – inpatient and outpatient)
 PURPLE – added from NHSN.
SELF-REPORTED
SID
NHSN
For metrics using the statewide databases, hospitals are encouraged to submit monthly data by 45
days after the end of each month. Point-in-time data results will be populated to each applicable
area and data points will be displayed, if available, on the monthly control charts. During an
open quarter, provisional results will be refreshed each month. Finalized, validated data points
will provide comparative results for all participating HEN hospitals.
NHSN metrics must have hospital approval for use in HEN reporting by conferring rights at the
measure level to IHC HEN to be included in control charts. Non-NHSN reporting hospitals or
those who do not confer rights must enter the self-reported process and outcome
numerator/denominator information where appropriate.
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Focus Area Measure Definitions
Readmissions (App I)
Readmissions Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. Observed interactions where teach-back is used by nurses per the number of observations
 Numerator: Number of observations of nurses where teach-back is used to assess
understanding
 Denominator: Number of observations of nurse teaching
2. Discharged patients with community providers included in post-discharge needs
evaluation
 Numerator: Number of patient discharges included in the denominator population
where community providers (e.g. home care, primary care, nurses, skilled nursing)
were included in assessing post discharge needs
 Denominator: Number of discharges for acute care, skilled nursing care and swing
bed patients in the sample
3. Discharged patients with follow-up appointment scheduled before discharge
 Numerator: Number of patient discharges included in the denominator population
with follow-up appointment scheduled before discharge in accordance with risk
assessment
 Denominator: Number of discharges for acute care, skilled nursing care and swing
bed patients in the sample
4. Discharged patients where time critical information is shared appropriately
 Numerator: Number of patient discharges included in the denominator population
where critical information is transmitted to the next site of care (e.g. office, LTC, HH)
or person continuing care
 Denominator: Number of discharges for Acute Care, Skilled Nursing Care and
Swing Bed patients in the sample
IHC HEN suggested resources:
 APPENDIX I – STate Action on Avoidable Re-hospitalizations – STAAR model
 http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/STAAR/Pages/Measures
Results.aspx
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Readmissions Outcome Measures: Data from SID (GREEN)
SID
1. Percent of all-cause, 30-day readmissions
 Numerator: 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
IHC HEN suggested resources:
 IHC HEN and subcontractor IHA developing strategy to provide monthly readmission
rates
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Catheter-Associated Urinary Tract Infections (App II)
CAUTI Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. Unnecessary Urinary Catheters (Urinary catheters not meeting criteria for appropriate
insertion)
 Numerator: Number of patients in the denominator population with new indwelling
urinary catheters inserted without appropriate indication documented at the time of
insertion
 Denominator: Number of patients with new indwelling urinary catheter insertions
for Acute Care, Skilled Nursing Care, Swing Bed, and Observation patients
IHC HEN suggested resources:
 APPENDIX II - Institute for Healthcare Improvement – IHI How-to Guide: Prevent
Catheter-Associated Urinary Tract Infections, page 24 (Login required with free access to
information)
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCatheterAssociatedUrina
ryTractInfection.aspx
CAUTI Efficiency Measures: Data from NHSN or SID
1. Rate of Urinary Catheter Utilization per Patient Day (Data from NHSN, PURPLE)
NHSN


Numerator: Number of indwelling catheter days (per NHSN definition)
Denominator: Number of patient days (per NHSN definition)
2. Emergency Department Catheter Utilization (Data from SID, GREEN)
SID


Numerator: Number of indwelling urinary catheter placements in the Emergency
Department
Denominator: Number of patients admitted to Acute Care, Skilled Nursing Care or
Swing Bed status through the Emergency Department
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IHC HEN suggested resources:
 AMA CPT codes that will be utilized to identify catheters inserted in the Emergency
Department:


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51701
51702
51703
CAUTI Outcome Measure: Data from NHSN (PURPLE) or Self-Reported (BLUE)
SELF-REPORTED
NHSN
1. Hospital-Acquired, Catheter-Associated UTI Rate per Catheter Day


Numerator: Number of hospital-acquired UTIs for patients in the denominator
population per NHSN definition
Denominator: Number of urinary catheter days per NHSN definition
*report housewide or develop housewide reporting capability
IHC HEN suggested resources:
 CDC National Healthcare Safety Network – NHSN Surveillance for Urinary Tract
infections
 http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf
 NHSN Urinary Tract Infection (UTI) Form
 http://www.cdc.gov/nhsn/forms/57.114_UTI_BLANK.pdf
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Central Line-Associated Bloodstream Infection (App III)
CLABSI Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. 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
 Numerator: Number of patients in the denominator population with full PICC line
and/or central line catheter insertion bundle compliance
 Denominator: Number of PICC line and/or central line insertions for Acute Care,
Skilled Nursing Care and Swing Bed patients
2. Inpatients with Full Bundle PICC Line and/or Central Line Catheter Maintenance
Compliance per the Number of Central Line Catheter Days
 Numerator: Number of patients in the denominator population with full PICC line
and/or central line maintenance bundle compliance
 Denominator: Number of patients with PICC line and/or central lines on day of
sample
IHC HEN suggested resources:
 APPENDIX III - CDC Checklist for Prevention of Central Line Associated Blood
Stream Infections
 http://www.cdc.gov/HAI/pdfs/bsi/checklist-for-CLABSI.pdf
 Institute for Healthcare Improvement – IHI How-to Guide: Prevent Central LineAssociated Bloodstream Infections, page 22. (Login required with free access to
information)
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCentralLineAssoc
iatedBloodstreamInfection.aspx
CLABSI Outcome Measures: Data from NHSN (PURPLE) or Self-reported
(BLUE)
SELF-REPORTED
NHSN
1. Hospital-Acquired, Central Line-Associated Bloodstream Infection Rate per Catheter
Day
 Numerator: 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 per NHSN definition
*report housewide or develop housewide reporting capability
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 1
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IHC HEN suggested resources:
 National Healthcare Safety Network – NHSN Surveillance for Central Line-Associated
Bloodstream Infections
 http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
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Surgical Site Infections (App IV)
SSI Process Measure: Self-Reported (BLUE)
SELF-REPORTED
1. Acute Surgical Inpatients with Full SCIP Compliance per the Number of SCIP Surgical
Episodes
 Numerator: Number of surgical patients in the denominator population with full
surgical infection prevention bundle compliance for SCIP 1, 2, 3, 9 (CMS IQR)
 Denominator: Number of SCIP 1, 2, 3, 9 eligible inpatient surgical episodes
IHC HEN suggested resources:
 APPENDIX IV – CMS’ QualityNet Specifications Manual – Select manual with the
most current version, click on Surgical Care Improvement Project (SCIP)
 https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage
%2FQnetTier2&cid=1141662756099
SSI Outcome Measures: NHSN Reporting Hospitals (PURPLE)
NHSN
Select 4 Surgery Types From the Following:
1. Colon Surgical Site Infection Rate per Inpatient Colon Surgical Episodes
 Numerator: Number of hospital-acquired colon surgical site infections in the
denominator population per NHSN guidelines
 Denominator: Number of NHSN-defined colon surgical episodes
2. Abdominal Hysterectomy Surgical Site Infection Rate per Inpatient Abdominal
Hysterectomy Surgical Episode
 Numerator: Number of hospital-acquired abdominal hysterectomy surgical site
infections in the denominator population per NHSN guidelines
 Denominator: Number of NHSN-defined abdominal hysterectomy surgical episodes
3. Hip Replacement Surgical Site Infection Rate per Inpatient Hip Replacement Surgical
Episodes
 Numerator: Number of hospital-acquired hip replacement surgical site infections in
the denominator population per NHSN guidelines
 Denominator: Number of NHSN-defined hip replacement surgical episodes
4. Knee Replacement Surgical Site Infection Rate per Inpatient Knee Replacement Surgical
Episodes
 Numerator: Number of hospital-acquired knee replacement surgical site infections in
the denominator population per NHSN guidelines
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 1
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
Denominator: Number of NHSN-defined knee replacement surgical episodes
5. Cardiac Surgery Surgical Site Infection Rate per Inpatient Cardiac Surgical Episodes
 Numerator: Number of hospital-acquired cardiac surgery surgical site infections in
the denominator population per NHSN guidelines
 Denominator: Number of NHSN-defined cardiac procedure surgical episodes
SSI Outcome Measures: Non-NHSN Reporting Hospitals (BLUE)
SELF-REPORTED
1. Colon Surgical Site Infection Rate per Inpatient Colon Surgical Episodes
 Numerator: Number of hospital-acquired colon surgical site infections in the
denominator population per NHSN guidelines
 Denominator: Number of NHSN-defined colon surgical episodes
2. Abdominal Hysterectomy Surgical Site Infection Rate per Inpatient Abdominal
Hysterectomy Surgical Episode
 Numerator: Number of hospital-acquired abdominal hysterectomy surgical site
infections in the denominator population per NHSN guidelines
 Denominator: Number of NHSN-defined abdominal hysterectomy surgical episodes
3. Hip Replacement Surgical Site Infection Rate per Inpatient Hip Replacement Surgical
Episodes
 Numerator: Number of hospital-acquired hip replacement surgical site infections in
the denominator population per NHSN guidelines
 Denominator: Number of NHSN-defined hip replacement surgical episodes
4. Knee Replacement Surgical Site Infection Rate per Inpatient Knee Replacement Surgical
Episodes
 Numerator: Number of hospital-acquired knee replacement surgical site infections in
the denominator population per NHSN guidelines
 Denominator: Number of NHSN-defined knee replacement surgical episodes
IHC HEN suggested resources:
 APPENDIX IV – CMS’ QualityNet Specifications Manual – Select manual with the
most current version, click on Surgical Care Improvement Project (SCIP)
 https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage
%2FQnetTier2&cid=1141662756099
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Ventilator-Associated Events (App V)
VAE Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. Percent of Ventilator Patients with Full Bundle Compliance
 Numerator: Number of ICU patients in the denominator population on mechanical
ventilation with full ventilator-associated prevention bundle compliance
 Denominator: Number of ICU patients on mechanical ventilation on day of week of
sample
IHC HEN suggested resources:
 APPENDIX V – Institute for Healthcare Improvement – IHI How-to Guide: Prevent
Ventilator-Associated Pneumonia, page 27. (Login required with free access to
information)

http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventVAP.aspx
VAE Outcome Measures: Data from NHSN (PURPLE)
NHSN
1. VAC - All Units*
 Numerator: Number of events that meet VAC criteria
 Denominator: Number of ventilator days
2. IVAC - All Units*
 Numerator: Number of events that meet IVAC criteria
 Denominator: Number of ventilator days
3. Possible/Probable VAP Rate - All Units*
 Numerator: Number of events that meet possible/probable criteria
 Denominator: 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
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IHC HEN suggested resources:
 National Healthcare Safety Network – NHSN Surveillance for Ventilator-Associated
Events
 http://www.cdc.gov/nhsn/acute-care-hospital/vae/
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Adverse Drug Events (App VI)
ADE Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. *Documented Blood Glucose Values Less Than 50 per Number of Measurements
 Numerator: Number of documented blood glucose <50 in the denominator
population
 Denominator: Number of Acute Care, Skilled Nursing Care, Swing, and Observation
patient blood glucose measurements (per lab reports/POCT, EMR, Charge Data, etc)
2. *Documented INRs Greater Than 5 for Patients on Warfarin per Number of
Measurements
 Numerator: Number of lab measurements in the denominator population with
documented INR >5 for patients on Warfarin
 Denominator: Number of Acute Care, Skilled Nursing Care, Swing Bed and
Observation patient INR lab measurements for patients on Warfarin
3. *, **Stat Narcan Administered Outside of ED per the Number of Opioids Administered
Outside of ED
 Numerator: Number of episodes when a reversal agent (e.g. naloxone) is
administered to a patient in the denominator population who is prescribed opioids
 Denominator: Number of Acute Care, Skilled Nursing Care, Swing Bed and
Observation patients prescribed opioids (all opioid formulations) – exclude ED
patients and opioid use for nausea or pruritus
*ADE Process measures for Blood Glucose, INR and Opioids are a surrogate measure for
measuring harm. These measures may include an Adverse Drug Event (ADE) or Potential
Adverse Drug Event (pADE). It is critical that the HEN team evaluate all data and assess
level of harm according to the NCC-MERP scale.
**This measure will be reported as a rate.
IHC HEN suggested resources:
 National Action Plan for Adverse Drug Event (ADE) Prevention
 http://www.health.gov/hai/ade.asp
 Institute for Safe Medication Practices (ISMP) – Improving Medication Safety with
Anticoagulant Therapy
 http://www.ismp.org/tools/anticoagulanttherapy.asp
 American Society of Health-System Pharmacists – Professional Practice
Recommendations for Safe Use of Insulin in Hospitals Adverse Drug Reaction (ADR)
definition
 http://www.ashp.org/s_ashp/docs/files/Safe_Use_of_Insulin.pdf
 American Society for Pain Management Nursing Guidelines on Monitoring for OpioidInduced Sedation and Respiratory Depression
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 2
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
http://www.aspmn.org/Organization/documents/GuidelinesonMonitoringforOpioi
d-InducedSedationandRespiratoryDepression.pdf
ADE Outcome Measures: Self-Reported (BLUE)
SELF-REPORTED
1. Adverse Drug Event Rate per 1,000 Patient Days
 Numerator: Number of adverse drug events in the denominator population
 Denominator: Number of patient days for Acute Care, Skilled Nursing, Swing Bed
and Observation patients
ADE Outcome Measures: SID (GREEN)
SID
1. AHRQ Statistical Brief #164 - Drug Complication per Inpatient Discharge
 Numerator: Number of adverse drug events that cause harm in the denominator
population
 Denominator: Number of Acute Care, Skilled Nursing Care and Swing Bed
discharges
IHC HEN suggested resources:
 Agency for Healthcare Research and Quality (AHRQ) – H-CUP’s Medication-Related
Adverse Outcomes in U.S. Hospitals and Emergency Departments
 http://www.hcup-us.ahrq.gov/reports/statbriefs/sb109.jsp
 National Coordinating Council for Medication Error Reporting and Prevention – About
Medication Errors
 http://www.nccmerp.org/medErrorCatIndex.html
 APPENDIX VI – Medication Therapy Intervention & Safety Documentation Program
User Manual (v 7.0), pages 8-9. Adverse Drug Reaction (ADR) definition:
 http://www.ihconline.org/UserDocs/Pages/USC-Medication-TherapyIntervention-and-Documentation-Manual--Updated-4-6-2012.pdf
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Falls & Immobility
Fall & Immobility Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. Inpatients Assessed for Fall Risk on Admission per the Number of patient Admissions
 Numerator: Number of patients in the denominator population that are assessed for
fall risk on admission
 Denominator: Number of patients admitted to Acute Care, Skilled Nursing Care,
Swing Bed and Observation
Fall & Immobility Outcome Measures: Self-Reported (BLUE)
SELF-REPORTED
(*) Do not include patients assisted or eased to the floor
1. Falls Resulting in No Apparent Injury Rate per Patient Day*
 Numerator: 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
 Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing
Bed and Observation patient days - exclude newborn and respite patients
2. Fall Resulting in Minor Injury Rate per Patient Day*
 Numerator: 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
 Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing
Bed and Observation patient days - exclude newborn and respite patients
3. Fall Resulting in Moderate Injury Rate per Patient Day*
 Numerator: 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
 Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing
Bed and Observation patient days - exclude newborn and respite patients
4. Fall Resulting in Major Injury Rate per Patient Day*
 Numerator: 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
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 2
3

Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing
Bed and Observation patient days - exclude newborn and respite patients
5. Fall Resulting in Death Rate per Patient Day*
 Numerator: Number of patients in the denominator population that have unplanned
descent to the floor resulting in death
 Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing
Bed and Observation patient days - exclude newborn and respite patients
6. Count of Assisted Falls
 Count: Number of Acute Care, Skilled Nursing Care, Swing Bed and Observation
events where the patient is assisted or eased to the floor
Fall & Immobility Outcome Measures: SID (GREEN)
SID
1. Fall Rate Resulting in Fracture or Dislocation
 Numerator: Number of patient discharges in the denominator population with nonPOA, fall-related ICD-9/ICD-10 code with fracture or dislocation (CMS HAC)
 Denominator: Number of Acute Care discharges
IHC HEN suggested resources:
 Institute for Healthcare Improvement – IHI Transforming Care at the Bedside How-to
Guide: Reducing Patient Injuries from Falls (Login required with free access to
information)
 http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientI
njuriesfromFalls.aspx
 CMS’ Hospital-Acquired Conditions - Falls
 http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/Hospital-Acquired_Conditions.html
Revised March 2014.V3.0
24
Pressure Ulcers (App VII)
Pressure Ulcers Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. At-risk Inpatients Receiving Full Preventative Pressure Ulcer Care per Number of At-risk
Inpatients
 Numerator: 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
IHC HEN suggested resources:
 APPENDIX VII – Institute for Healthcare Improvement – IHI How-to Guide: Prevent
Pressure Ulcers (Login required with free access to information)
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx
Pressure Ulcers Outcome Measures: SID (GREEN)
SID
1. Stage III, IV or Unstageable Pressure Ulcer Rate per Patient Day
 Numerator: Number of patients in the denominator population with non-POA
secondary ICD-9/ICD-10 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)
 Denominator: Number of discharges for Acute Care, Skilled Nursing and Swing Bed
patients
2. Stage II, III, IV or Unstageable Pressure Ulcer Rate per Patient Day
 Numerator: Number of patients in the denominator population with non-POA
secondary ICD-9/ICD-10 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)
 Denominator: Number of discharges for Acute Care, Skilled Nursing and Swing Bed
patients
IHC HEN suggested resources:
 Agency for Healthcare Research and Quality (AHRQ) – Pressure Ulcer Rate Technical
Specifications
 http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/TechSpecs/PSI%20
03%20Pressure%20Ulcer%20Rate.pdf
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 2
5
Obstetrical Adverse Events (App VIII/IX)
OB Adverse Events Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. Compliance Rate for Elective Induction Bundle
 Numerator: Number of patients in the denominator population with full elective
labor induction bundle compliance
 Denominator: Number of patients who have delivered and received oxytocin for
elective induction of labor
IHC HEN suggested resources:
 APPENDIX VIII – Institute for Healthcare Improvement – IHI How-to Guide: Prevent
Obstetrical Adverse Events, page 32.
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventObstetricalAdverseEvent
s.aspx
OB Adverse Events Outcome Measures: Self-Reported (BLUE)
SELF-REPORTED
1. Patients with Elective Deliveries Between 37-39 weeks per Patients Delivering Newborns
From 37 - 39 Weeks Gestation
 Numerator: Number of elective maternal deliveries between 37-39 weeks gestation
with no medical indication
 Denominator: All deliveries between 37-39 weeks gestation
OB Adverse Events Outcome Measures: SID (GREEN)
SID
1. Primary Cesarean Delivery Rate, Uncomplicated
 Numerator: 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)
 Denominator: Number of deliveries
2. Peripartum Hysterectomy Rate in Women With Placenta Previa
 Numerator: Number of peripartum hysterectomies in women with placenta previa
and/or placenta accreta/percreta
 Denominator: Number of deliveries
3. Peripartum Hysterectomy Rate in Women Without Placenta Previa
Revised March 2014.V3.0
26


Numerator: Number of peripartum hysterectomies in women without placenta previa
and/or placenta accreta/percreta
Denominator: Number of deliveries
4. Birth Trauma Rate - Injury to Newborn
 Numerator: Number of Newborns with ICD-9/ICD-10 code(s) for birth trauma
(AHRQ PSI 17)
 Denominator: Number of newborns
5. Obstetrical Trauma Rate - Vaginal Delivery With Instrument
 Numerator: Number of vaginally-delivering, instrument-assisted Moms with ICD9/ICD-10 code(s) for 3rd or 4th degree obstetric trauma (AHRQ PSI 18)
 Denominator: Number of vaginal deliveries with ICD-9 procedure code(s) for
instrument-assisted delivery
6. Obstetrical Trauma Rate - Vaginal Delivery Without Instrument
 Numerator: 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)
 Denominator: Number of vaginal deliveries without ICD-9 procedure code(s) for
instrument-assisted delivery
7. Obstetrical Trauma Rate – Composite UNDER DEVELOPEMENT
 Numerator: 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
 Acute myocardial infarction
 Acute renal failure
 Adult respiratory distress syndrome
 Amniotic fluid embolism
 Aneurysm
 Cardiac arrest/ventricular fibrillation
 Disseminated intravascular coagulation
 Eclampsia
 Heart failure during procedure or surgery
 Internal injuries of thorax, abdomen or pelvis
 Intracranial injuries
 Puerperal cerebrovascular disorders
 Pulmonary edema
 Severe anesthesia complication
 Sepsis
 Shock
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 2
7

 Sickle cell anemia with crisis
 Thrombotic embolism
 Blood transfusion
 Cardio monitoring
 Conversion of cardiac rhythm
 Hysterectomy
 Operation on heart and pericardium
 Temporary tracheostomy
 Ventilation
Denominator: Number of deliveries
IHC HEN suggested resources:
 APPENDIX IX – The Joint Commission – Perinatal Care (PC) measure PC-01 Elective
Delivery
 http://manual.jointcommission.org/releases/TJC2013A/MIF0166.html
 Federal Register, Vol. 77, No. 170/Friday, August 31, 2012/Rules and Regulations
 http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/FR-2012-08-31.pdf#page=394
 The Joint Commission – Welcome to Performance Measurement Network Q&A Forum
 https://manual.jointcommission.org/Manual/WebHome
 Severe Maternal Morbidity Among Delivery and Postpartum Hospitalizations in the
United Stated, William M. Callaghan, MD;
 http://www.ihconline.org/UserDocs/Pages/Callaghan_et_al.,_2011.pdf
 Agency for Healthcare Research and Quality (AHRQ) – Primary Cesarean Delivery Rate,
Uncomplicated Technical Specifications
 http://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V45/TechSpecs/I
QI%2033%20Primary%20Cesarean%20Delivery%20Rate%20Uncomplicated.pdf
 Agency for Healthcare Research and Quality (AHRQ) – Birth Trauma Rate – Injury to
Neonate Technical Specifications
 http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/TechSpecs/
PSI%2017%20Birth%20Trauma%20Rate-Injury%20to%20Neonate.pdf
 Agency for Healthcare Research and Quality (AHRQ) – Obstetric Trauma Rate – Vaginal
Delivery With Instrument Technical Specifications
 http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/TechSpecs/
PSI%2018%20Obstetric%20Trauma%20RateVaginal%20Delivery%20With%20Instrument.pdf
 Agency for Healthcare Research and Quality (AHRQ) – Obstetric Trauma Rate – Vaginal
Delivery Without Instrument Technical Specifications
 http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/TechSpecs/
PSI%2019%20Obstetric%20Trauma%20RateVaginal%20Delivery%20wo%20Instrument.pdf
 APPENDIX X – CDC: Severe Maternal Morbidity in the United States (ICD-9 code set
for OB Trauma metric)
 http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMor
bidity.html
Revised March 2014.V3.0
28
Venous Thromboembolism (App X)
VTE Process Measures: Self-Reported (BLUE)
SELF-REPORTED
1. Percent of Inpatients VTE Appropriate Prophylaxis
 Numerator: 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 at-risk patients admitted to Acute Care, Skilled Nursing
Care or Swing Bed with stays of >48 hours
IHC HEN suggested resources:
 APPENDIX XI – Society of Hospital Medicine; Greg Maynard, MD; Preventing
Hospital-Acquired Venous Thromboembolism
 http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/Co
ntentDisplay.cfm&ContentID=17773
VTE Process Measures: SID (GREEN)
SID
1. Inpatients Who Develop VTE per the Number Inpatient Discharges
 Numerator: Number of patients in the denominator population with non-POA
secondary ICD-9/ICD-10 code(s) for DVT or PE (AHRQ PSI 12)
 Denominator: Number of discharges for Acute Care, Skilled Nursing and Swing Bed
patients
IHC HEN suggested resources:
 Agency for Healthcare Research and Quality (AHRQ) – Perioperative Pulmonary
Embolism or Deep Vein Thrombosis Rate Technical Specifications
 http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/TechSpecs/
PSI%2012%20Perioperative%20Pulmonary%20Embolism%20or%20Deep%20V
ein%20Thrombosis%20Rate.pdf
 CMS’ QualityNet Specifications Manual – Select most current version, click on Surgical
Care Improvement Project (SCIP)
 https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%
2FPage%2FQnetTier2&cid=1141662756099
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 2
9
Safety Across the Board (GREEN)
SID
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
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)
 Numerator: Number of deaths for patients in the denominator population
 Denominator: 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
Revised March 2014.V3.0
30
Appendices
Appendix I
STate Action on Avoidable Re-hospitalizations – STAAR model
 http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/STAAR/Pages/Measures
Results.aspx
Process Measures: (Source information)
 Enhanced admission assessment for post-hospital needs
 Percent of admissions where patients and family caregivers are included in
assessing post discharge needs
 Percent of admissions where community providers (e.g., home care providers,
primary care providers and nurses and staff in skilled nursing facilities) are
included in assessing post discharge needs
 Effective teaching and enhanced learning
 Percent of observations of nurses teaching patient or other identified learner
where Teach Back is used to assess understanding
 Percent of observations of doctors teaching patient or other identified learner
where Teach Back is used to assess understanding
 Real-time patient- and family- centered handoff communication
 Percent of patients discharged who receive a customized care plan written in
patient-friendly language at the time of discharge
 Percent of time critical information in transmitted at the time of discharge to the
next site of care (e.g., home health, long term care facility, rehab care, physician
office)
 Post-hospital care follow up
 Percent of patients discharged who had a follow-up visit scheduled before being
discharged in accordance with their risk assessment
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 3
1
Appendix II
Institute for Healthcare Improvement – IHI How-to Guide: Prevent Catheter-Associated
Urinary Tract Infections, page 24.
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCatheterAssociated
UrinaryTractInfection.aspx
Process Measure 1: Unnecessary urinary catheters (Urinary catheters not meeting criteria for
appropriate insertion)
 Numerator:
 Number of new indwelling urinary catheters inserted without appropriate
indication documented at time of insertion
 Criteria should include at a minimum:
 Perioperative use for selected surgical procedures
 Urine output monitoring in critically ill patients
 Management of acute urinary retention and urinary obstruction
 Assistance in pressure ulcer healing for incontinent patients
 As an exception, at patient request to improve comfort (SHEA-IDSA) or
for comfort during end-of-life care (CDC)
 Hospitals may add to or modify these criteria for local needs; criteria may be
defined in policies or procedures
 Denominator:
 Number of records reviewed of patients with new indwelling urinary catheters
 Calculation:
 Divide numerator by denominator and report as percent
 Frequency
 Monthly at minimum
 Weekly reporting may be helpful during improvement effort
 Sampling & Measurement Tips:
 Start by collecting data for patients on unit where improvement efforts are
focused or urinary catheter usage is high
 Collect random samples by reviewing records of all patients on the unit with new
indwelling urinary catheters on one day each week. Vary the day and time of
review.
 Review records only for patients admitted recently (such as prior 72 hours or
since last review) to ensure patients are not counted more than once.
 Specify a timeframe in which documentation of indication must be noted in order
to count in numerator (e.g., within four hours of insertion time). Ideally,
indication should be documented at the time of insertion. Do not include
indications documented after the day of insertion.
 Include all patients with new indwelling urinary catheters in the denominator,
whether or not indication for insertion is documented. Those without documented
appropriate indication will not be included in the numerator and represent
opportunities for improvement.
Revised March 2014.V3.0
32


If insertion of indwelling urinary catheters in the ED is high, consider measuring
this separately for that area to determine the percent of unnecessary insertions in
the ED.
This measure can also be reported in the converse, i.e., Appropriate indwelling
urinary catheter usage, where the numerator is the percent of patients with an
indication documented at insertion that meets criteria
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 3
3
Appendix III
CDC Checklist for Prevention of Central Line Associated Blood Stream Infections
 http://www.cdc.gov/HAI/pdfs/bsi/checklist-for-CLABSI.pdf
Follow Proper Insertion Practices
o Perform hand hygiene before insertion
o Adhere to aseptic technique
o Use maximal sterile barrier precautions (i.e., mask, cap, gown, sterile gloves, and sterile
full-body drape)
o Perform skin antisepsis with >0.5% chlorhexidine with alcohol
o Choose the best site to minimize infections and mechanical complications
 Avoid femoral site in adult patients
o Cover the site with sterile gauze or sterile, transparent, semipermeable dressings
Handle and Maintain Central Lines Appropriately
o Comply with hand hygiene requirements
o Scrub the access port or hub immediately prior to each use with an appropriate antiseptic
(e.g., chlorhexidine, povidone iodine, an iodophor, or 70% alcohol)
o Access catheters only with sterile devices
o Replace dressings that are wet, soiled, or dislodged
o Perform dressing changes under aseptic technique using clean or sterile gloves
Revised March 2014.V3.0
34
Appendix IV
CMS’ QualityNet Specifications Manual – Select manual with the most current version,
click on Surgical Care Improvement Project (SCIP)
 https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FP
age%2FQnetTier2&cid=1141662756099
Table Number Table Name
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Coronary Artery Bypass Graft
Table 5.01
(CABG)
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Table 5.03
Colon Surgery
Code
Shortened Description
AORTOCORONARY BYPASS
36.10 NOS
36.11 AORTOCOR BYPAS-1 COR ART
36.12 AORTOCOR BYPAS-2 COR ART
36.13 AORTOCOR BYPAS-3 COR ART
36.14 AORTCOR BYPAS-4+ COR ART
36.15 1 INT MAM-COR ART BYPASS
36.16 2 INT MAM-COR ART BYPASS
36.17 ABD-CORON ARTERY BYPASS
36.19
17.31
17.32
17.33
17.34
17.35
17.36
17.39
45.00
45.03
45.49
45.50
45.71
45.72
45.73
45.74
45.75
45.76
HRT REVAS BYPS ANAS NEC
LAP MUL SEG RES LG INTES
LAPAROSCOPIC CECECTOMY
LAP RIGHT HEMICOLECTOMY
LAP RES TRANSVERSE COLON
LAP LEFT HEMICOLECTOMY
LAP SIGMOIDECTOMY
LAP PT EX LRG INTEST NEC
INTESTINAL INCISION NOS
LARGE BOWEL INCISION
DESTRUC LG BOWEL LES NEC
INTEST SEG ISOLAT NOS
OPN MUL SEG LG INTES NEC
OPEN CECECTOMY NEC
OPN RT HEMICOLECTOMY NEC
OPN TRANSV COLON RES NEC
OPN LFT HEMICOLECTMY NEC
OPEN SIGMOIDECTOMY NEC
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 3
5
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table Number
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Table Name
45.79
45.82
45.90
45.92
45.93
Code
PRT LG INTES EXC NEC/NOS
OP TOT INTR-ABD COLECTMY
INTESTINAL ANASTOM NOS
SM BOWEL-RECT STUMP ANAS
SMALL-TO-LARGE BOWEL
Shortened Description
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.03
Table 5.04
Table 5.04
Table 5.05
Table 5.06
Table 5.06
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Colon Surgery
Hip Arthroplasty
Hip Arthroplasty
Knee Arthroplasty
Abdominal Hysterectomy
Abdominal Hysterectomy
46.04
46.75
46.76
46.91
46.92
46.94
48.50
48.61
48.62
48.63
48.64
48.65
48.69
81.51
81.52
81.54
68.49
68.69
RESECT EXT SEG LG BOWEL
SUTURE LG BOWEL LACERAT
CLOSE LG BOWEL FISTULA
MYOTOMY OF SIGMOID COLON
MYOTOMY OF COLON NEC
REVISE LG BOWEL ANASTOM
ABDPERNEAL RES RECTM NOS
TRANSSAC RECTOSIGMOIDECT
ANT RECT RESECT W COLOST
ANTERIOR RECT RESECT NEC
POSTERIOR RECT RESECTION
DUHAMEL RECTAL RESECTION
RECTAL RESECTION NEC
TOTAL HIP REPLACEMENT
PARTIAL HIP REPLACEMENT
TOTAL KNEE REPLACEMENT
TOTAL ABD HYST NEC/NOS
RADICAL ABD HYST NEC/NOS
Revised March 2014.V3.0
36
Appendix V
Institute for Healthcare Improvement – IHI How-to Guide: Prevent Ventilator-Associated
Pneumonia, page 27.
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventVAP.aspx
Ventilator Bundle Compliance
In our experience, teams begin to demonstrate improvement in outcomes when they provide all
five components of the Ventilator Bundle. Therefore, we choose to measure compliance with the
entire Ventilator Bundle, not just parts of the bundle.
On a given day, select all the ventilated patients and assess them for compliance with the
Ventilator Bundle. If even one bundle component is missing, the case is not in compliance with
the bundle. For example, if there are 7 ventilated patients, and 6 patients have all 5 bundle
elements completed, then 6/7 (86%) is the compliance with the Ventilator Bundle. If all 7
ventilated patients had all 5 elements completed, compliance would be 100%. If all 7 were
missing even a single element, compliance would be 0%.
No. ventilated patients receiving ALL 5 Ventilator Bundle elements = Reliability of ventilator
No. patients on ventilators for the day of the sample
Bundle Compliance
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 3
7
Appendix VI
Medication Therapy Intervention & Safety Documentation Program User Manual (v 7.0),
pages 8-9 Adverse Drug Reaction (ADR) definition
Adverse Drug Reaction (ADR)
An ADR is harm directly caused by a drug at normal doses during normal use. ADRs are side
effects, but the term “side effects” tends to minimize the importance of the reaction and,
therefore, ADR is the preferred terminology. These reactions may not necessarily be severe.
Adverse drug reaction can be augmented pharmacologic effects, idiosyncratic effects, chronic
effects, delayed effects, end-of-treatment effects, or failure of therapy.
Example:
 Lower extremity edema from Norvasc 10mg daily for HTN
 Tylenol with Codeine #3 1-2 tabs q4-6h prn pain leading to severe drowsiness or
constipation
 Cough from ACEi therapy
Revised March 2014.V3.0
38
Appendix VII
Institute for Healthcare Improvement – IHI How-to Guide: Prevent Pressure Ulcers
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx
CALCULATION DETAILS:
Numerator Definition: Number of patients identified as at risk for pressure ulcers for which all
components of proper pressure ulcer care were performed and documented in the calendar day
prior to review. If a component of care is not applied due to a documented contraindication,
count it as appropriately performed for the purposes of this measure. Proper pressure ulcer care
includes the following five components:
1. Daily inspection of skin for pressure ulcers
2. Proper management of moisture, including both cleaning and moisturizing skin
3. Optimization of nutrition
4. Repositioning every two hours
5. Use of pressure-relieving surfaces
Numerator Exclusions: None
Denominator Definition: Total number of patients identified as being at risk for pressure ulcers
Denominator Exclusions:
 Patients admitted on current day or prior calendar day
PARTNERSHIP FOR PATIENTS REPORTING TOOLKIT 3
9
Appendix VIII
Institute for Healthcare Improvement – IHI How-to Guide: Prevent Obstetrical Adverse Events,
page 32.
 http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventObstetricalAdverseEvent
s.aspx
Revised March 2014.V3.0
40
Appendix IX
The Joint Commission – Perinatal Care (PC) measure PC-01 Elective Delivery
 http://manual.jointcommission.org/releases/TJC2013A/MIF0166.html
Numerator Statement: Patients with elective deliveries
Included populations: ICD-9-CM principal procedure code or ICD-9-CM other procedure codes
for one or more of the following:
 Medical induction of labor as defined in Appendix A, Table 11.05
 Cesarean section as defined in Appendix A, Table 11.06 while not in labor or
experiencing Spontaneous Rupture of Membranes
Excluded populations: None
Data elements:
 ICD-9-CM Other Procedure Codes
 ICD-9-CM Principal Procedure Code
 Labor
 Spontaneous Rupture of Membranes
Denominator Statement: Patients delivering newborn with >= 37 and < 39 weeks of gestation
completed
Included populations:
 IDC-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for planned
cesarean section in labor as defined in Appendix A, Table 11.06.1
Excluded Populations:
 ICD-9-CM Principal Diagnosis Code or ICD-9-CM Diagnosis Codes for conditions
possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix
A. Table 11.07
 Less than 8 years of age
 Greater than or equal to 65 years of age
 Length of stay > 120 days
 Enrolled in clinical trials
 Prior uterine surgery
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Appendix X
CDC: Severe Maternal Morbidity in the United States (ICD-9 code set for OB Trauma metric)
 http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMor
bidity.html
ICD-9 DIAGNOSIS CODES
Acute myocardial infarction
Acute renal failure
Adult respiratory distress syndrome
Amniotic fluid embolism
Aneurysm
Cardiac arrest/ventricular fibrillation
Disseminated intravascular coagulation
Eclampsia
Heart failure during procedure or surgery
Internal injuries of thorax, abdomen or pelvis
Intracranial injuries
Puerperal cerebrovascular disorders
Pulmonary edema
Severe anesthesia complication
Sepsis
Shock
Sickle cell anemia with crisis
Thrombotic embolism
Blood transfusion
Cardio monitoring
Conversion of cardiac rhythm
Hysterectomy
Operation on heart and pericardium
Temporary tracheostomy
Ventilation
Revised March 2014.V3.0
ICD-9
PROCEDURE
CODES
410.xx
584.x, 669.3x
518.5, 518.81, 518.82,
518.84, 799.1
673.1x
441.xx
427.41, 427.42, 427.5
286.6, 286.9, 666.3x
642.6x
669.4x, 997.1
860.xx - 869.xx
800.xx, 801.xx, 803.xx,
804.xx, 851.xx - 854.xx
430, 431, 432.x, 433.xx,
434.xx, 436, 437.x, 671.5x,
674.0x, 997.2, 999.2
428.1, 518.4
668.0x, 668.1x, 668.2x
038.xx, 995.91, 995.92
669.1x, 785.5x, 995.0, 995.4,
998.0
282.62, 282.64, 282.69
415.1x, 673.0x, 673.2x,
673.3x, 673.8x
99.0x
89.6x
99.6x
68.3x - 68.9
35.xx, 36.xx,
37.xx, 39.xx
31.1
93.90, 96.01 96.05, 96.7x
42
Appendix XI
Society of Hospital Medicine; Greg Maynard, MD; Preventing Hospital-Acquired Venous
Thromboembolism
 http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/Co
ntentDisplay.cfm&ContentID=17773
Risk Factors: Any two or more is an indication for VTE prophylaxis
 Any two or more is an indication for VTE prophylaxis
 Age over 40 years
 Obesity
 ICU admission
 Presence of central venous line
 Prolonged immobility, more than 24 hours
 Past history of Chronic Lung Disease or an inflammatory disorder
 Admitted with or a history of heart failure, pneumonia or serious infection,
varicose veins, nephrotic syndrome, sickle cell disease, pregnancy or estrogen use
High Risk Factors:
 Any ONE is an indication for VTE prophylaxis
 Major trauma (abdomen, pelvis, hip or leg)
 Ischemic (non hemorrhagic) stroke or paralysis
 Malignancy
Any prior history of deep vein thrombosis or pulmonary embolism
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