Delmarva Foundation
Condition H Collaborative
Table of Measures for Hospital Reporting
The measures consist of core measures required by each hospital.
Measures for Hospital Reporting
Measure Effectiveness
Measure
Description
Numerator
Denominator
Frequency/Data
Collection
Goal/
Comments
Tools/Resource
Efferent
Codes
Outside ICU
Percentage of all codes
occurring outside the ICU
Core
Code: Patients requiring
cardiopulmonary
resuscitation or intubation
Calculate as: (numerator/
denominator); as a
percentage
In-hospital
codes that
occur outside
the ICU
Numerator
Exclusions:
Codes
occurring in
the ED
All in-hospital codes
1 month
Denominator
Exclusions: Codes
occurring in the ED
Data Collection
Strategy: Each month,
determine the location
each code occurs from
code logs and records.
Establish a process to
identify all calls to the
RRS. One possible data
collection strategy: Each
call to the RRS should
result in the completion of
a documentation form or
record. These records
should be kept in a central
location (paper log book,
electronic record, etc.)
and used as the source of
the data.
Goal: 50%
decrease
Decrease the
number of
patients who are
coding within
your facility
outside of the
ICU and ED.
See sample Data
Collection Tool
See IHI 100,000
Lives Campaign,
How-To Guide:
Rapid Response
Teams (Appendix
C, p. 26)
http://www.ihi.org/N
R/rdonlyres/9134B6
0C-BB05-47358DF4D96D09CC9EAB/0/
RRSHowtoGuideFI
NAL71505.pdf
1
Delmarva Foundation
Condition H Collaborative
Measure Effectiveness
Measure
Utilization of
RRS
Description
Number of calls to the
RRS
Numerator
Number of
calls to the
RRS
Numerator
Exclusions:
None
Core
The numerator
includes all
calls to the
RRS.
Denominator
N/A
Frequency/Data
Collection
Goal/
Comments
Typically, this is done in
monthly increments, but
teams might find it useful
initially to track this
information weekly (i.e.,
period of 1 week, every
week, measuring calls per
week). Once your team is
well established, you can
move the measurement
period to monthly (i.e.,
period of 1 month, every
month, measuring calls
per month). Data
submitted to IHI should be
aggregated to monthly.
Goal: Increase
the use of the
RRS over time.
(This is an
organizationspecific
measure; it is
not suggested to
compare across
organizations,
so there is no
absolute goal.)
Tools/Resource
See sample Data
Collection Tool
See IHI 100,000
Lives Campaign,
How-To Guide:
Rapid Response
Teams (Appendix
C, p. 28)
http://www.ihi.org/N
R/rdonlyres/9134B6
0C-BB05-47358DF4D96D09CC9EAB/0/
RRSHowtoGuideFI
NAL71505.pdf
Data Collection
Strategy: Establish a
process to identify all calls
to the RRS. One possible
data collection strategy:
Each call to the RRS
should result in the
completion of a
documentation form or
record. These records
should be kept in a central
location (paper log book,
electronic record, etc.)
and serve as the source
of the data.
2
Delmarva Foundation
Condition H Collaborative
Measure Effectiveness
Measure
Core
Utilization of
RRS
Activated by
Patients and
Family
Members
Description
Number of calls to the
RRS activated by patient
or family member
Numerator
Number of
calls to the
RRS activated
by a patient or
family member
Numerator
Exclusions:
None
The numerator
includes all
calls to the
RRS that are
initiated by a
patient or
family
member.
Denominator
N/A
Frequency/Data
Collection
1 month
Data Collection
Strategy: Establish a
process to identify all calls
made by a patient or
family member to the
RRS. One possible data
collection strategy: Each
call to the RRS should
result in the completion of
a documentation form or
record. These records
should be kept in a central
location (paper log book,
electronic record, etc.)
and serve as the source
of the data.
Goal/
Comments
This is an
organizationspecific
measure; it is not
suggested to
compare across
organizations, so
there is no
absolute goal.
Tools/Resource
See sample Data
Collection Tool
3
Delmarva Foundation
Condition H Collaborative
Measure Effectiveness
Measure
Description
Numerator
Denominator
Frequency/Data
Collection
Goal/
Comments
Tools/Resource
(Binder Tab XX)
Quality Improvement
Codes per
1,000
discharges
The number of codes per
1,000 inpatient
discharges
Core
Code: Patients requiring
cardiopulmonary
resuscitation or intubation
Calculate as: (numerator/
denominator) x 1000; as a
number of codes per
1,000 inpatient
discharges
Total inpatient
codes
Total inpatient
discharges
Numerator
Exclusions:
Codes
occurring in
the ED
Denominator
Exclusions:
 Stillbirths
 Deaths in the ED
of ED-only
patients
An ED-only patient is
one who receives
care in the ED but
has not been
admitted to the
hospital.
1 month
Data Collection
Strategy: Obtain
numerator and
denominator from hospital
information systems or
other reliable sources
monthly as soon as
discharge and death data
are available.
Goal: Short
term, reduce by
25%. Long term,
reduce by 50%.
See sample Data
Collection Tool
See IHI 100,000
Lives Campaign,
How-To Guide:
Rapid Response
Teams (Appendix
C, p. 24)
http://www.ihi.org/N
R/rdonlyres/9134B
60C-BB05-47358DF4D96D09CC9EAB/0
/RRSHowtoGuideF
INAL71505.pdf
Stillbirths and EDonly deaths are
generally not
considered inpatient
discharges; we have
noted them explicitly
for clarification.
4
Delmarva Foundation
Condition H Collaborative
Measure Effectiveness
Measure
Acute care
inpatient
mortality
rate
Description
Number of in-hospital
deaths in acute care
inpatient population
divided by the number
Acute care inpatient is on
who is discharged from
acute care inpatient
status.
Core
Calculate as: (numerator/
denominator); as a
percentage
Numerator
Number of
acute care
inpatient
deaths
Denominator
Number of acute care
inpatient discharges
Denominator
Exclusions: This
measure is focused
on acute care
inpatient deaths and,
therefore, by
definition the
following patients are
excluded from the
calculation:
 ED-only patients
who are not
admitted as
inpatients
 Observation
patients who are
not admitted as
inpatients
 Short-stay
patients who are
not admitted as
inpatients
These exclusion
populations are not
considered by most
U.S. hospitals to be
acute care inpatients.
Frequency/Data
Collection
Monthly
Data Collection
Strategy: Obtain
numerator and
denominator from hospital
information systems or
other reliable sources
monthly as soon as
discharge and death data
are available.
For patient populations
not explicitly excluded, for
whom it is not clear
whether they should be
considered acute care
inpatients, consider
patients discharged with a
completed UB-92 form
included and those
discharged with the form
excluded.
Typically, it is
recommended to exclude
all DNR patients from this
statistic.
Goal/
Comments
Goal: Decrease
hospital mortality
by 10%.
Tools/Resource
(Binder Tab XX)
See sample Data
Collection Tool
For consistency,
hospitals that
include any of
the exclusion
populations in
their individual
definition of
acute care
inpatients should
exclude these
populations for
this measure. All
acute care
inpatients should
be included,
even in cases
where mortalityreducing
improvements
are not
appropriate,
such as comfort
care patients
who are coded
as acute care
inpatient.
5
Delmarva Foundation
Condition H Collaborative
Measure Effectiveness
Measure
Patient
Satisfaction
Indicator #1:
Provided
Clear
Direction
Number of respondents
who felt they were given
clear direction regarding
Condition H
Patient
Satisfaction
Indicator #2:
Felt
Comfortable
Number of respondents
who felt comfortable
calling a Condition H
Optional
Optional
Description
Calculate as: (numerator/
denominator); as a
percentage
Calculate as: (numerator/
denominator); as a
percentage
Numerator
Denominator
Number of
respondents
who ‘agree’ or
‘strongly
agree’ that
they were
given clear
direction
regarding
Condition H
Number of
respondents
Number of
respondents
who ‘agree’ or
‘strongly
agree’ that
they felt
comfortable
calling a
Condition H
Number of
respondents
Frequency/Data
Collection
1 month
Data Collection
Strategy: Establish a
process to identify all calls
to the RRS. One possible
data collection strategy:
Each call to the RRS
should result in the
completion of a
documentation form or
record. These records
should be kept in a central
location (paper log book,
electronic record, etc.)
and serve as the source
of the data.
1 month
Data Collection
Strategy: Establish a
process to identify all calls
to the RRS. One possible
data collection strategy:
Each call to the RRS
should result in the
completion of a
documentation form or
record. These records
should be kept in a central
location (paper log book,
electronic record, etc.)
and serve as the source
of the data.
Goal/
Comments
Tools/Resource
(Binder Tab XX)
Goal: 100% of
respondents
‘agree’ or
‘strongly agree’
that they were
given clear
direction
regarding
Condition H
See sample Data
Collection Tool
Goal: 100% of
respondents
‘agree’ or
‘strongly agree’
that they felt
comfortable
calling a
Condition H
See sample Data
Collection Tool
6
Delmarva Foundation
Condition H Collaborative
Measure Effectiveness
Measure
Description
Numerator
Patient
Indicator #4:
Needs Met
Post
Condition H
Call
Number of respondents
who felt their needs or the
needs of their loved one
was met post a Condition
H call
Number of
respondents
who ‘agree’ or
‘strongly
agree’ that
their needs or
the needs of
their loved one
was met post
a Condition H
call
Denominator
Number of
respondents
Frequency/Data
Collection
1 month
Goal/
Comments
Goal: 100% of
respondents
‘agree’ or
‘strongly agree’
that their needs
or the needs of
their loved one
was met post a
Condition H call
Tools/Resource
(Binder Tab XX)
See sample Data
Collection Tool
Optional
Data Collection
Strategy: Establish a
process to identify all calls
to the RRS. One possible
data collection strategy:
Calculate as: (numerator/
Each call to the RRS
denominator); as a
should result in the
percentage
completion of a
documentation form or
record. These records
should be kept in a central
location (paper log book,
electronic record, etc.)
and serve as the source
of the data.
Note: RT = respiration therapist; OT = occupational therapist; PT = physical therapist; SLP = speech–language pathologist; SW = social worker.
7
Condition H Collaborative
Delmarva Foundation
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